Malawi

UNC Surgery Partnership with Kamuzu Central Hospital: Strengthening Clinical Care, Training, and Research with a Long-Term Vision

Kamuzu Central Hospital (KCH) is the tertiary referral center for the central region of Malawi, serving about 5 million persons. Estimates of the hospital’s size range from 600 to 1000 beds; actual occupancy always exceeds intended occupancy. The hospital, centrally located in Malawi’s capital, Lilongwe, has five floors, four operating theatres, one ICU with four beds, and a radiology department with plain films and ultrasound (no CT, MRI, or trained radiologist). The only pathologist in Malawi works in Blantyre, about 200 miles to the south, and consequently pathology results take three months to obtain.

The University of North Carolina began work in Lilongwe almost twenty years ago through the efforts of the Division of Infectious Diseases. Over the years, this has evolved into a large-scale clinical care and research program known as the UNC Project. Additionally, the UNC Institute for Global Health and Infectious Diseases and the UNC Center for Global Initiatives, both committed to improving health in North Carolina and around the world, have been key supporters of work in Malawi.

In June 2007, Jonathan Samuel (PGY 5, General Surgery) travelled to Lilongwe, Malawi to meet with surgeons at KCH. Recognizing the great potential in forming a research collaboration, he worked over the next year with a group of UNC faculty members to develop several research initiatives. One project involved improving the trauma registry at KCH in order to better understand injury epidemiology, while the other project focused in particular on burn injury in Malawi.

With support from the NC Jaycee Burn Center, Dr. Samuel is currently conducting a one year research fellowship in Lilongwe. Upon arrival in July 2008, it quickly became apparent that there was an unmet clinical need and opportunity for training, so UNC Surgery in Lilongwe took an active role in these areas as well.

Feb. 2007 Update: Dr. Samuel has been awarded a fellowship from the Fogarty International Clinical Research Scholars Program that will enable him to spend an additional year in Malawi.  He is joined in his efforts by Adesola Akinkuotu, a UNC third-year medical student and Doris Duke Fellow.  See Dr. Myron Cohen's Global Health Update and Dr. Samuel's  entries on the Institute for Global Health and Infectious Diseases' blog site.

Clinical Care

UNC Surgery is taking an active role in providing clinical care at KCH:

• On several occasions, Dr. Anthony Charles, Dr. Clara Lee, and Dr. Carol Shores have visited KCH to perform specialist care, benefitting a number of patients who otherwise would have been neglected. Their visits also provide valuable learning opportunities on various surgical techniques by the staff at KCH.
• Dr. Samuel is taking call on average twice a week under the supervision of Dr. Arturo Muyco, Head of the Department of Surgery at KCH. This greatly assists with the general and trauma surgery clinical workload, and is an unmatched clinical experience.
• Lastly, a skin mesher, provided by the NC Jaycee Burn Center, has significantly improved skin grafting at KCH. Skin donor site morbidity is minimized because the mesher allows for greater coverage, and skin graft take is improved because meshing avoids accumulation of seromas and hematomas.

Discussing a patient on rounds in the pediatric ward (left, Dr Samuel; center, Dr Muyco)		Patients lined up in the recovery room after a busy day of operating

Training and Education

Dr. Samuel and Adesola Akinkuotu, a Doris Duke Research Fellow and 4th year UNC medical student in Lilongwe for one year, have organized a twice-weekly seminar series for the KCH Department of Surgery. Prior to this, KCH Surgery grand rounds, morbidity and mortality conference, or CPD (continuing professional development) activities were non-existent, so this was a vital improvement to the department.

Additionally, the Norwegian embassy began a collaboration with KCH Surgery to develop a training program in surgery for graduated medical students form the Malawi College of Medicine. UNC is now assisting with this effort, as it has become a much larger task than originally anticipated. The program is accredited from the College of Surgeons of East, Central, and Southern Africa (COSECSA), and the first trainees will likely enroll in August 2009. UNC faculty hope to play a key role in this program by assisting with lectures and clinical training.

Lastly, Dr. Samuel initiated a lecture serieson basic surgical concepts for the Malawi College of Health Sciences 3rd year clinical officer students. These clinical officers are the backbone of health care in Malawi, providing a significant portion of care at tertiary hospitals. At more rural district hospitals or health centers, clinical officers are often the most senior staff. Instructing these students on topics such as basic trauma care, benign anorectal disorders, and interpretation of radiographs, greatly improves their ability to care for Malawians. Additionally, this venue provides another opportunity for visiting faculty to participate in didactics.

Research

UNC strengthened the trauma registry at KCH by expanding the dataset, improving data collection, and implementing an electronic database. Andres Villaveces, at the UNC Injury Prevention Research Center, and Dr. William Miller of the UNC Departments of Epidemiology and Medicine, provided significant expertise. Beginning in July 2008, the database captured a full spectrum of injury-related data including mechanism and transport mode, injuries and treatments, and outcome. Preliminary results (.pdf) were presented at the American College of Surgeon's 2008 Clinical Congress, and the 2008 American Public Health Association Annual Meeting. The registry data is useful in a number of contexts, including assisting KCH to determine how best to improve outcomes, providing a summary of the trauma burden at KCH as required for COSECSA certification for surgical training, and informing a working group of injury stakeholders in Malawi organized by the World Health Organization.

UNC is conducting burn research at KCH. The two aims of this study are to (1) better understand the immune response to burns and how HIV affects this, and (2) to examine burn care at KCH in order to identify and correct weaknesses negatively affecting outcomes. One area being addressed is perioperative management of skin graft patients in order to minimize graft loss.

Lastly, UNC began a study of sigmoid volvulus. Sigmoid volvulus is common in many tropical countries in the developing world. Hypotheses include dietary factors and an anatomic predisposition. UNC is beginning a case control study of sigmoid volvulus to determine if those with the disease differ anatomically from those without the disease.

To read more about UNC in Malawi, see the Notes from the field blog.