Author: Children Deserve Better

I saw a 10yo boy in clinic this week. He’d “gone crazy” in the morning, breaking things, assaulting people, requiring restraint, hearing voices telling him the neighbors wanted to kill him, etc. Totally normal developmental history, excepting he doesn’t know his father and had recurrent bouts of malaria with high fever and delirium every 6 months from 1 1/2yo to 5yo. He’s been doing well in school and gets along well with his sibs. He is very beloved by all, including his stepfather, as the baby in the family. When he was seen in the Peds ED, he continued agitated and irrational. When I saw him two hours later he was completely normal: calm, rational, thoughtful, and shaken by the experience. No drugs involved. I don’t know what to make of it. Could I be seeing my first case of temporal lobe epilepsy? He’ll be back in two weeks and we’ll get an EEG. Did he have some scarring from the (cerebral) malaria, predisposing him to seizures?

There was a suicide of a boy at a private secondary school here and we are consulting with them about it. The school did all the right things, planning a strategy, alerting staff to be sensitive to kids who are struggling, having a full disclosure assembly as soon as the kids were back in school, contacting local therapists to see kids who seemed particularly vulnerable. We’ll likely be involved in running a staff/teachers’ group and one or more groups of children the school has determined are particularly vulnerable. There seemed to be only one clue he left, calling a friend and saying “Goodbye” the afternoon he did it. His parents were separated. Although he said that he was unhappy with the school last year, his first, he had gone out of his way to let people know how much he liked it this year.  What a waste.

I’ve just finished a good read—From Microsoft to Malawi—about an attorney, Michael Buckler, who joined the Peace Corps as a village teacher here after his marriage went south. It is a terrific view of the strains and adaptations Peace Corps Volunteers experience. I happen to think that the Peace Corps, overall, is probably our most successful foreign policy initiative. My hat goes off to those Volunteers living in villages, working creatively and hard as they adjust to a new culture, in conditions of deprivation: no electricity, no internet, no running water, a monotonous diet, dust everywhere until there is mud everywhere, social isolation from Americans, and reflexes that are all wrong for this culture. “The hardest job you’ll ever love.” is the motto.

What we are doing is Peace Corps “light”—-a comfortable house with running water most of the time, electricity and, thus, good internet half the time, a supplement to our Peace Corps Response Volunteer salary, and a reasonable amount of personal privacy not to be had in a village. There are wonderful fruits and vegetables in the markets to be had for a pittance. Pork is less than a dollar a pound. Goat is a bit more. There are small supermarkets, as well. And, still, it is difficult. It’s hard to function as a psychiatrist treating (mostly) major mental illness without a reliable supply of medications in extremely sub-standard rooms with little privacy. The ceiling tiles have fallen down in several of our rooms from leaks so there is only a tin roof between you and the sun. The rooms are steaming by 11AM. And, worse, I can see a lot of sky through them so they will be unusable during the rainy season. Stefan has notified Maintenance several times but no help is forthcoming. And at home the boundary issues are ever-present with our guard. She brought her darling 6yo daughter to work today (Sunday) and after introducing her to Linda, shooed the little girl into our house. “She wants to see it.” Linda said, “I am working, writing. George is ill in bed.” It could be flattering; she mistakes us for Malawians. But I think she has a particularly intrusive style. Just keep setting limits.

I had a young woman, a mother of 2, with severe mania admitted to the medical service for fluid and electrolyte replacement. She came to us having calmed considerably from her assaultive, agitated state of two weeks previous, now sleeping through the night. But she, by description, developed pseudo-Parkinsonism from the Haldol she had been given. When she came to us, she couldn’t walk and was wetting and soiling herself. A brief minute’s evaluation revealed that while she may have had pseudo-Parkinsonism from the Haldol, her mania had evolved into catatonia and her relatives couldn’t get any fluid or food into her. I visited her a day later on the medical ward with her grandmother and uncle in attendance. She was totally obtunded, unresponsive to verbal cues, and her iv had pulled out. I notified the charge nurse, filled out the requisite papers, and she was transferred to Zomba Mental Hospital where she can have iv’s and electroshock treatment. I can see why the mortality rate from inadequately treated catatonia is so high.

I also saw a 10yo boy in consultation on the Peds ward. He was stomach-breathing very rapidly during the day, but not at night. The pediatricians had worked him up adequately and found no physical cause for it. My psychiatric assessment was likewise negative; a happy, very bright, loved, very successful boy with no history of trauma and lots of friends.   He wants to be a doctor. My suggestion is for him to go home and return to Room 6 in 2-3weeks and see if the rapid breathing continues.

I got quite ill yesterday coming back from the market. It was a long walk, carrying a watermelon, a large papaya, and another bag full of vegetables. I just collapsed when I got home, with a pretty high fever, a headache, and the gi’s. I wondered about malaria, I felt so awful but the gi’s didn’t seem to go with it and my headache wasn’t as severe as I would have expected. So I skipped supper with the Scots and Brits—Linda went—and slept all day and all night. I am feeling better now.  Linda cares for me well, making broths, giving me Sprite and Coke, and even a home-made scone which seemed to agree with me.

It is so much easier to be a couple here. Caring for each other, intimacy, division of tasks, and just being able to talk. We are the only GHSP couple in Blantyre; there is one in Mangochi and one, with a new baby, in Lilongwe. One of the shared housing pairings has blown up and one volunteer moved out permanently. It is pretty stressful and unless your stars align I can see how that happens. What do they say about the people who do Global Health work? Martyrs, missionaries, misfits, and ….?  Even though it is difficult, I am not suffering and I see this as a wonderful opportunity for me. Some of our number never stop complaining about the working conditions, the living conditions, the language, etc. It gets old very quickly.

