When things go South, by Chiara Pittalis

I miss the days when things go wrong.

Days like when you drive hundreds of kilometres to reach the place where local fishermen have arranged a small boat to take you on a 2-hour journey across the lake to the district hospital where you have to collect your research data. When you arrive, hot and stiff from the car, there is no fuel for the boat, so you turn back to look for some. Then you are off on the boat. But as the shore gets further and further away and you are ready to say goodbye to the land, the boat engine stops. You are surrounded completely by water. You wait patiently in the middle of the petrol jerrycans under the scorching African sun, while the fishermen work eagerly on the engine. They talk fast in their local language, you don’t understand what they are saying but from their worried eyes and the sweat starting to appear on their foreheads you know you are in trouble.

As you are about to lose hope by some miracle the engine comes back to life, just long enough to bring us closer to the shore so we can be rescued. It is now afternoon and you don’t want to try your luck again with the sunlight going down. The fishermen are disappointed and start to make a fuss about the fuel. You try to go around the local boats and small shops to check if anyone is willing to buy the fuel so you can recover the cost, but the quantity is too large for the locals. There is nothing left to do but sit down under the shade of a tree and spend the next couple of hours negotiating with the fishermen. Eventually you reach a deal and you are free to go. When you finally find lodging for the night you are welcomed by an electricity blackout. What a day. You barely manage to get the dust off, but there is a plate of hot Chambo and a beautiful sunset waiting for you outside. Maybe life isn’t so bad after all. Next day, next hospital.

This story is about our experience in Malawi, but I could tell you equally interesting adventures from the other two SURG-Africa partner countries. Like the day when we got lost in Ngorongoro National Park in Tanzania and desperately drove for 6 hours to reach Wasso district hospital, a health facility so remote that emergency patients requiring referral to a larger hospital have to be transferred via helicopter. Or the day when we had to hitchhike to Mazabuka hospital in Zambia, 130+ kilometres away from the capital city Lusaka, because half way through the journey the police confiscated our car.

In Italy we have a saying chi non risica, non rosica, which roughly translates to no pain, no gain in English. I think this is true. Things can go wrong, but when you eventually come back to the office at the end of a field trip, I miss that feeling of satisfaction you get when you are completely exhausted but happy, because despite all the difficulties we have the data that we needed. The teamwork, friendship and support among team members is what got us through the four challenging years of SURG-Africa.

Some members of the SURG-Africa research team, during a conference in Krakow.

Why go through this pain? Why were the data we collected so important? They were important because they allowed us to gather the perspectives of district hospital non-specialist clinicians, who often work in isolation and are seldom asked their opinion. These providers are the ones at the frontline of care in these remote rural areas and nobody knows the situation on the ground as well as them. Yet, while much attention is given to finding ways to boost the number of specialist surgical providers in the cities and support their work, these non-specialist surgical providers in rural areas are often left behind. These imbalances, if we can name them as such, extend to international efforts. How many reports describe in detail the situation regarding surgical specialists, yet when it comes to non-specialists are lacking critical basic data?  For example, do we know exactly how many of them are out there in the districts providing surgical services?

These data were also important to fully understand how to improve the care of patients who come from rural, and often poor, areas and for whom the district hospital may be their only option to obtain life-saving surgery. These are the expectant mothers who have complications while giving birth, the victims of road traffic accidents, the kids fallen from trees or burnt by a hot stove, and many more. A 2016 Malawian study estimated that 79% of patients who lost their lives due to probable surgical conditions never received any surgical care. 

Was all the pain worth it? I believe it was, because in Malawi, as in the other two partner countries, SURG-Africa has given a voice to a large number of the district clinicians who despite all challenges provide these life-saving services to rural populations. These research efforts have helped to shed light on some of the obstacles to surgical care provision in rural areas. We hope our data can support national decision-makers in devising effective and durable solutions to fill these gaps.