22 January 2017
As we squeezed into two of the three tiny seats in row 2 on the “Big Bus” to Dedza, the ample man in the third offered me the Saturday “Nation”, one of the Malawi dailys. Reading it was much like other issues: descriptions of government officials being dismissed or investigated for corruption, tales of young girls in villages having to perform sexual favors for their chiefs or aid workers in order to get their ration of food, etc. I thought I’d write about that but as we got off the bus, it turns out he gave me the paper before he’d read it, so I returned it to him and don’t have it as a reference.
Dedza Pottery is a very large compound 5 km. outside the town of Dedza. It has been around for decades and the potters make lovely and whimsical stoneware pottery. There is a lodge and restaurant, as well, and Linda and I spent two nights here before I headed north to Mzuzu to teach some child psychiatry to clinical officers and nursing students at St. John of God College and to learn about their remarkable (by reputation) programs for the mentally unwell, the addicted, and mentally retarded (Learning Disabled) children. Linda will return to Blantyre to teach this week.
The Pottery is in a lovely setting, surrounded by lawns and flowers and trees and, beyond the property, hills. We happily walked here after the 3 ½ hour bus ride and the countryside became increasingly beautiful, always shockingly green and punctuated with small (800-1200ft) mountains. The area has been clear cut but there has been an active reforestation project here for 10 years and the young pine forests soften the rocky slopes of the hills. We climbed to the top of Dedza Mountain with a guide; the view of all the undulating greenery below was refreshing after the plastic trash and deforestation in a lot of the South.
During the past week before leaving Blantyre, I evaluated a man, 50yo, who was lying on the concrete floor of the clinic for a couple of hours, screaming. We were very busy and after briefly assessing that he wasn’t perishing, I left him to his several friends and family members and worked my way down the list of patients who had signed in earlier than he. When his family finally carried him in to see me, as he apparently couldn’t walk, it was quickly clear that he didn’t have a functional psychiatric illness but was delirious. Why? It turns out he has been HIV positive for some years, although his family had not been told. I needed to get him back to the ED where he could have a lumbar puncture to look for signs of infection and be admitted to the hospital for definitive treatment of his HIV/AIDS and whatever secondary infection might be consuming his brain. He’d been in the ED the night before and they, seeing he was deranged, sent him to Room 6 (Psychiatry Clinic) to be seen the following day. We really need to do an in-service with the staff there about distinguishing delirium from schizophrenia or mania, as this happens not infrequently and it delays treatment considerably.
Room 6 received two consultation requests. One was for a woman, 42yo who’d had pre-eclampsia and who’d given birth to her 6th child and gone home, only to become disoriented, confused, mute and not taking food or fluids after 3 days. She tried to harm her child, as well. After two more days the family brought her back to the hospital where she was found to have extremely high blood pressure. Treated with two antihypertensives, she, astoundingly, completely cleared and was discharged by the time I went to see her. [It was been wild in clinic this week, with an extra patient load, two of the three nurses out, no residents present, and only one psychiatrist, me. As a result, I was late to get to the consultations.] From reading the consultation request I thought she had a post-partum psychosis but it turns out she had eclampsia psychosis without a seizure, also known as “Donkin psychosis”. I have never heard of it but looked it up online.
After I found her bed empty (She was only in hospital for 2 days before she recovered.), I tried to locate her medical record. I was sent to the room where the Gyn ward’s records are kept. The clerk pulled out two large cardboard boxes full of loose papers and proceeded to go through them, finally pulling out 3 pieces stapled together with her name on them.
That is how the records are delivered to Central Record Storage. Electronic medical records would be wonderful, except there are no computers and often no electricity.
The other consultation request, whom I also didn’t see, was a boy with epilepsy who had a fit and fell into a cooking fire. He was about to have an above-the-elbow amputation of one forearm and hand because he had so badly burned the nerves and tendons that they were irreparable. He’ll be seen by the other psychiatrist who is now back in town from holiday.
I’m having a new sign painted for our clinic, on my dime. Our current one says, “Room 6 Psych”. It is written, as the other signs in the hospital are written, with red letters on a white field, but it must have been painted in place because the red paint is dripping. It looks like an invitation to a horror movie.
Mine will have the same regulation color scheme but will be allowed to lie horizontally until it is dry and will say, “Room 6 Mental Health”. The director of the hospital, when I said I would pay for it, was happy to approve it. Tiny steps.
