[Above photo: Looking across the Shire River from Mangochi. Walking by the water is encouraged by the crocodiles.]
25 June 2017
Stefan and I headed down the escarpment and north 3 hours toward the Lake at 5AM last Monday to spend 3 days in Mangochi, previously described in this blog (Recall mosquitoes, crocodiles, falciparum malaria, power and water outages and abysmal dining out). Our plan was to work in situ with the Family Medicine Registrars. The road from Liwonde to Mangochi is an hour of deep potholes and detours, hopefully with road improvements planned. Pity the cars and minibuses that negotiate it regularly. We found the College of Medicine hostel on the Mangochi District Hospital grounds and each were given a nice room with an “en suite” bathroom.
Then we entered the hospital to join the morning report/handoff. 5 deaths a day average for this hospital of 250 beds! A post-menapausal woman came to the ED with a history of several months of vaginal bleeding. Her hemoglobin was 2.6 (“normal” is 12.5-14.5). Because she had bled out slowly, she could still walk and do her household chores, although at a slower pace than usual. Privacy for a pelvic examination is difficult to come by so they didn’t do one. An ultrasound (very quick and easy with a handheld unit) revealed a large uterine mass, felt to be a fibroid tumor. She was scheduled for a hysterectomy the following day. Fortunately for all concerned, the intern felt uneasy and did perform a pelvic examination. Lo and behold, she had stage 4 cancer of the cervix. Cancel the surgery, call in the palliative care folks, and tell her family she is going to die soon.
We then supervised the registrars while they interviewed several psychiatric inpatients and a woman on the medical service with a likely post-partem psychosis. The registrars performed well, carefully and kindly gathering data and intelligently formulating a diagnosis and management plan. The psychiatry “wards” were a sight to behold. The two small concrete rooms, one for men and another for women, had doors opening to a dirt courtyard. They had mattresses on the floor. The beds had been removed, we were told, as there really was no room for beds. Beds also made containing aggressive patients difficult and dangerous. The patients generally spend the day sitting in the dirt outside, sometimes dragging their mattresses out. Since their courtyard is contiguous with the remainder of the hospital grounds, patients frequently abscond. (A good British word, “abscond”. Like “invigilate”, as in “to supervise an examination”.)
We conducted interviews with and discussions of each patient sitting in a circle on small plastic stools in the shade of the solitary tree in the courtyard. There was a lot of activity around us: one young man with probable hebephrenic schizophrenia was trying to make sense of his world by picking up bits of trash and putting them in a plastic bottle. At times he’d join our interview with another patient, then wander off to pee in the dirt or to wash his hands and get a cup of water from the gray water draining from one of the adjacent wards. The cup of water he placed on a branch of the tree, presumably for future consumption. Oh, I should mention that all the patients are on what Stefan branded “Drug Regimen A”—chlorpromazine (Thorazine) 200mg initially, then 100mg twice per day. And diazepam (Valium) 20mg initially and then 20mg twice per day. They were generally stuperous, appearing drunk and dazed if they could be brought to see us at all. If someone is manic or otherwise psychotic and agitated, starting on those drugs at that dosage might be OK, but to continue it makes for a very quiet, sleepy populace. And one size fits all? Hmm.
Remember the great quests of legend: Jason and the Golden Fleece, Aeneas seeking a homeland, the Odyssey? Trying to find breakfast each morning was a challenge. I asked at Chicken Line, le centre du haute cuisine de Mangochi, after supper the first evening if they had eggs, coffee, chips, and sausage for breakfast, reading them off the menu. “Yes”, I was assured. When does the restaurant open. “6AM”. At 6:30 the following morning we decided to play it safe and so returned there for breakfast. It turns out they have a breakfast menu, but no breakfast. I should have guessed from the absent main supper items the previous night —no chicken, no beef, no chambo— that the larder wasn’t exactly full. We had tea and Stefan went to the Puma station next door where he’d seen muffins for sale last night. “Not in yet”. Still, “The Vow”, an English-dubbed Indian soap opera blaring on the TV was compelling. An incredibly intricate plot enacted by stiff, primly coiffed actors and actresses: “That isn’t my real name. I haven’t told you my history.” “It doesn’t matter. I love you and want to spend the rest of my life with you.” “I hope Adak recovers from the accident.” “I do as well.” “If he doesn’t I’ll scratch your eyes out and cut your tongue off.” A tiny sampling.
