4 March 2018
[Above photo: I always loved dioramas. Each time we dust we get to rearrange the herd.]
The crash of broken glass awakened them. Then there was a second loud noise, as a crowbar was used to pry open the metal door from the inside, through the broken window. Suddenly there were flashlights, someone saying, “We are searching.” The first thought was, “It’s the police and there is someone in here.” Slowly the realization spreads that these are the “someones”. A home invasion. Six men, complete with clubs and machetes.
It happened to the three Scot psychiatrists, two women and one man. The former two are retired; the latter is younger, tall and muscular. They were kept in their respective bedrooms and made to sit in a corner on the floor. The man kept standing up and would be punched until he sat back down. One of the women, tiny and feisty, stood up and screamed at those rifling through her stuff. Her “guard” hit her in the face with a long plastic rod, giving her a black eye and knocking her to the cement floor, where she landed on her hip. After begging them to leave her passport, they tossed it to her. Laptops, tablets, cell phones, shoes, cooking oil, suitcases, and so forth were all taken. The two guards were tied up outside.
A honking at our gate, for we live 2 blocks from them, at 2:30AM awakened our guard, Catherine, who yelled, “Dr. Stewart, Dr. Stewart.” Linda was in deep sleep, bless her. I jumped up, thinking we’d been invaded and tried to pull on some shorts in a hurry, falling to the floor in my haste. Then a police vehicle with blue lights flashing drove into our yard and discharged the three Scots.
The remaining details are not so important, except that the police attempted to extract a $50 fee from each of them for taking and writing the report. (The standard fee is 5000MWK, about $6.75.) The Scots are settled in a quiet lodge for the week they have left here. We purchased three smart phones for them to use. We fed them last night. We’ll have an outing today with them. They are remarkably resilient. They were staying in the house next to our first one, owned by the College of Medicine. Peace Corps was right; the security there is terrible, despite alarms and some razor wire. There isn’t a strong and secure gate and there are no walls, just chain link fencing. Adil and Anneka were in that house last year, two young female physicians. I’d hate to think of what might have transpired if it had occurred during their occupancy.
It does strike me how things, everything, can change in an instant. A cardiac arrest. A distracted driver hits a bicycle. A home invasion. Prior to visiting our friends, Mike and Susan, in Central African Republic in 1972, they were invaded. Their bedroom had an air conditioner, so its noise masked other sound. Something awakened Mike, who saw four men gathering up their possessions. He wisely feigned sleep and all they lost were wallets and electronics.
This past week on two successive days we had two very psychotic, agitated, and violent patients. They required restraint and involuntary parenteral medication: diazepam and haloperidol. They each settled for a bit on a mattress on the floor while the nurses attempted to secure transportation to the mental hospital in Zomba, an hour away. The nurses were told they’d come by at 2PM. No one came either day. Follow-up calls revealed that “There is no petrol” or “The ambulances were all busy.” The problem is that if you plan for a 2PM transport, you can time medication to keep them sedated until they get admitted to the hospital. If they don’t show until 7PM, or not at all as in these instances, the patients are left in the care of their families, becoming agitated and violent again. Or they get up and abscond. The nurses work 8-4 and then the clinic, naturally, closes. The AETC (ED) is not staffed to keep agitated, violent patients, so there is nowhere for them to be. Patching the system so as to provide this very basic level of care, as Stefan is attempting to do, seems nigh impossible. It is pretty frustrating.
Linda is pursuing her Model Midwifery Ward in an exemplary way. Her several years working here previously, in Samoa, and in Congo have allowed her to understand the situation in a way that I am only beginning to grasp. I set up the Pediatric Mental Health Clinic as I would in the US—-get approval, find space, start it, perform the basic bureaucratic rituals and develop forms and procedures. Get the registrars involved. Well, I fear it will all collapse when I leave. I should have spent a lot of time with the nurses in Room 6, seeing if they even wanted to do this, letting them select a champion for it, and then I could have helped with the details. It needs to be theirs if it is to continue. There may yet be enough time to make it sustainable, but I’m not sure. I realize that I am just a blip on the screen here, despite my skills and training. Whereas Linda has worked so closely at every step of the way with her co-faculty, and with all the other stakeholders, that she has a much greater chance of her project continuing.
I saw a 17yo girl who’d made a suicide gesture and was feeling pretty miserable. Her mother died when she was 11yo of severe malaria, her father remarried and the status of stepchildren here is often one of a rejected outsider. I hooked her up with a Registrar for regular therapy but they didn’t make a good connection and she just appeared at my clinic one day two weeks ago, wanting to see me. I spoke with the Registrar, who has some difficulty just listening and not “doing something”. Four days ago she brought in her father; it is often a challenge to get a father into a psychiatry consulting room here. He was lovely and kind and understanding and we talked about how difficult his wife’s death was for them all, how they hadn’t discussed it together, and how he recognizes how unhappy his daughter is. They decided they would together join her mother’s relatives (yesterday) for the annual clearing and sprucing up around the mum’s tombstone in the cemetery, the first time he has been a part of it. And she will bring in the step-mother to meet with us sometime soon (I hope).
I can do good work with individual patients and sometimes they will have lasting beneficial results. But with a conservatively estimated 1.2 million children and adolescents in Malawi needing mental health services, training is where my time is best spent. And that is where most of my time is spent. I just wish I knew when I started what I do now. It’s always the case.
Even though DT didn’t really want the presidency when he was sneaked into it via the Electoral College back door, now he is saying to the Emperor for Life of China that he’d like his job to be permanent, too. His vision of what is of value in life and for humans and what is not is so stunted, self-serving, and ill-informed as to activate my area postrema, the medullary vomit center. Have we earned this by letting the welfare (jobs, education, health care) of a class of people be ignored? Is it our worship of the dollar and those with vast wealth, allowing them to dictate our lives? We are such a strange species of animal: Too clever, and stupid, by far. Too cruel. The mid-terms are a chance to turn things a bit.