Visiting Nkhata Bay district hospital, Malawi

Kiran Agarwal-Harding, MD

Harvard Combined Orthopaedic Residency Program

PGY4

Visiting Nkhata Bay district hospital, Malawi

The journey from Lilongwe to Nkhata Bay can take up to eight hours by public transportation. You follow the main highway M1 through the flat, dusty outskirts of the capital until you hit the rolling green countryside and stone hills between Kasungu and Katete. You pass by the pine forests near Kaningina Forest until you reach Mzuzu, the last big city before the road east to the lake. Nkhata Bay sits between green hills and forest that meet the clear blue water of Lake Malawi, which stretches to the horizon like an ocean.

On the morning of February 7th I set out by car to Nkhata Bay district hospital, which sits about 25 kilometers outside of the town, along the main road. The rainy season this year had been a dry one, causing widespread loss of crops throughout the country and fear of a coming food shortage. But this morning, the elusive rain arrived briefly; grey clouds sweeping in over Lake Malawi on to the shore, with scattered showers that drifted southwards as the sun began to rise. The main road was under construction, currently without tarmac, and had turned into a river of mud. Trucks filled with Carlsberg beers and Coca Colas were trapped and being pushed by large construction bulldozers spontaneously repurposed to serve as emergency rescue vehicles. Lines of traffic stretch in both directions with the brave or foolhardy few taking the risk to slip and slide though the mayhem to the paved road on the other side.

The operating rooms at Nkhata Bay District Hospital

The operating rooms at Nkhata Bay District Hospital

I finally arrived at the district hospital, albeit a bit later than expected. At first I drove right by, thinking the gleaming white buildings and security gate protecting a large verdant campus must have made this a fancy tourist lodge or foreign NGO headquarters. However this was indeed the new district hospital, now just three years in operation, donated and stocked in part with the aid of a foreign government.

At the hospital, I met with the orthopaedic clinical officers (OCOs) stationed there. We sat together and I introduced myself and the work I was doing in Malawi. We discussed my two projects currently in proposal phase: 1) a qualitative research study, involving interviewing patients with femoral fracture to understand their barriers to seeking care after injury, and 2) a capacity assessment study, relying on OCOs to report the availability of essential resources, infrastructure, and manpower to successfully treat musculoskeletal injury. I shared my plans to send the capacity survey to them in a few months’ time, and my intention to return to Malawi in June for further data collection and to conduct the patient interviews there at Nkhata Bay. The OCOs assured me that there were plenty of patients with femoral fracture typically on the wards, who I could invite to participate in my study.

I was then led through the hospital on a tour of the facilities pertinent to orthopaedic trauma care. Many of the facilities were new and seemed to be working well. However, the OCOs who guided me made it clear that problems existed, making their work much harder.

We started in the Accident and Emergency Department, where two rooms with two stretchers apiece were being used to manage all trauma patients. A triage and waiting area had been repurposed as another room to manage traumas.

All the chairs had been removed from the room, a large nursing triage desk stood stripped and abandoned in the corner, and two stretchers stood against the wall. All in all, I’d counted six stretchers in the department. Every once in a while, a truck or minibus will flip on the road, and the department will be overwhelmed with trauma patients.

New X-ray machines in the radiology department, all currently nonfunctional

In the Radiology Department, most of the X-ray machines had stopped working shortly after the hospital opened. The radiology team had resorted to using the portable x-ray machine for the bulk of x-rays in the hospital. The hospital had also been supplied with two c-arms – highly coveted devices in Malawi that can provide intraoperative x-ray and make available a variety of treatments otherwise out of reach for patients. At Nkhata Bay District Hospital, however, these c-arms were the workhorses of the x-ray department, used in the x-ray room with the expensive, yet nonfunctional, formal x-ray machine pushed to the corner. 

New X-ray machine that is nonfunctional, with a c-arm being used as a work-around

In the pharmacy stockroom, stacks of boxes lined the walls and large shelves filled the air-conditioned room. Unfortunately, rather than contain medications, most of the boxes were filled with male condoms donated from the Netherlands. Medicine on the shelves also appeared sparse. The hospital had no liquid morphine and was out of most antibiotics. The orthopedics team had been giving doses of chloramphenicol to patients prior to surgery, but after a bad batch killed a patient, they had stopped using perioperative antibiotics all together. 

We then entered the pediatric ward, separated into two wings for the medical and surgical patients. Large glass windows allowed for an easy view of the wards from the central nurses station. Behind the glass of the medical ward a large family had gathered, mostly young and middle-aged women who were all weeping inconsolably. In the surgical ward, half of the beds were being used for patients with malnutrition. In a few beds, young children with orthopaedic injuries lay. One young boy had fallen a few days prior and sustained an elbow fracture. The standard of care for this kind of injury is usually surgery. However, without the resources to provide that level of care, this young boy was in straight arm traction. The plan was to wait for the swelling to go down, then place him into a splint. It remains unclear whether patients like him go on to achieve acceptable function in their arms long term.

In the adult wards, many patients also lay in traction, mainly with femur fractures. Without Braun splints to control the position of the leg during skeletal traction, the orthopaedic team was foregoing skeletal traction for simple skin traction. Several of the patients on the wards had had their skin traction removed as the tape had begun to tear and irritate their skin.

While some aspects of care seemed to be lacking, others were in abundance. In a stock room in the surgical department, buckets full of new surgical instruments filled a large shelf. Many of the instruments were for surgeries the OCOs didn’t have the training to perform, and would wait there in buckets until a visiting team could come to use them. Boxes overflowed with new cervical collars, of which the referral hospital in Lilongwe was in desperate need.

Nkhata Bay District Hospital

My visit to Nkhata Bay district hospital made it clear that building a new hospital does not guarantee effective delivery of care. Problems inevitably arise and must be addressed continuously. The hospital cannot stand alone, but rather must integrate into a larger system, which needs constant attention and maintenance to run smoothly. I hope that documenting these challenges will provide a roadmap for improving the musculoskeletal trauma care capacity of Malawi in the future.