Orthopaedics Research in Malawi

An Interview with Kiran Agarwal-Harding

Kiran Agarwal-Harding, MD, (KAH) is a former T-32 training fellow at OrACORe who has spent the past two years researching the delivery of orthopaedic trauma care in Malawi. Kiran talked with Research Assistant Liz Stanley (LS) about his motivations for pursuing global orthopaedics research, his projects in Malawi, and the impact he hopes to make through his work.

LS: To start, could you tell us what the goals of your research are?

KAH: The primary focus of my research is on improving musculoskeletal trauma care capacity in Malawi, although I think the lessons learned through this research probably have generalizability to other low- and middle-income countries all around the world that struggle with similar issues.

Malawi is one of the poorest countries in the world and has a high burden of injuries, especially traffic-related injuries, with the fourth highest traffic-related mortality per-capita in the world. The population is very young: more than fifty percent of the population is less than eighteen years old. Eight-five percent of the population lives in the rural areas and sixty to eighty percent of people rely on farming to put food on the table themselves or as their primary industry. Understanding how this country deals with this huge burden of injury in a young population that relies on their limbs to feed themselves and their families was very compelling for me.

Understanding how this country deals with this huge burden of injury in a young population that relies on their limbs to feed themselves and their families was very compelling for me.

Kiran Agarwal-Harding, MD

During my COMET tenure, I visited Malawi several times. I’ve been trying to understand how the limited resources that do exist could be used to improve care without external input, as well as how to advocate for increased investment in healthcare by Malawi’s government itself and donor organizations. I think that this external input will ultimately be essential for improving the health system.

To understand the current resources, we examined what was available for managing patients with musculoskeletal traumatic injuries at each district and central hospital nationwide.

Another example is our ankle fracture study. We just performed a pilot knowledge assessment in which we asked providers how they manage ankle fractures. Here in the US, ankle fractures are generally treated with surgery; however, in Malawi, there are eleven orthopedic surgeons managing a population of almost nineteen million people. By necessity, most care in Malawi is nonoperative, which may not be the ideal treatment for most patients. Getting more patients surgical treatment requires understanding the referral network, understanding what resources are available, and prioritizing or triaging certain cases. The knowledge assessment was the first of a number of studies we’ve designed to address these issues. This study identified basic knowledge deficits related to injury identification and treatment that can be addressed through education initiatives. Referral and treatment strategies can also be standardized and optimized within the context of resources we know to be available in Malawi.

LS: Aside from these studies of the healthcare capacity for treating musculoskeletal trauma and the knowledge assessment of ankle fracture treatment, what are some of the methodologies that you’ve been using?

KAH: The first study that we did used a multivariate model to understand what factors are predictive of delayed presentation among patients with fractures presenting to outpatient orthopaedic departments in Malawi. Delayed presentation is a big problem because when people come to the hospital late, it’s more difficult to manage their injuries. If you can understand who is coming late, then perhaps it shows you a little bit why.

We’ve also used qualitative research methodology to examine health system navigation. I interviewed sixteen patients with closed femoral shaft fractures. It was a diverse group of adults to try to get a full spectrum of experience. Now that the interviews are complete, we’ve learned that femoral fractures can be devastating for the patient and their family: kids have nowhere to go, their education ends up getting derailed, they don’t have food or housing, the patients lose their job, and they have no source of income when they leave because they can’t work. So, these are life-changing injuries that push patients into these vicious cycles of poverty. If we don’t at least have the bare minimum of care available in these hospitals, then how can we take care of these patients? In our nationwide capacity assessment, we looked at the components necessary for skeletal traction.

Now that the interviews are complete, we’ve learned that femoral fractures can be devastating for the patient and their family: kids have nowhere to go, their education ends up getting derailed, they don’t have food or housing, the patients lose their job, and they have no source of income when they leave because they can’t work.

Kiran Agarwal-Harding, MD

We also wanted to understand the financial burden of femoral shaft fractures. We have an ongoing collaboration with UCSF as well as Beit CURE Hospital in Malawi through which we are a part of a prospective study that follows patients with femoral shaft fracture for a year after their injury. My small piece of this study is at enrollment, six months, and one year, asking these patients about the financial burden of injury. We’re asking about transportation costs to and from the hospital, their income level before and after the injury, their household income level before and after, whether their family members had to leave a job to take care of them because of the injury, what happened to their kids, what their housing situation is, whether they sold stuff to pay for their care, did they accumulate debt, these sorts of things. We’ve collected a little bit of data so far and the study is still ongoing, but it’s already clear that the effects of injury are really heart wrenching.