We go to Liwonde National Forest Preserve for 3 nights next weekend. We’ll sleep in a safari tent cabin in a tree. It is Malawi’s premier wildlife preserve, with abundant birds, large mammals, etc. Viewing platforms over water holes. I think what we’ll see in S. Africa over 2 ½ weeks around the Christmas holidays will likely be more astounding and certainly our Botswana/Namibia 5 week trip at the end will be fabulous. But it is nice to work into it. Over 1000 hippos in the huge Shire River, as many crocs, a huge variety of antelope, lions, warthogs, black rhinos, leopards, etc. I’ll report.

The Director of Peace Corps, Carrie Hessler-Radelet, together with the Acting- Director of Peace Corps Response and our country director, Carol Spahn, visited the Blantyre GHSP contingent at Queen Elizabeth Central Hospital yesterday. It is the 20^th anniversary of Peace Corps Response and one aspect of the commemoration is to visit a few Response sites in Africa. There was a wonderful demonstration, put together by Linda, of her nursing students in action, teaching a group of pregnant women, who sat on mats on the floor as they would in their villages, about the benefits and techniques of breast-feeding, including twins. There were other teaching exercises on the wards, as well. During the introductory remarks Carrie asked the GHSPers for comments. I talked about my initial weariness with the Silver Jubilee Celebration week of the College of Medicine and how I gradually found myself moved that this struggling little country could have started a medical college, and sustained and improved its offerings over 25 years. I then burst into tears, which was a little embarrassing, since the Deans of the Schools of Nursing and Medicine and the Director of the hospital were there, as well. The moment passed and I quickly reviewed my feelings for causes.

Four days ago I was in Room 6 (actually several rooms housing the outpatient mental health clinic) for our new weekly staff meeting. It didn’t happen because two patients were brought in nearly simultaneously by the police.

The first was a stocky, agitated woman of 43, barefoot and dressed in a ripped chitenje and torn blouse. She had beaten up all the passengers on a minibus (15-20). She is a successful professional with a lot of responsibility for people in her job of 20+ years. She also has a long history of Bipolar Affective Disorder with terrible manic episodes when she doesn’t take her medication. She has been in the main mental hospital (at Zomba) several times and clearly needed to be there again. It turned out that her clinic ran out of the depot antipsychotic she has injected once per month and which keeps her highly functional. Room 6 has run out of it, as well. The problem doesn’t seem to be money; rather, it is the inefficiency of the medication procurement process and bureaucracy. Anyway, she kept trying to leave, was on the verge of being violent with us, and, finally, a nurse and the ward clerk held and injected her with a sedative and an antipsychotic. After 15 minutes she lay down on a bench and fell asleep, awaiting family to transport her to Zomba.

The second was a 23yo woman, with a 2 month old infant, found wandering in Lunzu (a nearby village). The baby was seriously soiled and the mother said that since she lived underneath the lake she didn’t have to wash or change the baby. She was dirty and disheveled and terribly disorganized in her thinking, obviously psychotic, and unable to care for the child. Another nurse sat her down in a room and hustled over to the Pediatric Trauma Emergency Center and returned with a clean diaper and a tiny, soft gown for the baby. The nurse then washed the baby and carefully diapered and dressed him and gave him to the mother who, with instructions, was able to nurse him. Then the nurse washed his soiled garments and helped to settle the mother. The latter will also have to go to Zomba; social services will find a temporary placement for the baby. Of course, there was no gas for the ambulance to transport her and, since the police brought her in, she had no family to take her. So it would be a long wait on a hard floor awaiting her family, if they could be found, to take her on a minibus, assuming they have the fare.

I then responded to a consultation request by a young, Indian-Malawian intern, a graduate of the College of Medicine.  A 62yo woman was admitted to the Medical Service with “weakness”and the doctors wondered if she was psychotic. With the help of an incredibly bright young nurse, I found the woman asleep on a “floor bed”—-ie, mattress on the floor—with her guardian (niece) sitting on the mattress beside her. Mind you, this is a crowded ward, with not an empty bed and many guardians.  The beds are about 14 inches apart. With effort she was aroused and after taking a cursory but sufficient history and performing a minimally invasive physical examination, I determined: 1) she was in atrial fibrillation with congestive heart failure; 2) she had a major stroke 2 years ago from which she was recovering until a month ago when she had another; 3) she did not have a mental illness; 4) she was likely throwing emboli from her fibrillating atria; 5) there was precious little to be done for her, since anticoagulation and cardioversion were out of the question in this environment; 6) she could be given some aspirin and sent home to await more strokes, perhaps a terminal one.

In addition, I heard yesterday from one of our number that the electricity at the hospital in Mangochi had been cut the other night.  There was no petrol for the non-working-anyway hospital auxiliary generator and several women with obstructed labor had died, along with their infants, because no caesarian sections were being done in the dark. (I’m unclear as to why flashlights weren’t used.)

I haven’t talked much with anyone about the terrible hopelessness for people here, these lovely, bright, hard-working people. They continue to be friendly, to try to get enough food, to laugh, and to care for each other.  And to be receptive and engaging with the likes of us, who can always just jump on a plane and decamp if things get beyond our tolerance. I think my tears were a summation of the sadness I feel when seeing all of this. What accident of fate occasioned my birth as the healthy white child of two physicians, a citizen of the United States?

