Extreme poverty exacts its toll on the most vulnerable. These are variously defined, of course, but I think of children, mothers, and the mentally ill, especially, since I have experience with each group.
We just visited the Bwaila Psychiatric Unit in Lilongwe, a freestanding facility built in the 1930’s. It is the district government inpatient mental hospital for the area, and often draws from much more distant regions that have no such resource. It is a squat brick and concrete structure with a waiting room, an exam room, a nursing station, a men’s dorm of 14 beds, a women’s dorm of 11 beds, a courtyard for each dorm, and a small separate building used for multiple purposes. One of the latter is for the patients to watch the TV, which is fastened high on the wall in a welded protective cage with bars so thick ¼ of the picture is lost. There are two seclusion rooms, one off of each dorm, and steel-barred gates, as one would find in a prison, shutting the patients in their respective dorms. And bathrooms. And an open fire in the backyard where they cook the nsima and vegetables for the patients to eat at noon. Breakfast and lunch are brought from the hospital in the area.
While there are 25 beds, they often have 50-60 patients at a time. Staffing includes, per daytime shift, two psychiatric nurses, janitor attendants, and a clinical officer (equivalent to a physician’s assistant in the US, although with the responsibility of a physician) who is there some daytime hours. Patients have no occupational therapy, other than working in the very nice vegetable garden in the back yard once per week. There is no staff to conduct group or individual therapy, virtually all the patients are on medications (when they are available, which they may not be for months at a time), and they languish in their courtyard by day and dormitories by night. They are fed and kept safe. They are not bothering their communities at the moment. No physician or psychiatrist visits the facility.
Patients often try to escape, and succeed. During our visit one man was hoisting another on his shoulders so the latter could climb onto the high wall surrounding the courtyard. From there they walk to the lower wall surrounding the women’s courtyard and jump to the ground. Two male attendants shouted at them and they stopped their attempt.
Many are there for psychosis, mostly diagnosed with schizophrenia. A few are labelled bipolar disorder. Some enter with depression and suicidal ideation, although rarely after attempted suicide. Suicide in the developing world is most frequently completed with the ingestion of organophosphate fertilizer, it being available in the agrarian environment and known to be very effective. Many of the patients, whatever their underlying diagnosis, come in having smoked chamba(marijuana) or in states of alcohol withdrawal. There often is no diazepam in the pharmacy for several months, so seizures must be common. They are not routinely given thiamine on admission—“Their families buy it if they can.”—so I suspect Wernicke-Korsakov Syndrome is not uncommon. Although the HIV/AIDS prevalence is 10% of the Malawian population (and likely more in this subgroup), patients are not routinely tested for HIV on admission. If they are psychotic or have a delirium, they are treated with Thorazine and if they do not respond, HIV testing is done. If positive, the patients are put on anti-retroviral therapy and the nurses have noted that within two weeks their mental state usually begins to clear. Medically ill patients are referred to the nearby government central hospital; generally, they are sent back quickly as mentally ill patients are not welcomed there, according to our nurses. There is no capacity to do routine lab work at the mental hospital, other than a rapid malaria test. If lab work is needed, it must be sent to the hospital.
There is very little funding for much of anything, let alone mental illness, here. There are 4 psychiatrists in Malawi, reportedly all in Blantyre. I can see why our staff and instructors throughout the orientation here have told us just to observe for the first 6-8 weeks; there likely are good reasons for doing things as they do in a resource-deprived setting. We were encouraged by the examiner for the Medical Council of Malawi to mentor and correct bad practices, however.
Showing up on time and with regularity, lecturing, conducting teaching rounds with students and patients, having a hopeful attitude, being an entrepreneur in seeking small improvements to the care that is given, and self-care may comprise most of the year. It is bleak, in a way, and yet I feel excited to begin teaching and learning. It would be interesting to discover a self-care mechanism for staff and the medical students; that could be a valuable contribution and project for the year.
The circumstances certainly have the advantage of stretching my comfort zone!
A psychiatrist in Malawi 