We had a Department of Mental Health meeting this week. It sounds rather grand but the department is tiny, including the Director, Stefan, the only Ph.D. psychologist, Chiwoza, the Administrative Assistant for one of the NGO’s funding the psychiatry residents, Dalitso, and myself. As modest a group as it is, Chiwoza announced the beginning of two exciting processes: the development of the first Masters Degree in Clinical Psychology program in the country and the possibility/dream of our own building on the College of Medicine campus, an Institute of Mental Health. There is committed space on campus to build the latter. These, coupled with the start of the first Alcoholics Anonymous group in Malawi, the Child Psychiatry Clinic, and The Blantyre Child Study Group, are very exciting to me. It all feels heady and sustainable. I commented to Stefan that I couldn’t imagine him returning to the UK to subject himself to the strictures of psychoanalytic training, given the possibilities of making such a difference here. And yet I recall how much I enjoyed my work at home. The most satisfying experiences I have now are similar, working one-on-one (plus guardian, often) with patients. It is just different here, feeling such a pressing (?crushing) need and being able to whittle away at it significantly. From 0 to 1 feels like a much bigger step than from 4735 to 4736. To do this in the US I would have had to suffer all the boring and unnecessary crap one does as an academic/researcher or as a government employee/policy wonk. Here I can structure my work life almost entirely as I wish, although I’m tired of giving the lecture on Psychosexual Disorders to the medical students. No role-playing for that topic!
The first meeting of The Blantyre Child Study Group, 10 of us, was a success. People are hungry to learn and share. They want to meet every two weeks! Half are Malawian, only two of us are temporarily here, so I have every hope the group may continue after my departure. Perhaps I can even Skype myself into the meetings after I leave. I am applying for a small grant to allow me to form two similar groups in other cities—-Lilongwe and Mzuzu. It lifts my spirit to feel I can improve something here.
When the students evaluate patients in the Mental Health Clinic, I allow them to get into the hour+-long evaluation on their own, not breathing down their necks. Thus, on Tuesday morning I visited a boy in the Burn Unit, Joseph, with whom I consulted last week. He was at home in Mozambique when a gasoline tanker stopped in the village. The driver was illegally selling some gasoline; after a period of time he said everyone could have it for free. There was a run on the tanker. One of the runners no doubt had a lit cigarette and the tanker exploded. It killed 76 people outright. Joseph saw his uncles trying to rescue his cousin and ran to help. The cousin burned to death and he and his three uncles are in our burn ward in adjacent beds. Joseph has suffered 3rd degree burns over 25% of his body and 2nd degree burns over another 20%. They asked us to see him because he had been very agitated on the ward. When I first saw him he was as they said, not responding to me at all, sitting up, lying down, biting himself, shouting he wanted to go home, and singing at the top of his voice. After carefully evaluating him with the resident, we decided to give him a low dose of an antipsychotic, feeling he was delirious from the burns, the sensory deprivation in the ward, and the trauma of his experience. I have seen him twice since and he is improving dramatically, speaking English with me and responding appropriately most of the time.
Joseph’s father and older brother were by the bedside. Joseph was sleeping but easily aroused. He talked comfortably, in both Chichewa and English, with me and his relatives. Suddenly, he opened his eyes dramatically, fell back on the bed and rolled back and forth, shouting “Heehaw, heehaw, heehaw” etc. After a few minutes he then sat up and was completely alert and normal again. He obviously was either having a post-traumatic re-experiencing, a conversion disorder, or was malingering. His father and brother are convinced that a Spirit is talking through him, telling them what they should do. They want to take him out of the hospital for 2 days to a traditional healer in their village. They assure me they’ll bring him back in two days for readmission for his burn treatments and physiotherapy. The entire family, including his grandfather, agree with this plan. If it can be done with medical safety, and I see no reason that it cannot as they only change his dressings every 2-3 days, I am in favor of it. I cannot say how best to heal his mind.
I also visited the boy I described in an earlier post as having had typhoid misdiagnosed and definitive treatment delayed. He perforated his bowel, required 4 abdominal surgeries, and looked straight from Auschwitz, he was so starved. Innocent was his name. He wasn’t on the ward. He’d been discharged a couple of weeks ago and the nurse told me he was eating a lot, gaining weight, and walking! Remarkable. He was an extremely bright boy, obvious even when he was in extremis.
I saw the 14yo panga knife victim on Thursday in the Pediatric Mental Health Clinic. Wonder of wonders, he’s had no more seizures, is eating and sleeping well, is playing soccer with his friends (he likes playing goalie), and is totally present when I see him. There is no dissociation and he even smiled several times. I am stunned. I thought he was lost to this world. These people, Malawian villagers, are unbelievably resilient. I’ll keep him on a dose of phenobarbital at bedtime for no. Clearly his brain injury from the attack leaves him with a lowered seizure threshold. It is probable that my using risperidone, even a tiny dose, triggered the seizures. I am truly astounded at his recovery. And so happy for him and his mother, who is remarkably caring.
As I walked back to Room 6 to hear the medical students present their cases, I was feeling badly about the three boys and their life-changing misfortunes. Ambling along the endless corridors with windows on either side looking out on the open spaces between hospital wings, I could see the many guardians and caregivers lying on mats or in the dirt, mostly women in colorful chitenjes, getting a bit of sun before resuming their vigil at their relatives’ bedsides. I then heard an utterly beautiful harmony. Three ladies in uniform mopping down the long hallways as they do every day were singing together, each a different part, easing their boring and tiring work with beauty in song. This is what I experience repeatedly in Malawi: unfairness and ugliness and hopelessness and misery tempered by kindness, and beauty, and persistence. What these people might accomplish if only…..the list is very long. That, for me, is the problem.
A psychiatrist in Malawi 