Yet as I write this, I look out and see several spectacularly lovely jacaranda trees on the opposite hillside in full purple splendor.   I plan to meet with the Dean of the College of Medicine in two weeks to think together about how this mental health training program can be sustainable and grow. It doesn’t feel sustainable now. The head of department is a very bright and savvy educator, a tough and compassionate teacher, and an indefatigable worker. Yet he’ll head back to UK in a year or two and I cannot imagine that they can find a replacement who can keep up his pace. I couldn’t.

This experience is like facing high surf at the beach. There is a thrill when you can successfully oppose the waves and re-surface after they break over you; but there are some that just knock you down. I must be approaching the low that our instructors anticipated with us.

The frangipani tree in our yard is about to bloom and the rains are only, hopefully, a month off. The brown land will soon green itself.  Let us celebrate nurses for their intelligence and compassion and tenacity and resourcefulness.

I had my Malawian intestinal baptism this week. Awakening at 1:30AM I visited the loo 10 times in the next 18 hours. Only one was a very, very close call. I cannot tell the source, as at least one other person ate whatever I ate and no one else suffered. After the 18 hours, and gulping Imodium (Which I’m now told is not a great idea. It is better to allow things to flush out normally. It didn’t work, in any case.) like peanuts, just as suddenly my gut lay limp, exhausted no doubt. I did not feel ill with this challenge to my intestinal flora, as I did with amoebiasis the last time I visited Africa (1972, Central African Republic).  Or the two times I had giardia, backpacking in Yosemite and in the old Soviet Union. Remember that dysfunctional behemoth? I think I am just getting settled, acquainted with the local bugs. There was a bit of drama to the urgency, though.

And speaking of drama, our daytime guard, Catherine, sees me as a mark. First, I have to say that I respect her immensely, raising 3 children on her own.  I was the one to whom she passed the note, supposedly from her 14yo son Joseph, requesting his school fees one morning after Linda had left for work.  I was still in bed, working on my laptop. Into my bedroom she came with the note, having requested a pen and a copy book before that. She will wait until Linda has left for work and then approach me. Once she came in looking wan, fell into a chair at the dining table where I was working, and said, “I sick”. I felt her forehead and she seemed hot. Malaria? Then she said, “Minibus fare.” “How much?” “Two hundred kwatcha.” I didn’t have MK200, only 500, so I gave her that and she left. On Friday. On Monday I asked her for the MK300 change. She looked puzzled and I said we’d take it out of her housekeeping salary at the end of the month. I have no idea if she understood me. She nodded and I went back to work. Yesterday she called me—“Georgie. Georgie.” When I got up from my desk where I was writing exam questions for my lectures, she was in the hall. She said, “I thought, sick, sick. But, no, I miss Georgie” and gave me a hug. She repeated this then shook my hand; hers was clammy and wet and distinctly not inviting. Still, I am a bit unsettled. Is this pretty 35-40yo Malawian villager coming on to me, a 76yo visiting professor at the College of Medicine? Am I flattering myself? Or should I be wary?  I know by my standards that she has terrible interpersonal boundaries, but then Malawians have a very different standard for that than we do. If our mantra is, “Cogito, ergo sum” (I think, therefore I am.), theirs is “I am because you are and you are because I am.” It’s called uMuntu or ubuntu and is a pan-African (sub-Saharan) philosophy.  It is clearly derived from agrarian village life in an unpredictable climate where they need to help each other survive in rough times (Like this year!). In any case, Linda and I discussed it and when Catherine calls “Georgie” I shall call back, “I am working.” I’ll see how that goes. She’s pretty determined, though. I have a fantasy that I’ll get a medical student to interpret for me and I’ll do a series of interviews with Catherine, getting her life story from start until now. If it turns into anything, maybe she’ll be an opening to others in her village. The proceeds of said best-seller would go toward tuition for all of their children.

Linda’s middle son, the chemist for Novartis who resigned and started a distillery (Short Path) in Boston that produces the best gin ever, has an Irish girlfriend, an engineer in NYC. Her younger sister, Emma, is a 5^th year medical student in UK and is completing an 8 week African elective, 4 in Cape Town and 4 in Nkotakota (9 bus hours north of us on Lake Malawi). She’s visiting for the weekend and it is lovely to hear a thick Irish accent. It seems every medical school now has electives, if not a department, for Global Health. Columbia had a couple of elective spots in Africa when I was there. I so wanted to go but, because I was in psychoanalysis, the Dean of Students (He who shall not be named!) felt I was “unstable” and nixed my application. I still resent it. My roommate and friend Harold got to go to Bareilly, India and see digitalis administered to lovesick 20yo girls with palpitations. Still, I love what I am doing so much that I wonder if it might have changed the course of my life. I can’t really complain, however, as here I am.

Emma’s Irish grandmother met a Malawian priest, Father Ignatius, in hospital in Ireland 11 years ago. They have been friends since and grandmother (now 90yo) helps with fundraising for the church.  Father Ignatius drove here from Zomba today to see Emma. He is a lovely, engaging man who hails from Mulanje, at the base of the mountain. He took us for a ride, kind of like my dad would do in his “topper-downer” (convertible) on a Sunday Spring afternoon in Seattle. We went to Thyolo (think Cholo) to view the lovely tea plantations, stopping to buy bananas, avocados, and papayas. Also, we each had an ear of grilled corn—not exactly Silver Queen but very flavorful. He pointed out the Montfort Missionaries’ compound, the Limbe Cathedral, and a variety of other properties and schools run and owned by the church. They have very deep and charitable roots here. The tea fields are always special to see; there were a number of huge, umbrella-shaped trees with yellow flowers all over them scattered throughout. Father Ignatius said they were another variety of jacaranda. As a boy he used to pick tea during the Christmas school break to make money to buy his pencils and copybooks. How life has changed!

