On the Ground with Anthony Charles and the Malawian Surgical Initiative
School of Medicine
It’s just after 6 p.m. in Lilongwe and the Chipiku Plus grocery store is crowded with people doing after work shopping. We are here to gather basics: tea, cereal, juice, a large case of bottled water. Despite the crowd, the lines at the counter are moving efficiently. Suddenly the lights go out. No one scurries out. No one does anything out of the ordinary. By the light of several raised cell phones, the clerk continues trying to scan items. She’s unsuccessful but never breaks rhythm.
A minute or two pass. The lights flash back on.
“Welcome to Africa,” Anthony Charles says, slapping me on the back.
Home for the week is a simple house behind a brick wall and a metal gate. There’s a guard at the gate and a big dog named Zsa Zsa. Zsa Zsa is the more skeptical of the two. The guard is warm and friendly, ready to talk. He tells me he likes country and western music, Don Williams especially. He asks me how often I’ve traveled to New York. He proudly shows me around the grounds, pointing out the fruit trees. Oranges still green on the tree. Peach and mango trees that, now bare, will be dropping sweet fruit in December once summer arrives.
Home and settled, it’s time to work.
The Department of Surgery at Kamuzu Central Hospital starts its morning report meeting at 7:30. Anthony Charles, MD, MPH, turns on the lights in the sparse hospital conference room. It has been a few months since his last trip to Malawi, but it’s as if he’s here every day. He exchanges greetings with a few faculty and residents, but there’s no big introduction. He sits down, things get going, and as the surgeons present their cases from the previous day, he begins peppering them with questions.
“Why did you do that?”
“Did you consider trying this?”
In one instance, the presenting physician explains that he chose to delay an operation because the patient had a full stomach. This was unacceptable, Charles replied. The patient’s case should have been deemed an emergency. It warranted immediate surgery.
“If you got shot on your way here this morning, would you tell the surgeon, ‘no, don’t operate, doctor, I’ve just had breakfast?’”
It goes on like this for the full hour of the meeting.
“If you make a decision with a patient’s life in the balance, you’d better be able to defend it,” Charles explains afterward.
It’s winter in Lilongwe. Morning smells like smoke. Fires burn to heat homes and cook food. Those fires get out of control. Or worse, children slip and fall in. Winter is burn season.
In this city, traffic accidents have no offseason. Driving these busy roads, you squeeze your shoulders together, instinctively hoping that might help your car avoid the women walking along the shoulder, or the men biking just on the edge of your lane. At night, cyclists appear, flashing in and out of headlights, but otherwise unseen in the darkness enveloping the kilometers between the city’s residential and commercial districts.
Summer is mango season. Ambitious harvesters climb higher than they should. They fall. Bones are broken.
Trauma is constant here. Quality surgical care can’t keep up.
Walking through Kamuzu Central Hospital (KCH), there are people everywhere waiting to receive care. Obvious injuries are wrapped with fraying bandages. Men on wooden crutches slowly amble down the halls. Everyone smiles and waves. In the face of such difficulty there is warmth, kindness and pride. It’s dark. But it’s not desperate.
After morning meetings, as he does often when in Malawi, Charles scrubs in for a case. The plan was to conduct an exploratory laparotomy, looking for the source of free air in the patient’s abdomen. What Charles found was advanced stomach cancer that had spread to the patient’s liver. Without the ultrasound technology that’s standard in the United States, the cancer was undetected before incision. There was nothing that could be done surgically for this patient. Charles and the resident would just wash out the abdomen and close him up.
But there was a problem.
“They didn’t have the ideal suture that we’d use in the United States,” Charles said. “They didn’t have the next best thing. They had nylon, but the wrong size. So, I said let’s go old school and use silk, which I’d never use in the US. Every option that I gave them, they did not have.”
“That is emblematic of the problems they have here.”
Eventually, the operating team dispatched someone to another operating room, and he returned with the suture they needed.
In spite of the problems that persist, things are getting better.
For nearly 10 years, Charles has led the Malawian Surgical Initiative in partnership with Kamuzu Central Hospital and the Malawi College of Medicine, which is located in Blantyre.
Carlos Varela leads the Department of Surgery at Kamuzu Central Hospital, a post he has held since 2011. Varela is Malawian and completed his medical training at the Malawi College of Medicine in Blantyre. Postgraduate surgical training did not exist in Malawi when he entered residency, so he went to Cape Town in South Africa. “When I left for Cape Town, there was no postgraduate surgery training available in this country. When I returned after residency, the Malawian Surgical Initiative was up and running. What Prof. Charles has done has helped us to train so many surgeons here in Malawi,” Varela said.
Varela and Charles work closely and have an easy and apparent friendship. Keeping in near constant contact about cases and trends at the hospital, staying abreast of the needs of the residents in the program and, of course, playing a little good cop/bad cop during the morning meeting.
“I tell Prof. Charles that Malawi really is his second home,” Varela said. “He may go away for other things, but he’s always back, and everyone knows him around the hospital.”
Under Varela’s watch, Kamuzu Central Hospital’s surgical capacity has grown considerably. In 2011, when he returned home, there was one Malawian surgeon at the hospital. Today, there are seven.
“In years past, we would rely on expat surgeons to help us meet our demand. They would come and spend a month or two here and then leave,” Varela said. “They would have different skill levels and not be used to the cases they would see here, which can be very different from what they are accustomed to seeing.”
The Malawian Surgical Initiative has trained 16 Malawian residents so far, with eight currently in various stages of the five year program.
Clinical officers make up the base of the Malawian health care system. The three year post-secondary training gets them to a level similar to a physician’s assistant in the United States. Walking through Kamuzu Central, they are everywhere, dressed in white pants and short-sleeved white shirts. The Malawi College of Medicine, offering MD medical training, was founded in 1991. When Varela entered in 1997, he says there were 20 people in his class. In the last several years, classes have grown and now average around 100 students. Work as a clinical officer is steady and highly respected. Graduates of the Malawi College of Medicine who go into general practice can make a good living for themselves and their families.
Varela says this occasionally makes recruiting for postgraduate training a tough sell.
“People say, ‘I’ve just gotten out of school. I can start work and make money now. Why would I go back for more studying?’” Varela said. “The residents who join us, though, have seen that this program can really help them advance in their careers and improve health care in the country.”
There’s no doubt that fourth-year surgery resident Vanessa Nsosa will make an impact. Nsosa’s mother, Anastasia Nsosa, was Malawi’s first female chief justice. It takes a lot of smarts and a lot of confidence to ascend to such a position. Vanessa inherited all of it.
“I chose surgery because, during medical school on surgical rotations, I was very good at it,” Nsosa says. “Being a general practitioner didn’t sound like something special, and I wanted to be able to reach a little higher for patients.”
Throughout her training, she has had to be a ‘jack of all trades,’ facing trauma cases as well as GI and endocrine issues. When she’s working, she often thinks back to lessons learned in the morning report meeting.
“As a surgeon, you’ll face pressure. You have to think quickly and know what action to take; then you have to explain it to your colleagues and, most importantly, to the patient’s loved ones,” Nsosa said.
Being prepared to act quickly and decisively is the point of clinical training.
“You have to have the confidence to know that whatever problem comes through the door you’ll be able to fix it,” Charles said. “You can’t be a good surgeon without that attitude.”
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December 6, 2023
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