Posted by: rhoban | March 14, 2009

Day 13 – Trauma in Malawi

I’m just trying to get my head around this place. Every time I turn around, I get an earful about a completely different activity that UNC people are engaged in.

Surgery and trauma

Jon Samuel and his wife Lillian Brown (we'll hear about her work on Monday's broadcast)

Jon Samuel and his wife Lillian Brown (we'll hear about her work on Monday's broadcast)

Doctor Jon Samuel took me on a tour of Kamuzu Central Hospital. Samuel is a third year surgical resident who’s spending a year as a research fellow in Malawi. He’s also working as a surgeon there, seeing more and more varied problems than he would have back in the States. Here he describes some differences in the kinds of problems he sees and how they get treated here, versus in the States.

In this minute-long interview, Samuel talks about treating conditions he’d never see in the U S.

And in this piece (:49), Samuel talks about working in the pediatric surgical ward.

Samuel’s work here has been to compile a registry of all the trauma cases that come into the hospital. The aim is to help get hard data on the kinds of trauma that kill Malawians and what are the best treatments for them. His work is basic epidemiology – counting and compiling data in order to determine what’s the best thing to do about a problem.

Bad drivers ?

Malawi has THE world’s highest rates of motor vehicle death per kilometer driven. Here’s a smattering of the data:

Number of accidents per 100 million vehicle-kilometers:
1) Malawi 2730
2) Rwanda 1764
3) South Korea 510
10) Portugal 194
33) United States 74

In short, Malawi’s accident rate is 37 times higher than the US. The death rate per 100 million vehicle-kilometers is 1117. That’s four times higher than the next country, and many times higher than that of the US. Only 2.3 people out of every thousand actually have cars in Malawi, compared to 481 people per thousand in the US. So that means there aren’t that many drivers Malawi, but they’re really, really bad, or, what’ s more likely is that more people die per accident than in other places.

That’s why everyone, and I mean EVERYONE I talked to about the country said the same thing: “Don’t travel at night!!!” No overnight buses, no car trips after dark, except for driving a mile or two to go out and eat. And then, only with great caution.

Why so many accidents?

One of the reasons behind those trauma numbers is Malawi’s physical infrastructure… it’s part and parcel of the poverty that marks the country. The roads in Malawi are awful. There are few paved roads and what roads are paved are often a thin layer of tar and crushed rock pressed into compacted earth underneath. There are no shoulders to the road, which becomes a problem because traffic consists of not only motor vehicles, but bicycles, ox carts and pedestrians. When it rains, what little shoulder there is to the roads crumbles as the compacted earth at the road’s perimeter washes away. Potholes form easily during rainy season too.

Photo credit: Eve Vitaglione

Photo credit: Eve Vitaglione

Roads in Malawi are few, and only half are paved. For comparison, the Malawi’s about the same size as Arizona. But the National Forest Service in Arizona has 28,000 miles of roads, compared to 9,600 of roads in Malawi.

When roads exist, they’re not well built. I had the opportunity to watch to road building – it was taking place so that we could drive on it. The road consists of a long ribbon of dirt that’s raised about 6-8 feet above the ground around it. The dirt is graded, then a thin layer of tar gets sprayed onto the dirt, followed by a layer of crushed rock that’s shoveled onto the tar. Then, rollers push the crushed rock into the dirt and tar.

Just a thin layer of gravel is applied over packed dirt to create a 'paved' road

Just a thin layer of gravel is applied over packed dirt to create a 'paved' road

It’s a recipe for potholes, abrupt and crumbling shoulders and motor vehicle accidents. Once off the main road, it’s just dirt paths… or mud, depending on the season.

Poverty works to make roads unsafe in other ways too. Cars are held together with crude welding, they often lack one or both headlights, tires are often bald, maybe underinflated and people pack themselves into dangerously overcrowded minivans and pickups to get around. I think every car I saw in Malawi had a cracked windshield. Minivans intended for 7 or 8 passengers look like something from a silent film– there’s seemingly no end to the number of people who climb out when vans stop.

And, of course, roads have, at most, one lane in either direction. And everyone uses the roads, cars, buses, trucks, people, shepherds, cow herders, pedestrians, children, bicyclists, bicyclists hauling pounds of goods in the backs of the bicycles, dogs. You name them, they’re in the road, sometimes all at once. So, reckless passing often becomes an occasion for motor vehicle accidents.

Take a listen as Samuel describes what happens when there’s a mass trauma (1:02):

Cars in Malawi take a regular beating

Cars in Malawi take a regular beating

Often accidents involve crowded minivans that collide or overturn as they run off the road. Ambulances are few and Samuel has determined through his research that it takes patients on average 4 hours to get the hospital in a public ambulance. Patients arrive more quickly if they’re in a private vehicle – that takes on average two and a half hours. But… years of research shows that patients do best if they arrive in the first hour post-trauma. After that, mortality rises dramatically.

Samuel says he sees all kinds of traumas from vehicular accidents… drivers, passengers, bicyclists and pedestrians. No one’s immune.

Here’s a short video (1:33) I shot out of the window of a car (so it’s a little noisy). It shows the conditions of a typical road in Malawi.

Samuel is finding that next in the numbers are assault victims, frequently young men who arrive in greater numbers around the time they receive their paychecks. Samuel says alcohol is frequently a factor.

He says there are some women who admit to being victims of domestic violence. And finally, Samuel says, there are people who come in and are victims of ‘mob justice.’ Take a listen (:31):

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