As satisfying as the soap opera was, it didn’t fill the stomach. Driving back toward the hospital, we turned down a street of tiny ramshackle shops and stopped in front of Dango, a small thatched-roof spot. Yes, they had rice porridge and coffee. When it came, the porridge was good and smoky, if at times a little gritty. Well-cooked rice and ground nut meal were tasty and welcome. But the “coffee” was 6.7 parts chicory, 5 parts coffee, 1 part dextrose, etc. 1500MWK per cup!! I can order a full French press of excellent Mzuzu coffee with hot milk sitting in the lovely park at La Caverna in Blantyre for 800MWK.
Still, the porridge stuck to our ribs and, if caffeine deprived, we were ready for a morning of work. The following morning, ever hopeful, we returned to Dango to find, “No, the porridge won’t be ready for an hour”. Despairing but beginning to laugh uncontrollably at our misfortune, we returned to Chicken Line, as we’d been assured breakfast would await us today. Nope, we just sprayed the entire kitchen for cockroaches so unless you are insensitive to neurotoxins in your scrambled eggs you’d better pass.
Back to the Puma gas station next door. Muffins aplenty. And a strange-looking drink, Mlambe, made from baobab tree fruit. Loaded, we headed across the street to find some coffee. No coffee, but a nice pot of tea. And an unforgettable menu. Under the Pizza section, Hot Mexican Large. Not so hungry. If I must eat a Mexican, can you make it a small one? Another memorable item read, “Goat offals rolled around intestines, fried and locally boiled with small seasoning.” I am so glad that they didn’t boil them over the border in Mozambique and bring them to us. Nothing worse than cold fried/boiled goat offals rolled round intenstine, and so forth.
The registrars had medical clinics this morning, so we returned to the psychiatry service, seeking the new psychiatry Head Nurse. After interviewing the sister of yet another overly sedated patient, we tried to see if the nurse and her staff were interested in talking with us about anything. It turns out, she really wasn’t, except to let us know that she wasn’t interested in doing outreach at the district clinics unless she got an increased allowance. Certainly, her priorities were driven neither by curiosity nor quality of care. Understandable, perhaps, but disheartening.
Feeling somewhat defeated, we then sought coffee back at Chicken Line, hoping their supply truck had come in. Nope, the waitress told us, “No coffee”. “Where in town might we find coffee?” She looked puzzled and turned to ask her boss. He jumped up, found some Mzuzu coffee and made us a pot. It matters who you ask. I wonder if he could have found eggs and sausages the day before. Now we were treated to a Nigerian soap opera on the TV with a lot of very large people screaming at and assaulting each other, men and women. “It was 2000! You agreed on 2000!” A lot of high-expressed emotion.
We did again meet with the registrars and interviewed the existing patients some more. We had noticed on the previous day that the woman with a post-partum psychosis had dark, dark brown urine collecting from her catheter . Since her elder sister was in charge of her fluid intake, we gathered the nurses and sister and emphasized the need for pale yellow urine. Today, to our relief, it was pale yellow; they had given her enough fluids and she hadn’t gone into renal shutdown. Pretty basic medicine. We said goodbye to the registrars, encouraged them to contact us whenever they had psychiatric questions, and had lunch at Golden Dish (not so bad, if slow) with Aye, one of our GHSP Family Medicine doctors who was leaving for the US the next day. I must admire the 4 volunteers who were stationed there for the year; Blantyre seems like San Francisco or New York, comparatively.
By my conventional terms, the town of Mangochi is a wasteland. Yet if you gave up on eating out and any sort of nightlife, I can imagine working at the hospital to attempt to improve things could be fun. Almost anything you did would save a life or improve services dramatically. I guess entertainment could be found on TV: football (soccer) and Indian/Nigerian soap operas. Almost as entertaining, without the fear, disgust, and astonishment, as watching the DT Team attempting to shred our democratic institutions.