The Stone of Ages Evangelical Assembly is rocking and rolling down the hill from us. It sounds almost like Auntie Dot’s Bottle Shop in the market nearby on a Saturday night. My kind of church music, loud with passion and a good back beat and lots of swaying in time. Someone recently asked me if I was an atheist. I’m not sure how it came up. Being brutally honest, I said “Yes”. He looked shocked. After I told Linda, she suggested I say “I go to Catholic Church with my wife.” She is not my wife and I am not Catholic. I do go, however, and in this very prayer-full country, it may be the best course of action. Having just given a lecture to the medical students about Personality Disorders, I’m mindful of Antisocial Personality Disordered folks for whom lying is painless and guilt-free. This seems like a tiny lie, equivalent to claiming an $8 lunch with a friend/colleague as a “Business Meeting” for tax purposes. (I am prepared to be audited at any moment!) And while the (loose) associations are flowing, an example of my overweening Superego is from the second time my wife and I were robbed, living on the Sacramento River. The first time the insurance paid about 50 cents on the dollar. This time I vowed to myself, “Someone is going to pay.” I called a friend, who is an audiophile, to gather names and prices of high-end stereo gear to claim so I could at least break even. I awoke in a cold sweat at 4AM, having dreamed a headline in the Sacramento Bee: “Psychiatrist goes to Folsom Prison.” The chance to meet Johnny Cash aside, I realized my reimbursement plan wouldn’t fly with my conscience. So I called the police and revised the list. Yes, I forgot I lent the Sony Trinitron to a friend and, actually, I found the receipts which were for low-end Kenwood stereo components. There was silence and then the officer cleared his throat and said, “Is that all?” “Yessir!”  Thus was my life of crime abbreviated.

We are considering renting a Land Rover or such 4 wheel drive animal and traversing Southern Africa to go to and through Namibia and down to Cape Town to visit my sister and niece and the latter’s family. We’re in the early stages of planning and this is just a teaser to keep those of you who are considering abandoning reading my weekly offerings engaged. Writing this feels a bit narcissistic—“a bit” you say—but it is a way for me to keep a record of this year for myself as much as it is to inform others.   Feeling I have millions hanging on my every word keeps me from disappointing them. I have long realized what a procrastinator I am and how deadlines are so helpful for me.

Samson met our minibus at the boma (“center of town”) in Mulanje. He was short, dark, slim, stylishly (guidelike) attired, and instantly said, “George, I’m Samson”.  He jumped on and we roared off to Lujeri, the village adjacent to the Lujeri Tea Estate, Bloomfield Hills. We exchanged the minibus for a hired, ancient, Mitsubishi diesel pickup with a bad battery and drove across the Lujeri holdings, an immense undulating moss-green tea plantation, exquisitely cultivated and dotted with huge, ancient purple-blooming jackaranda trees, with Mt. Mulanje in the background.

We’d arisen at 5AM, gotten a minibus to the Limbe terminal, and boarded another minibus to get to Mulanje (1 1/2hours away). Of course, you wait until the bus is full before it leaves. For us it took an hour. “Full” going was 15. “Full” coming back was up to 21 at times. These are Toyota vans, mostly beaten to death, with 5 rows of seats, some broken. At one time there were 6 people squeezed into the seat in front of us. Plus, amazing quantities of inanimate cargo, like bundles of firewood and foam mattresses.  It’s all part of the experience and, as such, OK except if only ½ of your butt is on the seat and the other is hanging off in the air it isn’t too comfy. But the round trip cost us MK6600 (about $9) vs. MK46,000 (about $62). Since we are on volunteer salaries and trying to live on them alone, it makes a difference.

The minibus terminal was fabulous, reminiscent of Jemmaa el-Fnaa in Marrakesh. Hundreds of minibuses: parked, coming in, going out. Constant theatre with everyone, exclusively men, hawking everything from little, ingenious travelling displays. A man selling wash cloths, tooth paste and tooth brushes in case you left home in a hurry. Little radios, vegetable peelers, pots, pans, colanders, mandaze (fried dough balls), soft drinks, chitenjes (lengths of brightly and beautifully printed cotton cloth), cigarettes, and on and on. My favorite was the bartender near our minibus. He put a 30×20” rectangle of cardboard in the dust (the bar) and placed a 2 gallon jug of brown liquid (the mixer) and the same of a clear liquid (the alcohol) on it.  His pants pockets were stuffed with old ½ pint whiskey bottles. A customer would come by, he’d carefully pour a 50:50 mix into a bottle, and money would change hands. At 7AM! Everyone trying to eke out a living and survive. The men all looked rather dusty, harried, and ragged, whereas each woman passing by walked gracefully through the scene, baby strapped to her back with a chitenje, wearing another clean, brightly colored one as a skirt, carrying a tub of water or fruit or tomatoes or onions on her head, no hands.

I’ll digress to language and signage, some of which we saw on the ride to and from Mulanje. Malawian’s use of English is creative and their many signs express it. Like “The Lord is my Savior Pork Butchery” or “Everyone’s Got Problems Goat Butchery”. The “No Black-out Barber Shop”, referring to the frequent electrical outages—-ours went out at 6PM last night, went on in the middle of the night, awakening us to lights on everywhere, and has been off from 5AM (it is now 7:30PM). Carlsberg beer, which has been the only beer allowed in Malawi for 50 years, has a puzzling motto: “Probably the best beer in the world.” However, “Difficult to Understand Investments” is a new favorite. Many stores in every town have a name, often the proprietor’s, followed by “Investment”. Initially I wondered how such a tiny country could support so many stock brokers.  I think it means the owner would like some capital investment to increase his stock. With the idea you’d share in the profits. Which would seem to be few and far between.

