25 February 2018
[Above photo: A flock of Hammerkops on our wires—no albatrosses here!]
We have gotten soft, too accustomed to the creature comforts. We’ve not had a serious electrical outage or water shut-off for a year, I think. The former because we must be on the trunk line for the College of Medicine which is generally spared blackouts. However, even though we’ve been getting drenched going to and from work, Friday afternoon until Saturday evening we were without water. Well, we have a plastic bucket with 5 gallons sitting in the bathtub and we had two British Burkefeld water filters supposedly with a total of 3 or 4 gallons of drinking water (turns out they were both almost empty). And the geezer (hot water tank) in the attic can supply a certain amount by gravity. And we can always walk, bike, or drive to the grocery store and buy 2 gallon plastic jugs if it is necessary. I was surprised at our outpouring of whining and complaining. It isn’t like us. A year ago we would have welcomed it as an opportunity to innovate. “Let’s see. What can we use instead of water? Beer? Wine? Nail polish remover? Turpentine?” It doesn’t help that when the water resumes flowing, mud comes out of the tap for several hours. I sense unrelated stressors contributed to our discomfort.
My brain was too consumed with other issues for me to feel free enough to write an entry last week. Today, however, I am unburdened, relatively. I’m eating a new (for me) standard breakfast—granola with the addition of passion fruit, a banana, almonds, milk and home-made yoghurt. And a cup of tea. Linda has gone to church. And Hamza al Din, the Nubian musician, is playing the oud and singing via Spotify.
How strange it is to hear this hypnotic Nubian desert music streamed over the Internet. I love the apparent simplicity of his voice and his oud. I wondered if he was still alive, having been born when my sister was—1929—and looked on Wikipedia, finding not only that he died in 2006 at 76yo but that he died in Berkeley. I never heard him live and never saw an announcement of a performance. He was a master composer and musician and, had I known he was in Berkeley, I would have tried to find him. I probably would have bought an oud and tried, unsuccessfully, to imitate him. The album I bought in the late 60’s was entitled “Al Oud”, so we playfully referred to him as “Al”. The Bay Area has, over the years, attracted an amazing number of gifted and productive artists, and little Berkeley has had an outsized share of them.
We were requested to consult on a 13yo boy on the Pediatric Special Care Ward three days ago. He was admitted after having a dramatic change in his personality suddenly around 4PM last Sunday. He began to beat people, seemed confused, and was speaking “nonsense” (not sure what the word is in Chichewa). He had a fever and a positive Malaria Rapid Diagnostic Test two weeks previously and had completed a course of treatment. He’d had no previous episodes of being mentally unwell, nor was there mental illness in his immediate family. He was a Muslim and didn’t drink or smoke. I grabbed two of the medical students and we set off for the Peds SCW, far across the hospital. At one crossing corridor we had to wait while a gurney with a covered body and perhaps 75 wailing people passed, an all-too-common occurrence at QECH.
We located the boy outside the ward with his two young uncles and we all sat on some steps, a bit out of the melee, for a modicum of privacy. He was confused, thinking he was in an automobile repair shop (sort of the right ballpark) and that he saw his father drive by in a new car (His father doesn’t drive or own a car and is 75km away in his village.). He was restless, and as we sat there gathering information from his two young uncles and observed him, he repeatedly lay back on the concrete porch and then sat up, wiping his face as if to remove cobwebs. He had been afebrile since entering the hospital. His physical and neurological examinations and blood work were normal and his chest x-ray was clear. They had attempted an LP several times unsuccessfully, which seemed strange to me since he was young and thin.
He was improving, his uncles said, and the money his father gave them to support themselves while acting as his guardians was running out. His father wanted them to use the remainder to get a minibus back home so they could go to the mosque and pray over him. The family was convinced that it was demonic possession. Not knowing the cause of his delirium is troubling. I wanted the registrar to attempt the LP again. And to consider getting an MRI and to observe him for a few more days, at least. It was not to be and they left the hospital against medical advice. We were, however, unclear on his diagnosis, not treating him with anything, he was improving a bit, and the uncles had a tale of another relative who’d “gone mad” and prayers had healed him.
