A Lazy Weekend

9 October 2016

I saw a 10yo boy in clinic this week. He’d “gone crazy” in the morning, breaking things, assaulting people, requiring restraint, hearing voices telling him the neighbors wanted to kill him, etc. Totally normal developmental history, excepting he doesn’t know his father and had recurrent bouts of malaria with high fever and delirium every 6 months from 1 1/2yo to 5yo. He’s been doing well in school and gets along well with his sibs. He is very beloved by all, including his stepfather, as the baby in the family. When he was seen in the Peds ED, he continued agitated and irrational. When I saw him two hours later he was completely normal: calm, rational, thoughtful, and shaken by the experience. No drugs involved. I don’t know what to make of it. Could I be seeing my first case of temporal lobe epilepsy? He’ll be back in two weeks and we’ll get an EEG. Did he have some scarring from the (cerebral) malaria, predisposing him to seizures?

There was a suicide of a boy at a private secondary school here and we are consulting with them about it. The school did all the right things, planning a strategy, alerting staff to be sensitive to kids who are struggling, having a full disclosure assembly as soon as the kids were back in school, contacting local therapists to see kids who seemed particularly vulnerable. We’ll likely be involved in running a staff/teachers’ group and one or more groups of children the school has determined are particularly vulnerable. There seemed to be only one clue he left, calling a friend and saying “Goodbye” the afternoon he did it. His parents were separated. Although he said that he was unhappy with the school last year, his first, he had gone out of his way to let people know how much he liked it this year.  What a waste.

I’ve just finished a good read—From Microsoft to Malawi—about an attorney, Michael Buckler, who joined the Peace Corps as a village teacher here after his marriage went south. It is a terrific view of the strains and adaptations Peace Corps Volunteers experience. I happen to think that the Peace Corps, overall, is probably our most successful foreign policy initiative. My hat goes off to those Volunteers living in villages, working creatively and hard as they adjust to a new culture, in conditions of deprivation: no electricity, no internet, no running water, a monotonous diet, dust everywhere until there is mud everywhere, social isolation from Americans, and reflexes that are all wrong for this culture. “The hardest job you’ll ever love.” is the motto.

What we are doing is Peace Corps “light”—-a comfortable house with running water most of the time, electricity and, thus, good internet half the time, a supplement to our Peace Corps Response Volunteer salary, and a reasonable amount of personal privacy not to be had in a village. There are wonderful fruits and vegetables in the markets to be had for a pittance. Pork is less than a dollar a pound. Goat is a bit more. There are small supermarkets, as well. And, still, it is difficult. It’s hard to function as a psychiatrist treating (mostly) major mental illness without a reliable supply of medications in extremely sub-standard rooms with little privacy. The ceiling tiles have fallen down in several of our rooms from leaks so there is only a tin roof between you and the sun. The rooms are steaming by 11AM. And, worse, I can see a lot of sky through them so they will be unusable during the rainy season. Stefan has notified Maintenance several times but no help is forthcoming. And at home the boundary issues are ever-present with our guard. She brought her darling 6yo daughter to work today (Sunday) and after introducing her to Linda, shooed the little girl into our house. “She wants to see it.” Linda said, “I am working, writing. George is ill in bed.” It could be flattering; she mistakes us for Malawians. But I think she has a particularly intrusive style. Just keep setting limits.

I had a young woman, a mother of 2, with severe mania admitted to the medical service for fluid and electrolyte replacement. She came to us having calmed considerably from her assaultive, agitated state of two weeks previous, now sleeping through the night. But she, by description, developed pseudo-Parkinsonism from the Haldol she had been given. When she came to us, she couldn’t walk and was wetting and soiling herself. A brief minute’s evaluation revealed that while she may have had pseudo-Parkinsonism from the Haldol, her mania had evolved into catatonia and her relatives couldn’t get any fluid or food into her. I visited her a day later on the medical ward with her grandmother and uncle in attendance. She was totally obtunded, unresponsive to verbal cues, and her iv had pulled out. I notified the charge nurse, filled out the requisite papers, and she was transferred to Zomba Mental Hospital where she can have iv’s and electroshock treatment. I can see why the mortality rate from inadequately treated catatonia is so high.

I also saw a 10yo boy in consultation on the Peds ward. He was stomach-breathing very rapidly during the day, but not at night. The pediatricians had worked him up adequately and found no physical cause for it. My psychiatric assessment was likewise negative; a happy, very bright, loved, very successful boy with no history of trauma and lots of friends.   He wants to be a doctor. My suggestion is for him to go home and return to Room 6 in 2-3weeks and see if the rapid breathing continues.

I got quite ill yesterday coming back from the market. It was a long walk, carrying a watermelon, a large papaya, and another bag full of vegetables. I just collapsed when I got home, with a pretty high fever, a headache, and the gi’s. I wondered about malaria, I felt so awful but the gi’s didn’t seem to go with it and my headache wasn’t as severe as I would have expected. So I skipped supper with the Scots and Brits—Linda went—and slept all day and all night. I am feeling better now.  Linda cares for me well, making broths, giving me Sprite and Coke, and even a home-made scone which seemed to agree with me.

It is so much easier to be a couple here. Caring for each other, intimacy, division of tasks, and just being able to talk. We are the only GHSP couple in Blantyre; there is one in Mangochi and one, with a new baby, in Lilongwe. One of the shared housing pairings has blown up and one volunteer moved out permanently. It is pretty stressful and unless your stars align I can see how that happens. What do they say about the people who do Global Health work? Martyrs, missionaries, misfits, and ….?  Even though it is difficult, I am not suffering and I see this as a wonderful opportunity for me. Some of our number never stop complaining about the working conditions, the living conditions, the language, etc. It gets old very quickly.

We go to Liwonde National Forest Preserve for 3 nights next weekend. We’ll sleep in a safari tent cabin in a tree. It is Malawi’s premier wildlife preserve, with abundant birds, large mammals, etc. Viewing platforms over water holes. I think what we’ll see in S. Africa over 2 ½ weeks around the Christmas holidays will likely be more astounding and certainly our Botswana/Namibia 5 week trip at the end will be fabulous. But it is nice to work into it. Over 1000 hippos in the huge Shire River, as many crocs, a huge variety of antelope, lions, warthogs, black rhinos, leopards, etc. I’ll report.

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