Mount Mulanje is like a huge granite plug pushed upwards from below, towering at the highest of its 50+ peaks over 3000m, the highest in southern Africa north of the Drakensbad. It’s kind of the inverse of Yosemite, with similar granite shelves on which to walk. It is a massif, rather than a mountain, with incredibly steep sides leading up to the plateau, which is crisscrossed with ridges and valleys and dotted with cedar and fern forests and granite peaks, all within 600 sq. kilometers. It is a lawless place, although not of danger to us. There is illegal logging and as we struggled up the long, steep climb, punctuated with many and extensive ladders (of the flimsy variety), down would come buff, glistening, half-naked young men either barefoot or wearing flip-flops and carrying 60kg cedar beams on their heads or shoulders. There are extensive burned areas, where hunters set fires to flush out game and turn their dogs loose on the poor critters, completing their gristly task with a large panga knife (machete). But it is also wild and beautiful, with rivers and pools and glens. The Dept. of Forestry maintains a number of huts on top.  As newly minted members of the Malawi Mountain Club we have a key allowing access to pots, pans, dishes, mattresses, blankets, etc. The first hut, Madzeka, was one room, tin roofed, with a balcony and a fireplace for cooking. With a stream for water and a clear pool in which to bathe, it had intimate views and a very cozy feel. Each hut has, or is supposed to have, a hut keeper who lives at a little distance, supplies wood and water, washes the dishes, and keeps things spiffy.

We were supposed to spend the second night at Minunu Hut, but Samson learned that it had been emptied two weeks prior. The hut keepers are at each hut for two weeks, when they go down to their villages and their opposite ascends to care for things. Unfortunately, the second hut keeper has a broken leg so no one was minding the store and lawless elements intervened. So we stayed at Chinzima, part-way to Minunu. It had two rooms and a panoramic view of ridges and peaks, quite spectacular. It, too, was missing blankets so we improvised and with the help of a fire were quite comfortable. We passed by Minunu on our way out and it was incredibly lovely, perched above a long crystalline pool, with an apple tree in full bloom, a peach tree, and “Irish” potatoes in a garden. It turns out only the mattresses and most of the blankets had been taken. It is certainly worth a trip back. Excepting the exotic flora, plus a strange eagle and a white collared raven, we could have been in the Rockies or the Sierras.

As for the hiking, I struggled mightily on the way up. I felt bad partly because we ate breakfast at 5:30AM, partly because it was hot and I got behind on hydration, partly because I take a small dose of an antihypertensive medication, and partly because I haven’t been exercising much for 3 months. I got dizzy and faint and really struggled. Oh, and partly because it was a very long, very vertical walk. I felt much better after some food, water, and a brief, cold plunge in a lovely pool. The next day walking on the plateau was wonderful and I felt strong. On the last day we descended on a long and incredibly steep “trail” which is inaccessible during the rainy season. I was fine until the bottom when my legs became rubber. I felt no discomfort, just like I had muscular dystrophy. The legs refused to do what I wanted. I fell to my knees only once and wasn’t at all hurt. It was mostly strange. Seeing the occasional monkey leaping in a nearby tree was helpfully distracting. I occasionally felt similar as a teen, at the end of the day after skiing hard. When we ascend again, I’ll eat, drink, skip my antihypertensive, and be in better shape. It is amazing to me how much time I’ve wasted worrying I’d die young of a coronary, since both my father and grandfather did.  My heart keeps pumping. With full disclosure, honorable mention goes to Clement, our sweet porter, who carried our (heavy) pack.

It was a glorious 3 days and an excellent antidote to the bustle and dust and heat of Blantyre and the grim circumstances of Room 6 at Queen Elizabeth Central Hospital. I am so stiff today it is a miracle I can pump my bicycle to work. Seeing how simple, cheap, and entertaining riding a minibus can be, we’ll take more out-of-town excursions to places of natural beauty, including Mt. Mulanje again, of which there are many in Malawi.

The past week was the Silver Jubilee (25^th Anniversary) of the founding of the College of Medicine (COM) of the University of Malawi. The first class had their 4 pre-clinical years in UK or Australia and returned to the COM in Blantyre in 1991 for their clinical 5th year, prior to beginning their 18 month residency. The COM has its own teaching, research, and administrative campus, complete with hostels for students, a large modern library, research labs, a large computer lab, and a large, new sports complex.  It uses the sprawling 1200 bed Queen Elizabeth Central Hospital as its primary clinical teaching site, although students rotate through the newer Kumuzu Central Hospital in Lilongwe, as well.

I’ll try to capture some of the quality of the celebrations, as they say a lot about Malawian culture. To begin with, a theme, “Excellence Yesterday Today Tomorrow”, was chosen, logos designed, and miles of cotton fabric were printed. The fabric was then turned into drapes for stages, chitenjes for the women to wear, ties, scarves, and, most remarkably, skirts, dresses, and shirts. It seemed everyone bought some material and took it to their tailor, who fashioned a unique garment from it. I purchased a tie but gave it to an elder statesman (Hell, I’m 76yo. Am I a Young Turk?!), a Brit who had started a large malaria and infectious disease research program which is continuing, funded largely by the UK Wellcome Trust. He had to give a speech and hadn’t a stitch of commemorative garment. I then bought a scarf.

There were speeches, some celebratory (“We have been excellent, we are excellent, we shall be excellent forever.”), some visionary (“Only change is constant and we must continually adapt.”), to sobering (“We are successful at educating doctors. We are not so successful providing them with employment, so many leave for Botswana and Lesotho.  We must change that.”)  It wasn’t, honestly, so different than the lofty rhetoric I heard at my Harvard 25^th Reunion. Harvard was more successful in raising funds from the alumni on that occasion, I’ll warrant. The COM Alumni Association was just founded 5 months ago, speaking to the sorry state of the economy and doctor’s wages here.