My trip to Mzuzu was an eye opener. The further north you travel in Malawi, the less congested it becomes. There are many fewer people per square kilometer in the north and, consequently, there are still beautiful standing forests. Of course, there are the denuded hills but a vigorous reforestation project has been underway. When the government shut it down a few years ago, however, some disgruntled employees set fire to great swaths of pine trees, killing them. I guess if desperate and hopeless and angry enough we all will foul our own nest.
I was late getting off in the morning when I was to meet Amelia, a GHSP volunteer teaching community mental health nursing in Mzuzu. I walked a bit of the 30 minutes to the hospital, realized I wouldn’t make our meeting time of 7:20AM, and jumped on a bike taxi. Basically, a bike with a padded seat over the rear wheel and foot pegs. I had no bike helmet so if Peace Corps had seen me, I’d have been in hot water. It was pretty scary actually but certainly got me to the House of Hospitality quickly.
St. John of God is a standout series of programs: a lovely 26 bed mental hospital on a hill, a separate 30 day inpatient drug and alcohol detox center, and, across town by the College, a truly amazingly comprehensive program for Learning Disabled children and teens. They are starting mental health services for children and adolescents, in addition to the LD program. It was fun teaching the Clinical Officers, although at the end after thanking me, their instructor requested that the next time I would please give a lecture. I quickly said that I have never felt lectures were particularly useful for teaching, favoring a more interactive approach. I then realized that may have been offensive and said that I can certainly focus my remarks more the next time. The Mental Health Nursing students presented 4 different cases that we were able to discuss; they were a lively bunch.
The best part of the experience for me was driving to a small district clinic on the road down to Lake Malawi. It was a brick building sitting in the woods constructed by the community with a slab concrete floor, two rooms, no water or electricity, and window frames without windows. It was packed with people sitting quietly and patiently on benches. The nurse and the village representative made a list of who was there, charts were pulled from the wooden box we brought, and the nurse, the clinical officer, and Amelia all saw patients for 3 ½ hours. Most were established patients, most had chronic mental illness or epilepsy (which is treated by mental health professionals, not neurologists, in the developing world) and required medication adjustment or refills. It was an efficient, humane operation. St. John of God goes to all the district clinics once per month to provide these services. True community mental health. Basic but effective.
The three GHSP nurses working in Mzuzu took great care of me. We ate at Midlands, a really good and inexpensive Indian restaurant, at the chapatti lady’s spot in the midst of the market where two of us had lunch for about a dollar total, and at a couple of wonderful restaurants run by ex-pats in beautiful old houses set in gardens outside the city. There is a great chitenje market and I bought Linda 4 meters of black with electric blue dragonflies, thinking Ken the Tailor could make a stunning cocktail dress with it. We’ll see.
My bus ride back to Blantyre, all 10 hours of it, was entertaining as I chatted with a very interesting man who’d completed medical school at the College of Medicine, hadn’t practiced for reasons I didn’t explore and he didn’t offer, and was now finishing a Masters in Public Health at a university in Durban, SA. He gave me a really good perspective on Malawi’s slide downhill over the past 15 years. Even though the prevalence of HIV is considerably down, the population explosion and the fact that the country cannot feed itself has wreaked havoc on the economy and the environment.
We are going to have to leave our house, I fear. One of the others in our compound was invaded by 6 armed men who stole batteries and other things from the 3 cars parked there. Peace Corps is concerned about our safety, having had some very serious incidents over the years with regular volunteers (mostly people just out of college). We’ve each protested strongly but are also looking at other houses which Peace Corps will have to rent. We feel totally safe here, with bars, gates, guards, alarms, padlocks, and so forth. I’m certainly much more concerned about getting hit on my bike, being in a minibus crash, or being able to exit the house if there is a fire. We love our porch, our view, our spacious dwelling, and the possibilities for a really good garden but are working for an organization and must toe the line.
The inauguration was pathetic. The women’s marches all over the world have been inspiring. It is so sad to see our magnificent democracy, for all its flaws, being led by someone so unsuited to do so. And is he in Putin’s pocket, as it seems? But the mobilization of so many gives some hope. We unfortunately are reaping what we’ve earned by leaving so many poor, unskilled for this economy, and uneducated in the dust. It takes a dose of narcissism to run for president. His tops the heap, however, and will hopefully lead to his collapse soon.
Given all this, I’m going to stay another year. I realized, thinking about it this morning, that if I leave at the end of my contract in June, I’ll feel like I’m going home with my tail between my legs, slinking off. I can’t say I won’t feel the same after two years but at least I can see a few things through that I have begun. The needs are greater than I can ever hope to substantially improve, in a real sense. But I can try to do a bit. I also feel that I have no pressing work drawing me home. It is nice to feel needed here.