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Jun 20th 2016

Day 1 at Dignitas...and an unfamiliar surgery clinic

Day 1 at Dignitas...and an unfamiliar surgery clinic

Monday June 20/16

I looked at this picture that I took shortly after I arrived yesterday.  From the sky one realizes that the view can be from anywhere in the world.  A tilt of the head downwards of course brings ones current reality back into focus.   If we can all be under one roof though it does make one wonder whether we should all have access to the same 'amenities' of home. 

 

There is much to think about after my first full day in Malawi. I woke up to a beautiful view from the place I am staying at built on the lower slopes of the Zomba Plateau.    

 

An early start brought me to the head office of Dignitas. I met many of the tremendous people that form the backbone of this organization. In fact, as I walked around the site it and contrasted it to my later experience in the surgery clinic (which I will discuss below) it reinforced what a massive effort it takes just to do one thing well. We have a very impressive team on the ground in Zomba.  

 

 

The data management and IT infrastructure, logistical and communication support to allow the clinicians to do address any particular need is huge. DI has made enormous strides to integrate comprehensive care from the primary, often very rural settings to the district clinics and the central hospital. From what I saw of urology support today, Dignitas’ achievements become singularly more impressive. It has taken a tremendous concentration of brainpower, clinical expertise and financial resources to allow DI to really function in my mind at a world class level.  To try and scale that to every other, almost infinite clinical entity in a resource-poor healthcare setting seems almost impossibly daunting.  

 

Touring around the office and then the hospital clinic today allowed me to meet some of the faces you see in this video that captures the work that DI does well.


Have a look:

 

 

 

 

Much of the day was spent in the surgical outpatient clinic today at Zomba Central Hospital, ostensibly to review potential cases for me to do in the theatre tomorrow and on other days over the next two weeks.  After years of being trained to understand and then act upon best evidence, I quickly learned today that much of what I would need to rely on was judgement and experience and the imperative to do no harm. I met a PSA with a (likely) falsely elevated PSA of 49 in urinary retention.  It was suggested that an orchidectomy (done for advanced prostate cancer at times) might be a reasonable next step.   We will see if we can get him to void first.  I met a lady with a complex, clearly difficult to fix problem where essentially I offered nothing. She made a point to tell the clinical officer helping me (who doubled as my translator) that she was very happy because someone had just simply talked to her. Every patient who presents with persistent blood in the urine is started on Praziquantal, a drug used to treat the parasite Schistosomiasis, well before any basic workup including cystoscopy is considered.  Rare in the developed world, 'Schisto' is a very common cause of bladder cancer in Africa.

 

I learned that basic labwork is available (although not that PSA) but sending any tissue for biopsy is charged to a patient at 16,000 Kwacha (MWK).  Many may earn only 25-30000 MWK a month which makes such a basic test untenable.  When one learns that 600 MWK= $1CDN the extreme disparity in wealth distribution across the world is immediately apparant.  It is very daunting.  I quickly realized that any delusional notion I had that I could come and 'fix' or even improve things was probably niave at best. I did surgical ward rounds as a consultant in one room where 43 patients were present, many lying on mattresses on the floor!  The women and men I needed to see all patiently waited for me.  Nevertheless with all of the suffering there was a quiet dignity that I saw thorughout the day today.  It was very inspiring. We still have much to be proud of in the healthcare system we have in Canada. It is still excellent as one contrasts it to the majority of the world, although as I have written before, perhaps it is complacency that will be our undoing. Let's not get preoccupied with our usual obsession with 'first world problems'

In any case I have a list of cases to do tomorrow.  We will do some transurethral prostate work, which is new technology for Malawi.  Another visiting urologist brought some equipment in February and did two cases.  Tomorrow will be the further experience.    My new friend Daniel Nyirenda, a terrific clinical officer who is keen to learn will be there to help.  I expect much need for improvisation

Daniel Nyirenda

More to follow


Rajiv

Comments

Posted: June 20, 2016

By: Peter K

It is just staggering to see such disparity between countries like this and ours. Good luck tomorrow Rajiv!!

Posted: June 20, 2016

By: Marvin

Wonderful. Thanks for sharing.

Posted: June 21, 2016

By: Brian

43 patients in one room.... that says it all. Yes, we do have much to be proud of in the healthcare system we have in Canada. Looking forward to reading about Day 2... We can only cheer you on from afar.

Posted: June 21, 2016

By: David Kendall

Thanks for this, and for what you're doing. The world is a ridiculous place where there's infinite funding for endless war, but health care is absent.

Posted: June 21, 2016

By: Esther

Thank you for sharing your experience. It is truly inspiring. Keep up the great work.

Posted: June 21, 2016

By: Tasker

You are truly amazing to face these challenges head on.What stamina.Thanks for sharing

Posted: June 21, 2016

By: Gene Pilato

Thanks for sharing Rajiv! Great story.
Be well.
Gene

Posted: June 21, 2016

By: Keren

Rajiv,

It saddens me to think of the lack of care and resources available in this part of the world. It is uplifting to see you taking the time to help and make a difference. Thank you for sharing your journey.

Posted: June 22, 2016

By: Carlene Ledwidge

Sorry you did not get to do the open case yesterday to teach and
apply your wonderful skills as well as relieving stress from the patients who have been waiting for this procedure.Hope he can be stabilized to get his surgery before you leave.

Posted: June 23, 2016

By: Marguerite Hoffman

As we prepare today for our board meeting which seeks to find the wisest course for DI going forward, I have remembered many times the enormity of my reactions to my first visit to Malawi and the personal transformation that occurred as I endeavored to try to comprehend that we are all one, deserving of the opportunity for health, but the disparity in terms of resources splinters us into Us and Them.

Thank you for going, Rajiv, and I look forward to hearing more about your experiences in Zomba and throughout the SE zone.

All the best,

Marguerite

Posted: July 03, 2016

By: Fareedah Lila

Keep up the good work.

Few things that you may have noticed about us Africans, :

1. Less complain, more action. Very hard working for very little return.
2. Improvise and invent. When we don't have something,
We will improvise with whatever is available or invent something to make it work instead.
3. Sharing. Wether it is food, responsibility, happiness or sadness. Everyone helps.

I could go on and on. But I m sure you will experience it firsthand.

On a different note, would u like to visit some game parks while there?

Posted: July 05, 2016

By: Carla M

This is wonderful what you are doing and very interesting to read how you approach cases where you are. Please keep sharing all the details.

Posted: July 05, 2016

By: Thomas L

Hi Doc
Thanks for including me on your email list.
I am enjoying your updates having been in Zambia about a year ago so have some feeling for the type of country and people that you are seeing. It is amazing how well they survive with how little they have.
I'm sure your knowledge, time and presence will be greatly appreciated.
Hope you get time to travel around and see the country. Africa is truly memorable.
Tom

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