There was astounding syncopated drumming and dancing. The dancing was so sexual, such pelvic thrusting to the delight of the dancers and audience, it isn’t surprising the birth rate is so high! I imagine that the modesty of dress (no pants worn or short skirts above the knees for women) is what we’d call “reaction formation”, an expression of that sexual disinhibition in a reverse expression in an attempt to both express it and contain it. Lake Malawi sits in the Rift Valley, where we all started. Freud had it right in thinking that sexuality is a very fundamental motivator, as we could all see during the celebrations.

There were a lot of award ceremonies. For excellence in studies, in research, and in sports (intramural during the week) and a set for longevity of service. My experience of awards ceremonies, and I am a child of the ‘50’s, is that they are somber, even sometimes funereal, events. These were the opposite, with running, dancing, acrobatics, singing and other joyful expressions by the winners and the audience.

There were two skits, one performed by medical students and the other by COM staff members. Each took place of the back of a flatbed truck, each truck draped in commemorative cloth (blue, white, gold and black) and complete with props. The smaller was a family planning skit in which a mother is asked if she wants birth control and she says, essentially, “Why? I already have 11 children.” There was a husband, a large stuffed bear representing a child, and an assortment of medical students and doctors. It went on for awhile, all in Chichewa, to great hilarity.  The other skit was to honor the skills of all the departments in the hospital. A mother enters in labor. The baby is too big and she has a c-section by the Ob-Gyns. The baby requires resuscitation by the Pediatricians. Meanwhile, the father is so upset he has a cardiac arrest and needs CPR with defibrillation. The poor mother, seeing what has happened with her baby and husband, becomes depressed and needs Mental Health services. There was a surgical procedure, as well. The family was happily and healthily discharged to home. It was a scream!

Last night was a banquet, modest by our standards but lavish by theirs, in the gymnasium of the Sports Center, all dressed up. My bike chain broke on the way over so I was a bit greasy, wondering about getting home. We volunteers are not to walk around the streets at night; I thought I could ride home across campus so swiftly I’d be fine. Change of plans, it seemed. There were vodka fruit drinks—I am perhaps the cheapest drunk around and I couldn’t detect a bit of alcohol in mine—and a buffet supper and lots and lots of awards and speeches, including one by the former first vice president of Malawi after independence. A band of medical students and members of the COM played and crooned, the volume always too high for good conversation as is usual at banquets. I spoke with a government finance guy who asked if I’d be voting in the US election. We got off on Trump and how Malawians who thought about it were unable to grasp how we could have a candidate so crass and unsuited for the office of president. I said my GHSP commitment was only for a year but if The Donald was elected, I should remain 4 more.

In characteristic fashion, I didn’t get a formal invitation to the banquet, although the Master of Ceremonies made a point of telling me he had been looking forward to seeing me there.  I didn’t even know about it until 5PM the night before. Linda had planned to go to Zomba for the weekend, as I needed to work preparing lectures and exam questions, the latter a very exacting process. All questions go through committees for approval or not. So she wasn’t at the banquet, which was too bad for me.

After the last award and the last speech, the last bit of dessert enjoyed, and the final bit of conversation concluded, we all moved to a large balcony and watched a tremendous display of fireworks on the sports field in front of us. Judging from their ability to fashion those displays, I do think the Chinese are in ascendancy, even if their factories occasionally explode, killing all inside. I was offered a ride back by some kind staff in a Range Rover when I found that my shortcut across campus was blocked by a locked gate and I’d have to walk the bike home via a long, circuitous route.

The Jubilee grew on me. I was at first skeptical of the self-congratulations that accompany such events, knowing the health care conditions in Malawi. But I now am amazed at the vision, persistence, and creativity exhibited by so many that is required to create a genuine quality medical education training center in a country of such modest means. In their 6 week rotation through Psychiatry the medical students have a much more thoughtful and well-executed exposure to mental health issues that I received at Columbia University College of Physicians and Surgeons. I realize it isn’t 1964, but it is impressive.

Today I was born. In 1940. It seems incredible to live so long. Since my dad died at 55yo, and his father at 42yo, I thought 68 was my time. It was when I was discovered to have lung cancer. But, with help from many, including my close friend Harold, my wife, and my son, I dodged that bullet. Now we are planning a three day hike up Mt. Mulange, the highest peak in southern Africa in two weeks. With a guide and a porter, thank you. And staying in the Mountaineering Club huts, where there are bedding and cooking utensils. The high plateau is supposedly very beautiful, although when Stefan and Lucy went up a month ago a black mamba fell-slithered-rushed down the trail beside them. I’ll take my hiking poles!

The daily blackouts are trying at times, especially when I am preparing a lecture and wanting to review literature on-line. Or read my email. Or make supper. The propane burner cum tank which I bought and filled works very well. Our current catch-phrase is I’ll do this or that “while the power is on”. One of us jumps up at 5:30AM to make tea with the electric kettle since in the morning power often goes off at 6AM. If the power is off when we go to sleep, if awake in the middle of the night and the outside security lights are on, I have gotten up to read email, download a document, or review the literature to prepare a lecture. Talk about social control. You could train people to jump through all sorts of hoops by varying their utility services. They are having water shutoffs in Mangochi; we have two full covered tubs so we can drink and flush the toilets for awhile if we have cuts here.

