The Sorrow

 2 October 2016

The Director of Peace Corps, Carrie Hessler-Radelet, together with the Acting- Director of Peace Corps Response and our country director, Carol Spahn, visited the Blantyre GHSP contingent at Queen Elizabeth Central Hospital yesterday. It is the 20th anniversary of Peace Corps Response and one aspect of the commemoration is to visit a few Response sites in Africa. There was a wonderful demonstration, put together by Linda, of her nursing students in action, teaching a group of pregnant women, who sat on mats on the floor as they would in their villages, about the benefits and techniques of breast-feeding, including twins. There were other teaching exercises on the wards, as well. During the introductory remarks Carrie asked the GHSPers for comments. I talked about my initial weariness with the Silver Jubilee Celebration week of the College of Medicine and how I gradually found myself moved that this struggling little country could have started a medical college, and sustained and improved its offerings over 25 years. I then burst into tears, which was a little embarrassing, since the Deans of the Schools of Nursing and Medicine and the Director of the hospital were there, as well. The moment passed and I quickly reviewed my feelings for causes.

Four days ago I was in Room 6 (actually several rooms housing the outpatient mental health clinic) for our new weekly staff meeting. It didn’t happen because two patients were brought in nearly simultaneously by the police.

The first was a stocky, agitated woman of 43, barefoot and dressed in a ripped chitenje and torn blouse. She had beaten up all the passengers on a minibus (15-20). She is a successful professional with a lot of responsibility for people in her job of 20+ years. She also has a long history of Bipolar Affective Disorder with terrible manic episodes when she doesn’t take her medication. She has been in the main mental hospital (at Zomba) several times and clearly needed to be there again. It turned out that her clinic ran out of the depot antipsychotic she has injected once per month and which keeps her highly functional. Room 6 has run out of it, as well. The problem doesn’t seem to be money; rather, it is the inefficiency of the medication procurement process and bureaucracy. Anyway, she kept trying to leave, was on the verge of being violent with us, and, finally, a nurse and the ward clerk held and injected her with a sedative and an antipsychotic. After 15 minutes she lay down on a bench and fell asleep, awaiting family to transport her to Zomba.

The second was a 23yo woman, with a 2 month old infant, found wandering in Lunzu (a nearby village). The baby was seriously soiled and the mother said that since she lived underneath the lake she didn’t have to wash or change the baby. She was dirty and disheveled and terribly disorganized in her thinking, obviously psychotic, and unable to care for the child. Another nurse sat her down in a room and hustled over to the Pediatric Trauma Emergency Center and returned with a clean diaper and a tiny, soft gown for the baby. The nurse then washed the baby and carefully diapered and dressed him and gave him to the mother who, with instructions, was able to nurse him. Then the nurse washed his soiled garments and helped to settle the mother. The latter will also have to go to Zomba; social services will find a temporary placement for the baby. Of course, there was no gas for the ambulance to transport her and, since the police brought her in, she had no family to take her. So it would be a long wait on a hard floor awaiting her family, if they could be found, to take her on a minibus, assuming they have the fare.

I then responded to a consultation request by a young, Indian-Malawian intern, a graduate of the College of Medicine.  A 62yo woman was admitted to the Medical Service with “weakness”and the doctors wondered if she was psychotic. With the help of an incredibly bright young nurse, I found the woman asleep on a “floor bed”—-ie, mattress on the floor—with her guardian (niece) sitting on the mattress beside her. Mind you, this is a crowded ward, with not an empty bed and many guardians.  The beds are about 14 inches apart. With effort she was aroused and after taking a cursory but sufficient history and performing a minimally invasive physical examination, I determined: 1) she was in atrial fibrillation with congestive heart failure; 2) she had a major stroke 2 years ago from which she was recovering until a month ago when she had another; 3) she did not have a mental illness; 4) she was likely throwing emboli from her fibrillating atria; 5) there was precious little to be done for her, since anticoagulation and cardioversion were out of the question in this environment; 6) she could be given some aspirin and sent home to await more strokes, perhaps a terminal one.

In addition, I heard yesterday from one of our number that the electricity at the hospital in Mangochi had been cut the other night.  There was no petrol for the non-working-anyway hospital auxiliary generator and several women with obstructed labor had died, along with their infants, because no caesarian sections were being done in the dark. (I’m unclear as to why flashlights weren’t used.)

I haven’t talked much with anyone about the terrible hopelessness for people here, these lovely, bright, hard-working people. They continue to be friendly, to try to get enough food, to laugh, and to care for each other.  And to be receptive and engaging with the likes of us, who can always just jump on a plane and decamp if things get beyond our tolerance. I think my tears were a summation of the sadness I feel when seeing all of this. What accident of fate occasioned my birth as the healthy white child of two physicians, a citizen of the United States?

Yet as I write this, I look out and see several spectacularly lovely jacaranda trees on the opposite hillside in full purple splendor.   I plan to meet with the Dean of the College of Medicine in two weeks to think together about how this mental health training program can be sustainable and grow. It doesn’t feel sustainable now. The head of department is a very bright and savvy educator, a tough and compassionate teacher, and an indefatigable worker. Yet he’ll head back to UK in a year or two and I cannot imagine that they can find a replacement who can keep up his pace. I couldn’t.

This experience is like facing high surf at the beach. There is a thrill when you can successfully oppose the waves and re-surface after they break over you; but there are some that just knock you down. I must be approaching the low that our instructors anticipated with us.

The frangipani tree in our yard is about to bloom and the rains are only, hopefully, a month off. The brown land will soon green itself.  Let us celebrate nurses for their intelligence and compassion and tenacity and resourcefulness.

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