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May 22nd 2017

Building a Urology Program in Zomba, Malawi.

Building a Urology Program in Zomba, Malawi.

I have previously described visiting Zomba Malawi in June 2016.   As a member of the board of Dignitas International it was an opportunity to explore the great work that we do, understand some of the underlying challenges of global health and also begin to evaluate and explore the development of a urology service at the Zomba Central Hospital. I have written about it elsewhere.  That trip to Malawi was followed this past January with an excursion to Kenya and Uganda, again in an attempt to better understand the challenges of global surgery.


As one begins to study surgical care on an international scale the problem not surprisingly is massive, almost overwhelming.   The core issues around surgical care extend far beyond having the equipment and expertise to do a procedure.  The lack of an integrated surgical triage system, severe anaesthesia shortages and a national healthcare system that barely copes at the best of times are glaring realities. Furthermore, constant efforts to fend off the scourge of corruption siphon away much time, energy and resource. Nevertheless, beginning with one’s own area of interest and expertise seems like a good place to start- “Start with what you know”.   It is with that in mind that I ventured back to Malawi in early April to develop a program in urology defined by a training element to better advance healthcare in this region through the lens of a men's health program.    I also joined a group of my fellow board members at Dignitas International while there to help develop and refine the vision of that great organization moving forward.  I will write about that separately.


In February 2016 my old MGH colleague Bob Macmillan (pictured left) came to Malawi and brought some surgical equipment to provide what in the industrialized world passes for routine urological care. Urinary symptoms as men age are common and the relief of those symptoms, sometimes requiring a simple surgical procedure, is readily available around the world. Bob MacMillanFurthermore, in the developed world with access to medication and good primary care, many men can be managed effectively without ever needing surgery.  In Malawi, where there is no such infrastructure, a man will present only late, requiring surgery but with severely limited access to that care. The lack of availability of fifty-year-old technology as well as the expertise to use it essentially renders these men chronically disabled.  In the southern region of Malawi, Zomba Central Hospital serves a population of roughly 4 million people.  It is estimated that in this region there are at least 2000 men, unable to void on their own, walking around with chronic indwelling catheters.   Many have had catheters present for years.  The need is clearly great.  Acknowledging this issue does not even begin to look at tackling the enormous challenges of prostate cancer and bladder cancer in Africa.


 Zomba Central Hospital




As one thinks about how a program in urology might look like, it is worth considering some objectives:


  1. Supply and stock some necessary equipment.  This includes operating scopes and ongoing supplies.   Ensuring proper maintenance of such equipment will be a challenge in the longer term, requring some creative solutions.
  2. Provide basic urological care in Zomba.   Ideally, this would involve a ‘rotation’ of about 6-8 urologists coming for 1-3 weeks over the course of a year.  Rotations would be spread evenly throughout year in order to ensure no unduly long gaps in service. 
  3. To train the onsite clinical officers to carry on with simple TUR  (endoscopic) work between visits from visiting urologists.   This would help to address the backlog of men suffering with chronic indwelling catheters
  4. Identify a Malawian medical graduate and surgeon to train in a College of Surgeons of Eastern Central and Southern Africa program (COSECSA). This is a three-year program after two years of basic membership training.
  5. Work with the Malawian Ministry of Health to commit to a salary for our fully trained urologist to then come back to Zomba Central Hospital and anchor the urology program further.
  6. Integrate the University of Toronto Urology residency into the Zomba urological services.  This could be set up on a rotational basis, likely on elective for 4-6 weeks and include the provision of urological care while perhaps integrating some general surgery and obstetrical experience for the residents.
  7. Look to partner with other organizations to help better deliver urology care through a lens of men’s health.  This could have the effect of improving compliance in the management of chronic diseases such as hypertension and diabetes and enable men to take ownership of their health, thereby improving directly maternal and family health.  Some novel ideas around prostate cancer detection could also be explored



At first glance these objectives seem very ambitious but I am pleased to share that some progress has already been made.  With the University of Toronto’s support, I have established a nascent global urological surgery program that will serve as the vehicle to support and fund this work.


More information can be found by following the link here:



Having spent some time last month in surgery using the equipment that Dr Macmillan brought was crucial.  However, in order to perform the work better and most importantly train the local clinical officers (CO), will require much more.   Duncan Goche is a capable young surgery CO, interested to learn as much urology as he can.  The challenges of equipment I think are significant and can best be solved by working with our partners in industry to help supply and support us.   The U of T fund’s primary purpose would be to support the remaining service and educational initiatives.  It will not be to used to purchase equipment.    In addition to a possible roster of Canadian urologists, I have also established a relationship with a German group, led by Dr Henning Mothes, that will aim to supplement our efforts.    Two members of this group were planning to leave for Zomba in May.   Dr Macmillan himself plans to go perhaps at the end of the year.  Others will hopefully follow



With Duncan Goche


The most important piece of our project remains establishing and promoting the development of specialty physician skills locally.   Only then can we hope to scale our efforts and the resources that will be required to make it happen.  The clinical officers are the easy initial group to focus on but training a Malawian surgeon within an African training program to become a urologist will ultimately make this more sustainable.  In that regard we have had some success as well. Dr Wanengwa Chisenga has been selected to go to Lusaka, Zambia, where there is an established urology program that meets the standards of  COSECSA, the body that credentials specialty surgical care in most of Africa’s Rift Valley countries.    A Malawian medical graduate, Dr Chisenga has completed his basic surgical training in Malawi.  He will now spend three years in Lusaka and then come back to the program that we will hopefully have further established in Zomba.  He left three weeks ago!    My aim would be to leave urology at Zomba in his hands after he is credentialled with perhaps some ongoing outreach from consultant surgeons in Canada and Germany.  The senior residents at U of T will continue to be supported to supplement the service further.  In time as we study the outcomes from this project we can use the lessons learned to develop urology programs elsewhere in Africa.                                            


It is early days and I suspect how we define ‘success’ might be 5-10 years down the road but in the 16 months since Dr Macmillan started things off it has been a nice start!


