Listening to Malawi

16.7.2016

The crepe myrtle is in bloom everywhere in this city, from lily white to shades of pink, lilac, lavender, heliotrope, and royal purple. Extravagant scarlet canna lily blossoms frame walkways. The trees have fledged and walking along the Potomac or among the ancient townhouses of Georgetown in the evening heat is a marvelous segue from cool Downeast Maine to equatorial Africa.

We’re in DC, having completed the first 5 of 8 days of orientation. It has been well beyond expectation. In preparation for our assignments in Liberia, Uganda, Malawi, Tanzania, and Swaziland, the 59 of us have had 8AM-5PM lectures about everything from tropical dermatology (have that one after, not before, lunch) and personally avoiding malaria to pedagogy and learning our (local) language. Mine is Chichewa. Zikomo gambili (Thank you very much.) We are taught by renowned experts in each field. Our curriculum has been carefully—dare I say, lovingly— constructed and we’ll be as prepared as one can be.

The Global Health Service Partnership is a 4 year old joint effort between Seed Global Health, Peace Corps Response, and PEPFAR. The latter is the President’s Emergency Program for AIDS Relief, a magnificent effort conceived of by John Kerry and Bill Frist and enacted by GW Bush. President Obama has continued and expanded it. It has been a game changer in Africa, which carries the largest burden (70%) of HIV/AIDS in the world. The incidence—rate of new cases over a specified time period—and prevalence—the amount present in a population at one time—have dropped remarkably over the past ten years through the efforts of many courageous and hard-working people. (See, I was not dozing in class. I can listen better with my eyes closed!).

We’ll serve a year and then consider, and be considered, for re-enrolling for another year. It is difficult to feel like much more than a medical tourist if you don’t work in the country for at least a year, from my experience. The brilliance of this program is that it builds health care capacity in-country and deters the brain-drain from each country served. Over 20% of US doctors were trained in developing countries. I can understand their desire to come to the US for what they imagine is a better way of life and a better chance for their children to move up the ladder. However, it just devastates a poor country, which is already terribly understaffed with medical personal, to go to the expense of training them and to have them leave. So we’ll be training medical and nursing students and residents in situ, hoping they’ll stay at home.

I’ll join the Department of Mental Health, College of Medicine, University of Malawi in Blantyre, the commercial hub of the country, located in the south at about 3000ft elevation. It is in the Shires. It was settled by Scottish missionaries and is the oldest European-founded city in E, W, or S Africa. It is about the size (a million, give or take) of Malawi’s capitol, Lilongwe. Malawi was formerly a British colony called Nyasaland and is a peaceful democracy. The country is known as “the warm heart of Africa” because of the kindness, gentleness, and generosity of its people. It is a poor, agrarian society, heavily dependent on the rainy season being cooperative (enough, evenly distributed), and was ravaged by AIDS.  It is very beautiful, according to Linda who lived there fresh out of nursing school for 2+ years  with Peace Corps.  She lived in a small village, got malaria, and had a black mamba living in her back yard. “They are very timid; they’ll get out of your way.” Reassuring? (The puff adder who was in her kitchen didn’t and needed to be removed by the gardener. A bite from either of those pets will send you down for the count.)

Yes, I am anxious. I anticipate the workload may be a lot and I worry that there will be so much unaddressed trauma, let alone malnutrition and disease, in kids that it may get me down. The inevitable bouts of diarrhea aren’t enticing, either.  But I know I can be of help and accompanying the anxiety is excitement. I suspect it will be a tremendously positive learning experience for me and in ways I cannot anticipate.  It will be a remarkable shakedown cruise for our new relationship, as well.

As a psychiatrist and psychoanalyst with a subspecialty in child and adolescent psychiatry, I’ll have to get the lay of the land before I teach much. Respect, curiosity, and humility are a fair start for the medical students I’ll teach. I’ll gradually learn what mental illness means and how it is traditionally viewed and treated. Certainly depression, suicide and both physical and sexual trauma will be common. Since medications are in short supply, I can focus on the therapeutic relationship, listening at multiple levels, and basic concepts common to us all like transference, countertransference, defenses, anxiety, and the unconscious. It will be so much fun I can hardly sit at this computer! And we are told that the students are incredibly eager to learn, bright and hard-working. It represent something quite amazing for them to become doctors, I think, emerging as many do from dire poverty and being at the vanguard of a large expansion of health care services in their country.

John Kerry, came by Thursday evening with inspirational well-wishes for us. His daughter, Vanessa, is the co-founder of Seed Global Health and an incredibly energetic, approachable, and far-thinking physician leader  She is rightly proud of what she has accomplished and wanted to show us off to her Dad! I feel extremely privileged to be able to join this party.

[I plan to write this blog frequently so you can sign up here (I hope) to have it delivered to your email if you wish. A more geographically accurate photo will grace future editions.]

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