Three of us travelled to Zomba today to visit the primary mental hospital for the country. The little town of Zomba is pretty, sitting at the foot of the escarpment leading up to the Zomba Plateau. Zomba Mental Hospital sits across the street from the Zomba Central Hospital; at the apex of the triangle is the Zomba Prison. Quite a triad in very close proximity.
Zomba MH is a 400 bed hospital, of which currently 155 are occupied. This is divided between men and women, about 2:1 and between Acute (av. 14 day stay) and Rehabilitation (av. a month). There is also a small Infirmary, largely for the severely developmentally delayed, many of whom were picked up wandering and cannot say where they are from. So they may stay for years.
We first met with the Director, a bright, sophisticated nurse with some years of experience. She was very welcoming and served us mango juice and cookies as we talked. She and Stefan discussed the issue of medication procurement; the funds have been set aside for a modest, basic formulary but the wheels of bureaucracy just turn very slowly. It is somewhat of a crisis, however, since most hospitalized patients are psychotic for one reason or another and require medication. The small mental hospital in Lilongwe (4 hours away), Bwaila, has been transferring patients to Zomba because they are have out of medications. And if the two central hospitals are out of meds, the district health centers and district hospitals surely won’t have any.
We met one of the three Clinical Officers who showed us around. He was bright and informed, having worked there, basically as a psychiatrist, for 6 years, evaluating patients, doing physical examinations on all of them, prescribing medications, giving electroconvulsive therapy to those profoundly depressed who don’t respond to medication, deciding upon the dates of discharge, etc. Both ECT machines are unfortunately broken at this time.
The hospital is remarkably clean and has a neutral smell—neither of cleaning agents nor bodily secretions/excretions. It is on a gradual slope, all one story with many connecting cement corridors. Some windows were broken and the ceiling tiles were missing in many parts of the buildings, clearly because of leakage during the rainy season. There are 8 beds in each room, 4 rooms per ward, and separate courtyards for each section. There is apparently some occupational therapy and there are TV rooms. We walked through the courtyards among the patients and some approached us while others seemed indifferent to our presence. None were threatening. It was eerily quiet and no staff were interacting with patients, other than to redirect them away from us. Everyone seemed subdued, as if by Thorazine. Hmm. As we walked out after our tour, music was being played for a dance class.
We had lunch at African Heritage, a very pleasant outdoor café with a gift shop and then went with Stefan to check on the house the Scottish Mental Health Foundation rents for their volunteer psychiatrists. It was up on the base of the escarpment, a four bedroom home with a front verandah overlooking the large garden below (mangos, avocados, papayas, frangipani) and the entire valley with mountains beyond. $180/month.
I think I am slipping into accepting the limits of psychiatric treatment here. It’s not that I won’t attempt to press for improvements. It is just that it will do no good to anguish over it. It is pretty astounding, however, to think that the major mental hospital in the country cannot keep its extremely modest formulary stocked. There is a lot of perspective to be gained here. And a remarkable opportunity to train residents and medical students about relationship, rather than the manipulation of neurotransmitters.