Training surgeons in Malawi

Surgeon Sven Young hurries back to a consulting room at Kamuzu Central Hospital in Malawi’s capital Lilongwe. A worried woman has brought an infant with back pain.

The Norwegian surgeon, from UiB’s Department of Clinical Medicine, studies X-rays of the infant before consulting with his local assistants and calming the worried woman. He then uses his smart phone to photograph the X-ray.

“Tomorrow I am going to a medical congress and will have the opportunity to discuss the case with a colleague,” Young explains. “Taking a photo with my mobile phone comes in handy.”

This example shows how modern technology can be of help even in an impoverished country such as Malawi.

Local low-tech

According to Young, discussing local patients with other African doctors is often more useful than inquiring from colleagues in Norway.

“Back home in Norway we may have the best and most modern equipment, whereas here in Malawi we are stuck with equipment that is one or two generations old in medical terms,” he says.

He points out that the hospital’s surgical ward was opened in 1977, thanks to aid from Denmark, giving hope to the local health care system. Due to lacking maintenance, however, the decay is now clearly visible and Young and the other doctors face a daily battle in maintaining standards.

Training local specialists

Since 2008, Young and his wife have spent a total of almost four years on and off in Malawi, as part of a surgery-orthopaedics collaboration between Haukeland University Hospital (HUS) in Bergen and Kamuzu Central Hospital in Lilongwe. This project was run by Young, Professor Asgaut Viste, also of UiB’s Department of Clinical Medicine, and specialist nurse Anne Mette Koch of HUS.

“The project aimed to improve quality and increase capacity in surgical treatment at the hospital in Lilongwe,” explains Young. “We are training local general and orthopaedic surgeons in Malawi as well as more operating room nurses.”

A continuation of the project

The doctors from HUS were helped by their partner university hospitals in Oslo and Stavanger, who also sent surgeons to Malawi; but in February 2014, the project period ended and financing fell away. Nevertheless, Young saw a need to continue his work one way or another.

“Our project was initially funded for two years. After this we had to reapply to a different entity,” he sighs, pointing to the often-labyrinthine setup of Norwegian aid programmes. “But even a five year project is far too short to build a sustainable environment of surgeons in a country with such an under-resourced health care system as in Malawi.”

Shattering myths about surgery

Then an opportunity to apply for the NORHED programme arrived (see FACTS). Making the most of his UiB association, where he successfully defended his PhD thesis in January 2014, Young got funding for a new five-year project. His dissertation was about fracture treatment in low-income countries, using his work in Malawi as a base.

“I am surprised at how well-established myths about surgery in low-income countries are. Many people in the west still believe that there is less need to treat injuries than to treat and prevent infectious disease in these countries,” he says. “Another myth is that there are too many infections after surgery in low-income countries. This is not correct.”

He believes that such myths prevent the introduction of modern surgical practices in countries like Malawi.

“In Malawi people with a fractured femur are still treated with traction and prolonged bed rest – a treatment the west left behind more than 50 years ago,” says the surgeon.

Surgeons must argue their case

Young’s research shows that infection rates are not much higher in Malawi than in rich countries, despite a greater number of serious injuries, a lack of resources and poor infrastructure.

“Risk of infection is no argument against introducing modern fracture treatment in low-income countries,” argues Young. “It is easy to criticise the media and others for showing greater interest in epidemics and subjects with more immediate tabloid appeal. But we as surgeons need to get better at raising our voices in public and stating our case.”

Traffic accidents are the leading cause of death among young people in the world; more so than epidemic diseases such as HIV/AIDS, malaria or tuberculosis. In addition, for every person who dies in traffic, there are three to ten people who become disabled for life.

A sustainable future

In most developing countries, there is no social security network to take care of those who fall outside of the labour force. This again leads to increased poverty for many citizens in low and middle-income countries.

“We want our work in Malawi to be sustainable in the long run. This is why we are also involved in preventive measures, such as public information campaigns and distributing pedestrian reflectors to people who walk along the roads in the dark. But our main focus is to train more Malawian specialist doctors and nurses,” says Young.

However, educating and training more health care professionals in Malawi is by no means the only challenge the country is facing.

“It is hard to get doctors to remain in the country to work at public hospitals, or in Malawi at all, during or after education. So we have included an incentive scheme in the programme, with scholarships during training.”

Using NORHED to improve hospital standards

Sven Young also hopes that the NORHED project can help pave the way towards future financing for Kamuzu Central Hospital.

“Our dream is to build an orthopaedic wing with all the amenities expected in a modern hospital,” he says. “Today, the richest Malawians travel to South Africa even for minor surgery. If we could offer better facilities and well-trained surgeons here, we could generate income directly in and for the hospital, thus becoming less reliant on aid – and the local doctors and nurses could be offered more decent wages.”

He adds that being able to offer private health services to the local elite is important for Malawi’s professional prestige.

“It is almost impossible for Malawian physicians to live on public hospital salaries alone,” says Sven Young. “They need alternative sources of income within the public health care system if the work to build sustainable public health solutions in Malawi is to succeed.”

This article is a longer version of an interview from the UiB Magazine 2014/2015. You can download a PDF of the full magazine or you may browse the magazine online.