The Well Is Dry

27 November 2016

Not literally dry. I just have nothing pressing about which to write. But don’t stop reading here—this is a fertile country, the rains have begun in earnest, and I’ll come up with something.

Like mudguards for my bike. I ride it everywhere and it saves me 30 minutes a day minimum, travelling between home to the Queen Elizabeth Hospital clinic, to get a bite of lunch somewhere, to the College of Medicine, to the market, and back home. Now that it is raining and the roads are soupy, I don’t want to get striped so I walk. But I am going to construct some mudguards out of 1.5 liter plastic bottles cut in half and attached with zip ties. I think it will work wonderfully, if perhaps it looks a bit funky. The closest, and only, bike store is some miles away in Limbe and, besides, it seems like a good idea to recycle these bottles. Berkeley has at least one bike store in every neighborhood. With bikes that would be the envy of any Malawian bike owner.

My child study group is coming together, with 11 potential members, half of whom are Malawian which is crucial for me. It is difficult to overestimate the number of NGO’s here, all with skilled personnel and varied agendas, all pumping some money into the economy through jobs, and all subject to folding their tents and going home. I feel Malawi must be for, and run by, Malawians. Ideally my job will not be needed in a few years—the initial charter for GHSP is 5 years, I believe. The idea is to train locals to take over the academic and training jobs in health care. Our three psychiatry residents (I’ve only met two, as one is training in Cape Town where they all spend two years.) are excellent and will be able to take over in a few years and do a fine job.

While I am greatly enjoying my 25 minute psychotherapy sessions with, now, 4 children, Linda points out that it isn’t how I will best use my time. It is a pleasure and a luxury for me to do something I enjoy so much. But she’s right (as she frequently is!).  I’m here to train, to develop something sustainable so when I leave in June it won’t collapse.  So I am going to begin to train medical students to do brief therapy during their 6 week rotation with us.  I’ll include the one available psychiatry resident.  I’ll supervise them for each case. It feels pretty weird to me, since I have spent so much time in training and learning how to conduct a therapy, to expect I can just throw them in with the kids and hope for the best. But, talk is talk and if I can get everyone to listen to the kids, to facilitate their talking, to identify themes and concerns, and to just be non-judgmentally with them, it will be a whole lot better than no one doing it. And who knows, maybe a few will get hooked and in 5 or 6 more years there will be some fully-trained child and adolescent psychiatrists here.

We are writing exam questions, preparing exams. The Brits, from whom this program is descended, are pretty crazy about exams. Written exams with Single Best Answer (Remember to alphabetize the answers and each must have some validity for the question.), Extended Matching Items (4 questions, 8 answers, don’t forget to rate all questions for difficulty as follows: What percentage of poor students would be expected to answer this question? 30%, 0.3? 80%, 0.8?), and Short Answer Questions (with a prescribed format.). Then OSKIE’s, the directly observed examination using real patients or actors. Then Long Case Questions. There are Final Exams for the 4th year students every 6 week rotation, Integrated Exams for the 5th year students in January, Mock Exams for the 5th year Residents in Psychiatry in January (to prepare them for the real deal), and their Qualifying Exams in March (Not sure I have all the names correct.). With banks of questions, for both written and oral exams, of varying degrees of difficulty. Constructing these is a major effort—and pain. I haven’t taken an exam since my Child and Adolescent Board exam in Detroit in 1994 but I don’t think we were so obsessed with test questions then. Still, we culled out 4 students who failed the last rotation because their performances were substandard and there was consistency between the written exam, the oral exam, and the long case write-up, so I guess there’s some validity to the process. They will be better physicians for repeating the psychiatry rotation.

We just came back from a wonderful lunch at Peter and Caroline Finch’s home. It is outside of the city, down a long and treacherous dirt road, then up a little valley through a park-like setting with a swimming pool in its midst. There are 3 houses on the property, widely separated. They rent from the Argentine couple who own it all. It is incredibly beautiful. As we sat on their porch drinking gin and tonics, 4 or 5 Hamerkop (large brown waterside birds, quite raucous, looking prehistoric like little Pteranodon) gathered at one side of the swimming pool. The birds made a racket and the dogs chased around the pool to catch them.  The birds just sailed across to the other side and resumed their cries. The humiliation was too much for the dogs, as the Hamerkop began to mount and copulate each other, flapping their wings and crying out in fun while the dogs would tear around the poolside trying to catch them. I don’t think the Hamerkop were terribly frightened. The dogs figured they looked pretty stupid after awhile and lay back down on the grass.

Peter and Caroline are both from Zimbabwe. They moved to Britain for training—he’s a gastroenterologist, she is a nurse—for their careers, and to raise their children, returning to Africa 3 years ago. They are lovely, intelligent, fun, kind people and I hope and expect we’ll continue to expand our friendship. Peter took early retirement from the National Health Service and is working for the College of Medicine, teaching at Queen Elizabeth. They had planned to return to Zimbabwe and buy a house, so they packed a shipping container full of all their belongings, including furniture, carpets, art, a fridge and all their large appliances, etc. in the UK. When it was impossible for them to get a visa for Zimbabwe, they moved here. Caroline is active in their church and has noted that the Malawian children in the childcare don’t develop symbolic/representational play. You know, the little boy playing with the toy car: “Brum, brum. He pulls into the gas station to fill up. Then he races up the hill to catch the bad guys.” As our kids played. Here a child will sit passively holding or looking at toys given to them. It’s interesting to imagine what effect that might have on their future development, since representational play is thought to be very important in childhood.

I managed to take the briquette press to Samaritan 2 days ago. They were pleased, if not thrilled, and as soon as I get the instructions for preparing the leaves, cardboard, and other vegetable matter, they’ll start training their youth to manufacture the briquettes. It was the last day of the three month rotation for a group of social work students I’ve met with there. I taught them D.W. Winnicott’s Squiggle Technique to help them to engage recalcitrant children. They all had a great time practicing it and showing the group their drawings. I also did a writing practice with them—Linda does this with her nursing students very creatively and I am shamelessly copying her—which they also enjoyed. Putting words to paper in order to communicate with another is central to their work, so getting better at it can only help them. I wish I’d had that in medical school.

Darkness is descending. There was a storm yesterday evening just before we went to bed. Lightning struck so close that the thunder reached us virtually simultaneously. Crack! Scary.

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