The students and I talked a lot about the difficulty, as physicians, of living with uncertainty and the necessity of tolerating, if not scientifically respecting, indigenous explanations of illness. After clinic I drove my bike through the soaking noon downpour to get a bite of lunch and slosh into the lecture theatre to review with the students their filmed interviews from the morning. They are really such fun, so good natured, and, mostly, very open to learning psychiatry and even a bit of psychoanalytic theory. The heavens seem to be opening about the time I leave clinic these days and either I can shelter in place or get wet and have a bite of lunch. I don’t seem to dissolve and am just uncomfortable until my clothing dries. I have a waterproof cover for my backpack, so my computer and wallet stay dry.
I keep looking for the Sunbirds we had in the yard last year at this time. They are tiny, brilliantly colored, and so entertaining. Something similar may have happened as did with our barn swallows in Maine. They simply disappeared from one year to the next, having nested Spring and Summers in our barn since it was built in 1918. Since they migrate to South America for the Maine winter, we assume that their southern habitat was destroyed and with it their lives. I hope that hasn’t happened to our Sunbirds.
I completed the two-afternoon whirlwind course on Child Mental Health two days ago for our nurses, registrars, and psychiatrists (8 of us in total). It covered Normal Development, Assessment, Diagnosis, and Management. We ended the second afternoon dissecting numerous vignettes I had written. There was lots of lively discussion and a tea and samosa break each session. I’ll improve parts of the workshop but I think it was generally a good start and will help them to keep the clinic going well enough. I’ll continue to bring challenging child and adolescent vignettes to our weekly clinic meeting for discussion.
We’ll drive across Mozambique to the Indian Ocean in 4 weeks for 10 days of R&R. I cannot wait for the food, as beans and rice and stewed chicken or goat, and cooked pumpkin leaves get pretty boring, as does the local Indian fare. Linda’s cooking is always a wonderfully creative treat but it’s nice to eat out occasionally and to find a restaurant with interesting food, which is not easy here. The food in Mozambique, with the Portuguese influence and the access to fresh seafood, holds promise. It’s something I’m also anticipating with excitement for next year in Myanmar, if my assignment there is ever finally assured. We need to go to the Mozambique consulate here and get visas. Mozambique has apparently emerged from years of civil war and is a beautiful and friendly place to visit. With a long ocean coastline, fertile soil, and abundant mineral wealth, it is poised for economic success if it doesn’t all get siphoned off at the top. I may even do a dive or two, since it is supposedly excellent for scuba. It’ll be hard to match Apo Island in the Philippines which is at the northern tip of the Celebes Triangle, supposedly the area of highest concentration of undersea life anywhere (it includes Papua, New Guinea).
I wonder why the exotic holds such interest for me. I also love the familiar but now I am drawn to teaching in settings similar to this. I can recall feeling somewhat scornful of physicians who committed to working only abroad, knowing how special that would make them feel and imagining that was their primary motivation. Feeling special here—different—as we are, is not something I enjoy. I do like being able to make a change in a way that I couldn’t in the US. I’m redundant there and not here, so I have a free hand to work. I can see how if someone were doing only clinical work in a very under-resourced setting their standards of care could easily drift downwards. The combination of clinical work and teaching tends to keep me constantly trying, at least, to provide a high level of care.
The Scot psychiatrists are coming for supper tonight. They generally love it in Malawi and have a wonderful time. Many are repeaters. They lighten my teaching load a lot. And it is good for the students to have eager, fresh perspectives. And for Stefan and me. So I’d best dust, sweep, and mop the house in preparation, as it is needed. We have running water!
A psychiatrist in Malawi 