11 February 2018
[Above photo: A sea eagle snatching up a chummed fish.]
In anticipation of our summer trip, I went to the Police Headquarters for the Southern Region of Malawi to get an Interpol document certifying that my car wasn’t stolen. I had a brief moment of anxiety—I didn’t know Patrick or his pedigree when I bought it from him. It was plausible to me, certainly, that he purchased it on the internet, picked it up from Mombasa where it had been shipped from Japan, and drove it to Blantyre, but I had no proof. While at Interpol, I realized how tense I get when in the presence of police here. Instead of having fleets of cruisers on the roads, they maintain frequent stationary and mobile police stops as a way of having less capital outlay and employing more officers. I always greet them with a smile and a wave, I don’t argue, etc. Today at a stop one of them said he was hungry and asked if we could help him. I said, truthfully, that we had no food. “Just a few kwatcha?” I replied, “We don’t do that. I’m sorry.” “OK. Have a safe trip.” But “Interpol” suggests spies and international criminals and arrests and warrantless Extraordinary Rendition to a damp, moldy cell in a stone basement in Bulgaria, etc. It didn’t help that the “office” was dirty with broken furniture, papers scattered around, etc. And the “waiting room” had dark, oily spots on the walls where people sat for hours, resting their heads. Which led me to think what does prison look like here? Much, much worse, I am sure. I think that if Mental Health is the tail on the end of the dog of government funding, I am sure that prisons are the very tip of that tail. I was friendly and cheerful and engaging and I got a clean certificate of ownership and left. Around police officers I often find, and it may be my imagination, that I am repeatedly reminded of their power. Like the guard at the front who, when I approached the open automobile gate, shut it before I could walk through, nodding me toward the pedestrian passage. There were no cars coming. He just wanted to assert his authority. And, of course, the less real power people in such a position have, the more they want to exercise what little they can.
The young woman I wrote about last week who I hosptalized returned to clinic this week. She spent 2 days at Zomba Mental Hospital and now was cheerful, calm, and appropriate, confirming (for me) my diagnosis of a personality disorder. I’ll see how I can be of help to her, although my tolerance for drama is certainly less than it would have been 8 years ago in my office in Berkeley, in part because of the general level of illness acuity here. I know how difficult and time-consuming the treatment of a Borderline Personality Disorder can be, as well, and I don’t feel I have that luxury here. Nor will I ignore or neglect her. However, I must be realistic about how much I have to offer her and the cold fact that I’ll be gone at the end of June.
I saw a 17yo girl, bright and engaging, who was brought to Room 6 by her mother. Before I saw them I was told of possible diagnoses of Munchhausen by Proxy and Opiate Addiction. Google the former. Basically, a caregiver seeks the attention of medical personnel by inducing illness or forcefully suggesting, repeatedly, that their child is seriously ill and tenaciously pursues extreme treatments for the child. This girl has had 5 surgeries on her abdomen, primarily for symptoms of constipation and abdominal pain. Now she is left with no colon, multiple peritoneal adhesions, and, reportedly, large, disfiguring keloid scars. She wants to study to become a neurosurgeon and is a brilliant-enough student to gain admission to the College of Medicine. And she is taking daily oral and injectable opiates for her pain. What a travesty! She’d seen an excellent surgeon at QECH, a good friend of ours, who informed the mother that she didn’t need surgery. Her mother, who seems to be a powerhouse, chased down a surgeon at a private hospital and he operated on her. Three times. She had a fourth surgery by his partner and finally flew to Bangalore, India for a fifth. All I said to the mother was, “I hope all of this wasn’t unnecessary.” I’ll see the girl in therapy and try to wean her off narcotics, although it may be a challenge since she’ll likely have anatomically-based pain from her adhesions at times. Who knows, maybe she had Hirschprung’s Disease where the unlucky patient develops toxic megacolon from having underdeveloped colonic nerve endings. Or Crohn’s Disease. I’ll try to locate the pathology reports.
In preparation for my medical evaluation for ADD, I got some lab work at one of the private hospitals. It was so strange to be in an attractive healthcare facility with clean walls and floors, nicely kept grounds, and fresh paint. It seemed a bit sterile and safe and I clearly prefer working at crumbling QECH with its crowds of mourners and guardians lying around the courtyards, scores of colorful chitenjes drying on lines and bushes, and a general sense of purposeful confusion. Getting some blood drawn and then having an EKG took several hours as the latter is only done in the ED and it was busy on a Sunday afternoon. I expected it all to be normal but when I looked at the results two days ago I appear to have mild hypothyroidism and the machine read-out of the EKG says I have had a septal infarct. The latter I cannot believe, nor does the Peace Corps physician, and she will have a cardiologist friend in Nairobi review the tracing. I’ll repeat the thyroid function panel at the College of Medicine lab in a couple of months; I’m not intolerant of cold, am not lethargic, and my hair is fine, not coarse. My resting pulse is 65. My mother had mild hypothyroidism as she aged.
The entire experience is interesting to me. I realize how I’ve felt invulnerable since surviving my lung cancer and have enjoyed pushing myself physically since then—up the mountains in Acadia, along the Haute Route, hiking in the Drakensberg and the Cederberg, and our Mulanje trips. I enjoy stretching myself biking around Blantyre which has a few hills. I know, at a new level, how difficult it is to get sophisticated medical care here. And it makes me aware of the reality of my age; if not frail, I’m not 25yo anymore. I’ll see where this all leads.
We have enjoyed 2 nights at Kumbali Lake Retreat, an off-the-grid collection of [thatched—surprise!] huts set above the lake, each remote and private from the others. It is a really cute place in a wonderful location near Salima, east of Lilongwe where we’ll drive later today in order to have my medical appointment and for Linda to meet with her nursing students tomorrow morning. We putted down the coast in a steel-hulled boat the owner’s husband built and we snapped photos as the staff tossed fish for the Sea Eagles to snatch. I haven’t quite mastered capturing those moments yet, often catching talons only or, in one instance, just the spray after the pick-up. Beautiful birds, however. Last night was a dramatic sound and light show accompanied by heavy rain. At one point we heard a lot of vocalizing off the coast; I worried a fisherman had gone down in the storm but I learned this morning that they sing and shout a lot when they are returning from a night’s fishing. So would I!
We’ve eaten our meals with a very interesting guy who’s the managing director of a company in UK that consults on health care governance—policy development and implementation—at high levels throughout the developing world, especially in Africa and SE Asia. It is to help government make health care funding transparent, so as to stem the “leakage” into private pockets of external (and internal, by extension) monies. Greed, corruption, and self-enrichment is rampant, not unlike in our country. It is so easy to point fingers at corrupt dictators in banana (or “shithole”) republics and so difficult to recognize, and to clean up, the mess at home.
I now have three books going simultaneously. Is this disorganization stemming from Attention Deficit Disorder or simply hunger for variety of experience. It is time to finish one!
A psychiatrist in Malawi 