LS: What has the biggest challenge been for you in doing research in this setting and getting such granular detail?

KAH: I think that the biggest challenge of any of this is just time and space. This research cannot occur without being in Malawi. I could not have done the capacity assessment without visiting these hospitals. I could not have done the knowledge assessment without sitting down with staff members and understanding the challenges they face. You cannot do this kind of research without knowing the people and the system. You can’t do it without the connections or without the people knowing that you’re not just there to further your own career by writing some paper in your ivory tower, that you’re doing it to build capacity there in a really genuine and authentic way. So, I think that being half in Malawi and half here has been a challenge. And it’s been wonderful. To be here, you can write really well, do great analysis, and you have an amazing group of people here. But, it’s always a balance, which I’m sure I’ll struggle to find for the rest of my career: how do you find a balance between being there, and understanding the situation, and being here, and trying to raise awareness and design something that can effect change in a meaningful way. So I think that I will always be straddling two different worlds, given the roll that I’m in, which is a blessing, but can certainly be a challenge.

This research cannot occur without being in Malawi. I could not have done the capacity assessment without visiting these hospitals. I could not have done the knowledge assessment without sitting down with staff members and understanding the challenges they face. You cannot do this kind of research without knowing the people and the system.

Kiran Agarwal-Harding, MD

I have always come away from my time in Malawi so impressed with how dedicated my collaborators are to trying to change their health system and to reveal the mistakes and problems so that they can be addressed. That’s been really inspiring to me. There’s a certain style, in Malawi, to being that’s very endearing. Malawi is referred to as the warm heart of Africa. It’s a beautiful country with resilient, brave people who face tremendous challenges. It’s very easy, as a Westerner, to go into these environments and to see the deficits, to see people leaving work early because it’s so frustrating, to see people being slow, and to get frustrated or angry and think “Oh, these people are lazy,” or “These people don’t want to change or learn.” And I’ve seen people talk that way. To me, it represents a lack of cultural understanding, and also a lack of personal understanding. You must recognize your own prejudices and your own inflexibility in order to understand the context that you’re working in. So, I think that the biggest challenge with all global health research is always understanding the context and toeing this line of “What’s my role in this circumstance?” When I go to Malawi, is it my job to try to take care of patients and make care better? Is it my job to teach people? Is it my job to do research? Where do I fit into this system in a way that doesn’t rob people of their own capacity, but rather builds something meaningful for the future?

You must recognize your own prejudices and your own inflexibility in order to understand the context that you’re working in.

Kiran Agarwal-Harding, MD

LS: With all of these different things that you’re juggling and all that you’ve learned, where do you see your career going in the future?

KAH: Good question, it’s been on my mind these days too. I have two more years of residency left, so my focus now is on learning to be a good surgeon. That desire comes from my experience of being in the operating room in Malawi and wishing that I had more to teach, and that I could contribute in a meaningful way to complex cases. That’s my next focus.

At Harvard, I’ve been working on gathering all the people who have this interest in global orthopaedics. We have projects and collaborations going on in Malawi, South Africa, Colombia, Uganda, and Haiti. And “global” orthopaedics is not just international: we have huge problems with healthcare in this country, and see many of the same issues, particularly among rural communities and communities of color. A big example is access to care for Native American communities: Indian Health Services in many parts of the country are really strapped for resources and don’t have great access to specialist orthopaedic surgeons. So, what I’ve tried to do with some of my co-residents is bring together people with an interest in improving access to orthopaedic care and get them talking. We call ourselves the Harvard Global Orthopaedics Collaborative, HGOC. The idea is to get together and talk and to give opportunities for residents who are junior and want to learn, and form a strong base from which we can effectively work with our collaborators around the world. We need to know what the problems are, we need to identify the talented people who can address them, and we need to come together so that we can support one another to address these things. I just hope that my career is going to be somehow involved in that. We’ll see.

LS: Well I wish you the best of luck, thank you for taking the time to speak with me!