Yesterday at 3:58PM, after a considerable increase in the afternoon rolling thunder, there was a terrific squall. A dense, dark thunderhead approached from the east, and the skies opened. Heavy tropical rain, with some hail thrown in, poured down, filling gutters and drains and ditches. I now understand the complex system of concrete drains surrounding every house and on every street. It was thrilling, as wild Nature can be. We watched it from our front porch, pelting Linda’s herb and nasturtium garden, knocking blossoms off of the frangipani tree and causing the frogs to begin croaking for the first time since we arrived in August.
We spent the morning—3hours—walking the 30 minutes into the boma (old town), doing Saturday errands and buying fruits and vegetables in the market for the week. We discovered DAPP, a Danish-owned thrift store—bales of used clothes are sent from wealthy nations to every town and village in the country, supporting a huge cottage resale industry—where all clothing sells for no more than $1.30 and all shoes for no more than $2.60. I needed nothing so bought nothing; that is the way on a volunteer salary, buy from need not for fashion or whimsy. It suits me just fine—fewer choices in the morning when dressing for work. The Blantyre Central Market is pretty large and has almost everything you could want, including handmade furniture, pottery, hardware, clothing, and acres of fresh food. Lychees are in for a month or two, in huge sacks: one kg for 90 cents. It is the third favorite fruit for me after Philippine mangoes (especially from Guimaras in the Western Visayas) and Thai mangosteen. Sitting with a bowl of lychees and a good friend on the porch and steadily emptying the bowl is a rare pleasure, peeling and slurping. Anyway, we bought several kilos, plus a mountain of tomatoes and avocados and lettuce and string beans and cukes and the rest and hiked them all home. After re-hydration, I was off on my bike to the local grocery store for the few items not found in the Central Market. Later, with a break in the storm, I dropped off our hill to Kamba (tortoise) Market to buy mangos, bananas, and 3 kg of goat meat. A Seed Global Health visitor will be with us tomorrow night for supper. Visiting firepersons take all of the GHSPers out to supper when they are in town; it is, however, much more fun and easy to talk with everybody if we do a potluck supper at someone’s home so we’ll host this one with Linda’s now-famous goat stew. In any case, both goat meat vendors had closed up shop just before the rain and there were no bananas so I settled for mangoes and went home.
The path back up the hill crosses the Luperi River, really a small, fetid stream during the dry season. It was a torrent and huge mats of grass and debris were washing downstream. The dust has washed from the leaves of trees and from the air. There is promise and hope again. After that good rain, many farmers will plant their fields and pray it continues steadily. Being a farmer dependent on the whims of Nature (and the adverse actions of Man) is a perilous pursuit. There aren’t enough wild animals, roots, and berries for us all to be hunters and gatherers, despite the fact that their timecards have shown they worked about 16+/- hours per week. So we depend on farmers who depend on the weather over which they have no control. Another compelling argument for a woman’s choice and birth/population control.
The elderly gentleman I wrote about two weeks ago, whose diagnosis I missed, died. When the nurse called him with the MRI appointment, the family said he was no longer. It is questionable if I made a different diagnosis and ordered the MRI two weeks ago if it would have made a difference. He may have had an advanced malignancy or another cause for his dementia. And, while there apparently is a neurosurgeon in Blantyre, he is gone for the month so placement of a shunt, if indicated, wouldn’t have been possible. But it doesn’t really matter, in the sense that you can get 100 diagnoses correct but if you miss one, it feels terrible (to the patient, especially, but also to the physician). I always want to learn from my errors and I have from him. I view the many dementia patients I see differently, looking harder for reversible causes. I saw an HIV positive housewife with progressive dementia last week; without other risk factors, like alcoholism, a strong family history, hypertension, etc. I sent her directly to the ED for a spinal tap. Lo and behold, she has cryptococcal meningoencephalitis, for which she is now being treated. So I made a good call. But it is a burden of medicine, since we all will make some errors, that clever diagnoses do not erase the erroneous ones. I suppose the other major burden for the physician is being unable to cure at times. I understand the powerful motivation over the ages to improve our knowledge and ability to help the ill.
I purchased a few toys and a basket in which to carry them for our new Pediatric Mental Health service. We’ll separate children—-up to 16yo—-from the adult clinic and see them in a room in the Pediatric ED. The latter is quite spacious and the rooms are quiet. There are no acutely psychotic patients yelling or thrashing about with their hands tied behind their backs, as often is the case in Room 6. I imagine it would be pretty scary for a child to be in the midst of that. The separation of the children was Stefan’s (the Director of Mental Health) idea which he’s been working on for awhile. It is the first shred of a specific public mental health service for children in the country, other than those provided by the NGO’s. One Stop is a remarkably good program for the evaluation and treatment of sexually abused children; it has a number of centers throughout Malawi and is funded, in part, by UNICEF. There are, of course, numerous orphanages, in part because of the AIDS crisis, but I suspect the quality and quantity of specific mental health services, even at the best of them, is very limited. A far cry from our incomplete but very extensive system of caring for children’s mental health needs in the US. From here, it is something to feel proud of, the will to care for children in the US.
As a final note today, four medical students failed their 6 week psychiatry rotation and will have to repeat it. One of them asked to speak with me so we met on Friday. A very sweet, smart, hardworking guy, he is the oldest of 4 in his family. He comes from a tiny, remote village. He said that he’d had a lot on his mind that distracted him during the rotation. Could you tell me about it? I asked. His uncle, who has been paying his upkeep (He has a full scholarship for tuition.) notified him that after December he could no longer support him. So he has been worrying and scrambling to see how he can raise the money. His father hasn’t been around for years. The student has sought work but there are no jobs that pay enough to make a difference and most are menial labor, which wouldn’t work with his studies. These students study hard. He’s never failed a class, let alone a course, before, he says. I wondered if he was the only medical student from the village. Yes. Couldn’t he talk with the chief and see if the village could help support their Favorite Son. Oh, no. Many people are envious of him. So much for The Warm Heart of Africa. Linda has been approached several times to support nurses in training. Peter is tough and resourceful and will come up with the money, somehow. In a country this poor, everyone needs help. A man in Kamba Market yesterday approached me, wanted my phone #, wants to be friends, and wants to go to the US except that the transportation there is so expensive. My first impulse is to support the medical student, pick up his tab. But I am giving a lot otherwise and the $ need is insatiable. We’re already supporting our guard’s son in secondary school. Another nagging, potentially corrosive burden; I can’t pay for everyone but I don’t want to be insensitive to their needs. It’s a daily occurrence.
The country will soon become lush with greenery.
A psychiatrist in Malawi 