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. Furthermore, 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:
- 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.
- 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.
- 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
- 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.
- 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.
- 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.
- 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