Finally, I would like to acknowledge that the project to date has relied on significant input and advice from Dr Frans Zoetmulder, the tireless surgery chief in Zomba as well Dr Eric Borgstein for matters related to surgical training and COSECSA.   I thank them both.














With Dr Eric Borgstein in Blantyre                                                                           Dr Frans Zoetmulder at ZCH


 Support for the University of Toronto Faculty of Medicine Urology Global Health initiative can be found by clicking on this link





Posted: May 23, 2017

By: David Graves

This is wonderful work you are doing Rajiv! It is uplifting to read about it.

Posted: May 23, 2017

By: Tasker Kelsey

Excellent blog.I congratulate you for all your wonderful volunteer work.Proud to have you as my Specialist.

Posted: May 23, 2017

By: Ed Collis

Humanity benefits greatly from your great, unselfish, works.

Posted: May 23, 2017

By: John Bemrose

So much need in the world, so few of us attending to it. Thanks for your work, Rajiv. And for news of the wonderful Dignitas.

Posted: May 23, 2017

By: Charlie

Fantastic!!!!!--- your commitment and enthusiasm come through very clearly.

Posted: May 23, 2017

By: John Bemrose

So much need in the wider world, and too few of us addressing it. Thanks for your good work, Rajiv, and for your news of the excellent Dignitas.

Posted: May 23, 2017

By: Paul Fahey MBA, CFA

Your work is inspirational and very important Rajiv. Thank you so much.

Posted: May 23, 2017

By: Joy Gooding

Thank you for writing this blog and raising awareness of the challenges and opportunities for health in that part of the world. Your amazing work will change the lives of many. Wishing you well.

Posted: May 23, 2017

By: Robert Eisenberg

First steps are the hardest, but everything transformational started with little steps. To do nothing because one can do little is the greatest cynicism. What you are doing is inspirational - congratulations and thanks.

Posted: May 23, 2017

By: Patricia Campbell

Tremendous job in seeking to advance care for peoples in that part of our world! Great ideas and team spirit helping to make this a success.
Thanks for your selfless endeavours!

Posted: May 23, 2017

By: Tayo Denton

Awesome work, Rajiv.

The planned objectives look well considered and even better, that it has started. That elephant is looking smaller by the day :)


Posted: May 24, 2017

By: Sheila Sontz

So proud of you for making something from nothing. You found a need, and are filling it. Hopefully other docs will join in and take the opportunity to be part of something great there. Well done Raj.

Posted: May 25, 2017

By: Tim Allan

Thank you for the blog and your amazing humanitarian work! I guess it is one step at a time. All the best and continued success!

Posted: May 26, 2017

By: Carlene Ledwidge

Interesting read.Your time knowledge and caring will be greatly appreciated by the people in need.Good job!

Posted: May 29, 2017

By: Fareeda Lila

Hi Dr. Singal.

I just read your Malawi blog. I don't know where to start so I will just say what comes in my heart.

Be blessed !!!!!!

As you know that I am an African, born and raised in Tanzania. Urological care is a subject that is very dear to my heart as I lost my father to prostate cancer.

Loved your list of initiatives. All very doable when done in small steps.

From my perspective, there are a lot of experts in medical field in Africa. But the challenge is getting them to work in rural areas for a fraction of the pay they can make in big cities or private organizations. Prevalent corruption also takes its toll on equipment and medical supplies.

If I may, I would like to add to your list a couple of things please.
1. Full time employee with limited medical knowledge to keep an eye on the efforts as well as equipment.
2. Paying some or part of someone's education with a contract that the said person will work in the rural area for a minimum of 3-4 years at a reduced pay.

These are just my thoughts.

I would love to help in any way that I can. Although I can't do what you or your team are doing. But please be rest assured that my prayers are with you.

Be blessed

Fareedah Lila

Posted: June 09, 2017

By: Thomas Moore

Very impressive in so many ways. You are certainly doing your part Rajiv. One step at a time. No doubt that in the 10 year horizon, unimaginable improvement will have occurred.


Posted: December 21, 2017

By: Dr. Allen Chiura

Dear Dr Singal. I am a US trained urologist from Zimbabwe. I moved back home 6 years ago after living in the US for 30 years. Your sentiments about your emotions during the AUA in San Diego were not yours alone. I come to the AUA every year and each year I feel progressively more and more disconnected as that is no longer my reality.
I am working in our large government central hospital in Harare and have a private practice also. As you correctly state its a daunting task but with small steps progress can be made. We have a urology residency program and are now producing a qualified urologist every two years.
I applaud you for caring enough to come to the continent and committing to improve the urological services available in that part of Malawi.
For my part, I am closer than you are and would be happy to find a way to help. Feel free to email me.

Allen Chiura

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