Building paediatric surgical services in Central and Northern Malawi

Photo of paediatric OR in Malawi that opened in Oct. 2018 

You might guess from how I spell paediatric that I’m from the other side of the pond. I arrived in Blantyre in southern Malawi eight  years ago, when I joined the county’s only other paediatric surgeon. As our numbers grew, we needed to spread out. In March 2016, I moved to Lilongwe, the capital of Malawi, where there was no specialist paediatric surgeon. The adult surgeons handled emergencies as best they could, but complex elective cases were either sent to Blantyre or treated by Dr. Oluyinka Olutoye who would visit from Texas Children’s.

Our service grew to over 500 surgical cases under general anaesthesia each year, and many more surgeries were performed with sedation on the wards. We saw 30 to 50 patients each week in clinic. While it was incredible to see these numbers, we knew it was not sustainable for our small team. We needed to train more local specialist paediatric surgical teams, surgeons, anaesthetists and nurses. However, in early 2019, I lost my funding. Thankfully, I had a great collaborative relationship with Baylor College of Medicine through Global HOPE (Hematology-Oncology Pediatric Excellence), as I would operate on many of their cancer patients. Dr. David Poplack, director of Global HOPE, told me he believed cancer can be the tide that lifts all boats. He saw paediatric oncology as a way to improve children’s services in general. Thanks to his efforts and those of Dr. Jed Nuchtern, chief of Global Surgery at Texas Children’s, I joined Texas Children’s Global Health in June 2019.

It was an eventful first year. From Jan. to Nov. 2020, we logged 387 cases in the operating room, a drop in our usual output, which we believe was due to COVID-19 related restrictions. Of these, 200 were major cases such as congenital anomalies, tumour resections, abdominal and urological operations. We had 187 minor cases such as hernias and biopsies. Because we deal with a lot of late presenting cases, many hernias we see are large and can be fatal if left untreated.

It’s interesting once you provide a service, word spreads and patients flock in. Before we were here, I suspect families had less hope of getting treated, or if they did, they would have to wait a long time to receive care or be sent to Blantyre. While healthcare is nominally free in Malawi, associated costs such as travel, food and time off work can still mean surgery for your child is a catastrophic expense, especially if you are a subsistence farmer. The local traditional healer is more accessible, relatively affordable and may be more aligned to local belief systems.

Suppose you are a parent of a sick child. You keep your child at home, or treat them with traditional medicine, until you and your child can no longer bear it. Maybe you sought help at a local healthcare centre but did not get the assistance you needed. By the time you seek treatment with our team, your child’s medical condition has gotten complicated. Usually, we can do something to help, but sadly, we will still encounter complications, amputations and deaths that could have been avoided with earlier presentation. This is why it’s so important that we provide an effective and timely service. People need to learn that KCH is somewhere they can rely on.

In 2019, we reached several major milestones, including receiving partial accreditation by COSECSA (College of Surgeons of East Central and Southern Africa) as a training centre for paediatric surgery and enrolling our first trainee. But, we also experienced some COVID-19 related setbacks in 2020. Since April, schools have been closed, livelihoods have suffered and I have never seen the hospital so empty. Where were these sick children? Were they being treated in the districts, being told to stay at home, or unable to get to hospital due to transport difficulties? We know that previous Ebola responses in West Africa led to increased malnutrition and decreased immunizations. When health systems are so strained, diverting precious resources will lead to a decline in essential services. Overcoming the backlog will be challenging, but once we have done this, we hope to get back on track to providing safe, timely and quality surgical services to the children of central and northern Malawi.

We are lucky to work here. Our families go through so much, yet complain so little. They are an inspiration to us.