29 April 2018
[Above photo: Large pachyderm in our proxcimity after bathing (in mud).]
I’m not making much headway writing this. I’m alone on the front porch of our tent-chalet, overlooking the Thawale Camp waterhole. The first distraction was the birds—a Common Scimitar-bill, a brilliant blue bird with a large violet back patch, a black head and a long black tail with a long curved beak and a nimbleness surprising to me. Then a family of Arnot’s Chats. A Bateleur Eagle just flew over. I hear Emerald-Spotted Doves and Cape Turtle Doves calling incessantly: “My mother is dead, my father is dead, what shall I do, do, do, do…..” and “Work harder, drink lager”, respectively. Suddenly an immense bull elephant lumbered out of the bush, with gravitas and purpose, to drink, spray himself, and roll in the mud at the waterhole in front of me. He then walked very close to the dining area where Linda is writing before exiting through the main parking lot. I ran up to take photos [see above]. I returned to my deck and a male nyala, grazing, passed by 20 feet from where I’m sitting. I then heard clacking and snorting and a male impala raced by, chased closely by another male. They’ve been battling for territory; often one will dehorn the other or even kill him as they crash together. The defeated one slinks away to join a celibate bachelors’ group. The victor parades around the locale issuing a loud, snorting noise to mark his territory. A family of warthogs, very tasty I am told, trotted by, the piglets incredibly cute. Oh, and a Cape Buffalo slipped into the waterhole somewhere in there.
Last night was pretty rough, as the jungle noises were substantial. Complete quiet, then intense and repetitive calling, bellowing, howling, bleating, and trumpeting (elephants). (Good lord, another immense bull elephant just entered from stage left to drink and bathe at the waterhole!) I heard munching outside the tent screen and, looking out, saw a large, black shape feeding its way past the tent. It’s shape seemed like a Sable antelope, one of the larger and more lovely. So snatches of sleep were punctuated by very loud noises that seemed to express either ecstasy or terror. Maybe just pillowtalk. I couldn’t decifer. Finally, around four AM a pack of hyenas started barking and calling rather urgently, as if some walking protein were available to them. Despite the lack of sleep, as we arose at 5:30AM for an early game drive, it was a fascinating night and gave me a visceral sense of what it is like to keep a constant awareness, especially in the dark when the cats hunt, lest you be eaten. Despite the nearly-full moon, it is pretty dark under the trees and there are plenty of shadows to hide a lurking predator. But, then, I’m anthropomorphizing the animals. This is what they know. They live in the present. They are fearful but likely not anxious. They don’t talk with each other about the narrow escape the night before. It is a constant battle in the animal kingdom and the winners get to eat. frolic, jockey for position, and reproduce another day.
A couple, a pediatrician and a nurse from Lilongwe, told us about a man asleep in his tent at S. Luangwa National Park in Zambia who was batted by a lion, giving him a deep cut on his temple. Another tale we recently heard was of a boy in Namibia who opened his tent to get a better photo of a hyena outside. The latter promptly killed him. (That’s the real version. Mine had a pack of hyenas barreling into the tent and devouring him, belt, shoes, and all, but Linda has called me on it so I’ll tell the true tale.) All of the aggression triggered a dream in which I was observing a particularly vicious fist fight at a bus stop. One man gave it everything from the beginning, like a ceiling fan, and quickly disabled and knocked the other man to the ground. It felt chilling in its efficiency.
Now a younger bull elephant has drifted in from the side and is greeting his elder, he of the extraordinary tusks. And six White-crested Helmet Shrikes scavenge the bush in front of me.
I have been thinking of shortages, of which there is no shortage here. Start with no electricity and no water at times. Which also means no internet or hot water. We can cook on a gas burner. There is a shortage of privacy for patient interviews. There have been no sterile gloves, at all, at Mangochi District Hospital for months and the post-surgery infection rate is in the high 80th percentile. There are often no plastic envelopes for our new patient files and none to be purchased. Gas stations are frequently out of gasoline. Often there is no soap (or water) with which to wash our hands in clinic; everyone here shakes hands as a form of polite greeting, which I like. There are shortages, and stock-outs, of our small formulary of psychiatric drugs, despite assiduous inventory and timely ordering procedures. We are short of staff, chronically. The lab is often out of reagents to perform basic blood tests. There is no shortage of patients, however.
Shortages are a fact of life here. I think they breed both ingenuity and apathy. People find remarkable workarounds, rely on history-taking and physical diagnosis more than their Northern and Western (Europe, US, Canada, Australia, etc) colleagues do, and at times feel dispirited and that their efforts are futile, given that the shortages are man-made—funds being diverted elsewhere, inefficient bureaucracies, poor facilities, etc.
On April 1 I mentioned a 47yo woman I saw in clinic with untreated seizures for 15 years, 4 years of progressive dementia, and blindness in her left eye developing over the past year. I was convinced that she had a benign brain tumor, like a slow-growing meningioma. Her MRI showed brain atrophy and extensive small-vessel disease, as well as collapse of her left eyeball. The latter is from trauma, the former from untreated hypertension. At her last visit her blood pressure was 162/103. So she’s off to hypertension clinic. She’s had no seizures since I started her on medication for the same. And she’ll visit the eye guy to see if they can determine the cause of the death and collapse of her eyeball. Untreated hypertension, chronic alcoholism, and HIV are the major causes of dementia here and often strike the middle-aged, who generally do not have access to basic medical care. We do live in quite a bubble in the developed world.
I’m starting to read a book—Linda exchanged a copy of her Sunday Morning Shamwana with Claire Wendland for her A Heart for the Work— which so far seems remarkable. It concerns the education of medical students in both the developed world and Malawi in Western medicine and medical technology and about the export of both to developing countries. We assume that medicine is culturally neutral, being science-based. She writes quite convincingly, as both a physician and an academic anthropologist, that the picture is considerably more complicated. It does resonate, so far, with my experiences, both of my own medical education/indoctrination and the training and situation of doctors-to-be here. Why is life so complex? My own included, I might add.
A nyala just cantered down the pathway to our chalet, 15 feet from where we sit. We are in the middle of it here, gloriously. There are now 14 lions in Majete and 20 leopards. All very secretive, so we have seen none. Majete is 270 sq miles and only 30 is used for the safaris, so it is no wonder they are eluding us. No matter, on our travels in July and August we’ll see plenty, I am assured.
Jordan and his girlfriend, Paulina, are excellent travel companions and fun to hang around. I’ll drive them to Mua Mission tomorrow to see the cultural center and museum and we’ll spend a couple of nights on Domwe Island off of Cape Maclear. Linda has a full teaching schedule and must work, poor dear.
I have finally been offered, and have accepted, a Fulbright to Myanmar for the 2019 academic year, starting in January. I’ll teach in one of the medical schools there, either in Yangon or in Mandalay. I’m quite excited about it and am already preparing myself for the year by extensive day-dreaming, most of my assumptions being, no doubt, fallacious. Burma seems far from where I am sitting at present, although time flies. “Fruit flies like a banana. Time flies like…..?”
A psychiatrist in Malawi 