I resurrected the bike that Peace Corps gave me. It had a new chain but otherwise: both front and back brakes were locked, both derailleurs function only partially, the rear tire was flat in a day, and my helmet was missing the liner so the little Velcro buttons used to hold the liner in were very scratchy. I have three much better bikes at home. Excepting that the best bike is the one you have with you. So I’ve adjusted, lubricated, replaced, and removed things, respectively, and ride to work, either at the College of Medicine or at Queen Elizabeth, each of which is less than 5 minutes by bike. I seem to move slowly in the morning so the speed helps. Chipitala (“Hospital”) Road is busy only with pedestrians and tiny plywood stalls where they sell everything. The fresh French fries (“chips”) are truly fabulous—-how far I’ve fallen from Berkeley gustatory standards—-with salt, vinegar, and hot chili sauce. (“Nali-HOT” is a local product and universally used in case of dull seasonings.) All in a little blue plastic bag. Which litter the roads, so we wash and reuse ours as many times as we can. In any case, the biking on Chipitala is fine but elsewhere it is variably and, often, wildly, dangerous. No shoulder, narrow road, loaded minibuses racing to make more fares. I look for less direct, less travelled routes and footpaths, always wearing a helmet. You can spot PC vols on bikes from a distance; no one else wears a helmet.

I consulted on a 77yo man in clinic today. The students have started in clinic and they actually do the heavy lifting, while Stefan and I oversee their work. This man has been seriously deteriorating recently, wandering naked, getting lost, urinating in the house, etc. His son brought him in. He has been drinking heavily all day starting at 6AM, every day, since before the son was born. And the son is 45yo. So his dad has alcoholic dementia and alcoholic cerebellar degeneration; his gait is so ataxic he can hardly walk, even with support.  The saddest part for me is that he is a rare bird here, having studied in UK on two occasions. The last stint was to get an MA in a profession of which he was the first black African to occupy a position of leadership in all of Africa. It was sobering for me and the students, as I gave them a 1 ½ hour lecture yesterday on Alcohol and Substance Abuse. Funny thing was, although he was quiet and stooped, when he sat still you wouldn’t have known how compromised he was. His English was simple but impeccable.  However, when I asked him to touch his finger to his nose and asked him the date and location, he became wildly ataxic and lost, floating in a timeless, unrecognizable world.

On a happier note, the ubiquitous pied crows are endlessly present and entertaining. They look like other corvids, about raven-size with the addition of a white collar and a white bib. Formal, dressed to the nines. Playing, using tools, fooling around. Our weeping willow with red bottle-brush blossoms is now stunning. From a Californian’s perspective, it looks like some pretty drunken grafting was going on. On a gardening note, Linda gave Simon the gardener 3500 Kwatcha (about $5) to buy some seeds for a vegetable garden. Four hours later he was roaring drunk and expansive but with no seeds. Linda does not believe in co-dependency and said either he get the seeds by Monday or she’d report him to his employer. Myself, I’d feel sorry for him and probably give him another 3500K and a supportive handshake and hope for the best. Well, she scared the shit out of him and he is working like he should; we have three garden plots planted and watered. I have no doubt if we’d followed my lead he’d be drunk again the next day. So tough love helped him not be stupid, lose his job and feel like a failure. Lessons everywhere. There is a saying that you can ruin a Malawian’s day by not bargaining for something they are selling. If you pay full price, they’ll curse themselves for not charging more. And the smile on their face after you have bargained, and they are content with the price, is wonderful! So different than with we azungus (whites) from the US; every transaction here is a social experience of note.

In celebration of my birthday, and celebrations seem important markers of familiarity in this very different (dare I say “strange”) land, Linda cooked a wonderful meal and we invited all the GHSP volunteers in Blantyre plus some friends for supper. In preparation I bought another bottle of Malawi Gin (for MGT’s), we laid in tonic and made ice lest the power die (which it did), and I went to GAME for a special on Carlsberg Green. It was 465K a bottle as opposed to the uniform, monopolistic 550K. I rode my bike a mile and a half up the hair-raising highway to the store, bought the case, and removed my seat so the case could sit, strapped with bungee cords, on the bike rack. Then I walked it home awkwardly, it being pretty top heavy. When the sidewalk was crowded, the bike would threaten to flip away from me into the concrete spillway 5 feet down. So as I’m sweating and pushing and tugging and wondering why I didn’t just take Stefan up on his offer of a lift in his car, this slender woman passes me, gracefully swaying with about 75# of chick peas on her head, baby strapped to her back with a colorful chitenje. Why didn’t I just ask her to hike the case on top of the chickpeas? She surely could have done it. I can feel feeble and dull here when confronted with the locals’ resilience.

The birthday was fun. The power was out so we had candles everywhere. Linda had purchased a wok pounded out of an old barrel and made tortilla chips, which she deep-fried over the propane burner, to scoop up the salsa. The slow-roasted dry-rubbed pork shoulder (Thank you, David Edwards!) was beyond delicious! Linda saved a taste for the local pork vendor in the little market (chunks of pork on a slab, under a tin roof, no refrigeration); I suspect he may be buying slow-roasted pork from us in the future! Fresh cornbread, delicious cole slaw, beans, and fried rice (a la Darron) completed the meal. For dessert, apple pie (Elizabeth), carrot cake (Anneka), and absolutely the best ice cream I’ve ever tasted, fresh, homemade passion fruit (Polly and Karl). Conversation was lively, reaching from local gossip to the history of the Italians in Malawi (They refused to use the British railway to transport goods, which totally infuriated the Brits.) to the endless stream of casualties of medicine on the wards at Queen Elizabeth. I have to restrain my enthusiasm for my current state of employment, the medical students, and my Chief; I think I am having, at present, the most fun and rewarding experience of any of the GHSPers.

