QECH is a 1300 bed rambling, shambling affair built sequentially over many years. The new administration building is two stories. Otherwise, it is a series of one story buildings, connected with covered walkways, stretching over a huge, fenced-in area (everything is fenced-in here. The brick manufacturers must be as rich as Croesus.) 1200 beds underestimates the occupancy, as Linda saw 3 pre-mee’s per incubator yesterday. Labor and delivery has 1000 births a month. There are 240 nurses, divided in two shifts, not counting weekends and holidays, for 1200 patients.
As I walked up to the Psychiatry Clinic, Room 6, I was thrilled to see 5 women in uniforms mopping the hallway. The thrill stopped short when I entered the waiting area to find broken benches and a bleak, dark concrete room. There are several rooms used for consultation with patients. All are dark, with tired furniture and no decoration, often a bare lightbulb hanging from the ceiling as the only illumination. Some of the rooms have only partial walls, so privacy isn’t conferred. In one room the ceiling is literally falling in. In the room we used, Stefan mentioned that we could look out the window and watch the rats run up the adjacent eaves.
I am shadowing Stefan for the week and when I arrived he introduced me to the translator, the clerk, and the three psychiatric nurses. Later, I met one of the psychiatry residents who is about to conclude his training (5 years).
Our first 5 patients were (names changed): Timothy, a 27yo agitated, paranoid man accompanied by his younger sister. He has not been sleeping or eating much, shouts a lot, and is convinced that he is the president of the country and that people from his village are envious of him. They are spying on him everywhere and plotting to do him harm. Midway through the interview he got up suddenly and left. Stefan followed him and they talked outside for 45minutes until they both returned and Timothy agreed to take some risperidone and return in two days. We have no antipsychotics in depo form.
Next was Virginia, a pretty, slim 12yo brought in by her mother. She has been having right occipital headaches and bursts into laughter at times. At others she has appeared unresponsive for up to 10 hours. She had an episode of complete “blindness” a year ago that lasted for a day. Our history failed to elicit trauma, either physical or sexual, or a clear picture of a seizure disorder. Her mental status examination was normal. We’ll see her again in two weeks and then consider an MRI (there is a mobile machine that travels between Lilongwe and Blantyre), an EEG, and a neurology referral.
Then a return visit from a 21yo student with a history of cutting, food restriction, and wandering in the night, all night, which is very dangerous here. She was referred for regular psychotherapy, which a very few people provide in this city of over 1 million.
Then we saw 17yo girl who had been very assaultive and possibly had a manic episode a year ago. She looked overmedicated but was otherwise doing quite well, having passed her school exams this Spring. Stefan lowered her medication and will see her again.
Finally, another very agitated man with pressure of speech came in with his mother. He has been off his antipsychotic meds, has HIV, is apparently compliant with antiretroviral therapy, and has been admitted to the mental hospital at Zomba on 5 previous occasions. He agreed to a trial of antipsychotics; he insisted on his sanity and shouted at his mother when she rolled her eyes. He hasn’t, however, been violent.
After 5 hours in clinic, Stefan and I walked to a café for a bite and then he introduced me all around at the College of Medicine, showing me my office. We went over the schedule for the upcoming round of 45 medical students. He has put together an enviable program, certainly infinitely better than my psychiatry rotation at Columbia University in the mid-60’s. Of course, as many of the students will be Medical Officers—general practitioners in rural clinics after completing an 18 month internship following medical school—they will be the first line of treatment for all psychiatric illness. It seems pretty overwhelming for them, to me at least.
Linda’s day was equally amazing. We are going to be working hard in circumstances that will surely test both our abilities and our capacity for hope.
A psychiatrist in Malawi 