People here are not fat like so many in the US, despite a heavily carb-loaded diet. They move and work constantly, carrying all on their heads, shoulders, or bicycles: huge sacks of charcoal, huge sacks of potatoes, other fruits and vegetables, kindling wood, bags of grain, planks, furniture, you name it.  Malawi is too poor for the motor scooters which plague SE Asia.

There are very few joggers and little need for recreational exercise. Life is physical and lived close to the ground here.  Life span is 58 for men, 61 for women. Knowing now some of what can get you here, it’s understandable but lamentable. HIV/AIDS is now remarkably down to 10% of the population.

Tiwonana. (See you later)

We just finished the first week of teaching, a week of Child and Adolescent Psychiatry for half of the 4^th year class at the College of Medicine. My co-teachers were Heather Gardiner, a child and adolescent psychiatrist from Scotland (now living with her husband, a professor of forestry, in an old limestone pile on a hill outside of Bordeaux) and Kathleen MacKay, also a Scot from outside Aberdeen, who has specialized in the Developmentally Disabled (mentally retarded, intellectually disabled, developmentally delayed. It’s like being half asleep, lying on a piece of grit and rolling about fitfully trying to get away from it. There is no easy way.). Both have been here before, for two week blocks of teaching, and both are delightful and thoughtful women.

The students, all 42 of them, were bright, fun, hard-working, and engaged. If the other half of the class, whom we teach in the Spring, are similar, this will be a great year. It is pretty bleak after graduation and internship for medical students as the government doesn’t, but should, fast-track them into jobs or residency training programs, of which there are several here, including General Psychiatry. So some get jobs, some languish, some go to Lesotho or Zambia or elsewhere to work, although they want to be at home in Malawi. It is incredible how things work (or don’t) here, like medication procurement. It directly affects patient care in the worst way and there is no good, logical reason it should be so dysfunctionally bureaucratic. But it is. A bit like doing jazzercise in a swimming pool of warm molasses. I must be ready for breakfast! I’ll have more about the teaching and students as the year progresses. They are a high point and to watch them roleplay an interview with a patient is hilarious when they are trying to demonstrate bad technique—-finger pointing, talking on the phone, firing questions, groaning loudly, “That’s horrible.”, and so forth. Excellent dramaturgy.

We visited a large home/program for street kids, Samaritans.  It is run on a shoestring and provides the children with safety, food, clothing and shelter, basic education to prep them to go to the neighborhood public school, vocational training, and, crucially, caring relationships with good boundaries. The kids, as everywhere, were open and fun to interact with and the students got a real kick out of eliciting their stories. Three girls were there from Zambia. Their mother died in childbirth with the youngest girl, at which point the mother’s relatives stole all the family belongings and threw the children out on the street. With their father and paternal grandmother they slipped over the border into Malawi, lord knows why. Their father ran off, not to be seen again, clearly overwhelmed. Grandmother was alcoholic and smoked chamba (marijuana) and when they confronted her, she beat them. So they ran away. Samaritans sweeps Blantyre twice per week for street children and picked them up. They are 13, 11, and 7yo, bright and cute and very happy to be in a safe, caring place. There are goats and pigs, and a garden of vegetables in the compound.

Samaritans is looking for a new vocational project—somehow the bicycle repair ran its course, although the bricklaying continues. I shall apply for a small Peace Corps Grant to bring in a young volunteer, Anya, who is teaching villagers how to make briquettes from a slurry of leaves, cardboard, and rice hulls, all of which are plentiful. They are put through a simple press, built by a local carpenter for about $20, and dry for a few days. 5-7 suffice to cook a meal, saving trees and the labor of gathering the increasingly scarce wood that is available. A teenager can make 30 briquettes per hour, so with a few machines they could have quite the factory. The director of vocational training was thrilled when I suggested it to him. A psychoanalyst and child/adolescent psychiatrist’s scope of practice is pretty wide here.

Lying in bed under the white mosquito net, with my eyes half closed, is like going through the fog on Penobscot Bay, travelling from our island to the mainland. We take turns getting tea and the one up first wraps the bottom of the net and tosses it onto the ceiling of the net, creating a lovely white cloud floating over the bed.  Small pleasures.

I am astounded at the resiliency and ingenuity of Malawian villagers. They have little or nothing to eat much of the year, no bank account or steady job for income, few clothes or possessions, and extremely simple dwellings. They are subject to everything from puff adders and mambas to malaria (It is all falciparum here, the bad kind that kills you with cerebral malaria and/or Blackwater Fever.) to you-name-it parasites, and on and on. Smiling, sitting in the dirt all day, colorful stacks of tomatoes and cucumbers and eggplantsbefore them (all of which they have grown and carried to market), a baby strapped to their backs with a beautiful chitenje, gracious in bargaining, curious, and friendly. Certainly it makes me think about what I get irritated by and how petty most of it is. And given the primitive level of health care available to all of them—-The Clinical Officer in each district health center is basically a Physician’s Assistant who makes complex diagnoses, prescribes medications, and does surgery,. He/she will see 300 patients in a day— they seem impossible to kill! Clearly they were the beginning of us all, as the Leakey’s determined and as their continuing vitality suggests.

I’m reading The Doctor Stories by William Carlos Williams.  His description of ol’ Doc Rivers puts me in mind of this place. Williams’ poetic sensibility and humanity and practicality is the perfect antidote to the despair you can feel here if you allow yourself to slide.

We are becoming accustomed to the rolling blackouts. The drought has so lowered the water level in reservoirs that conservation is necessary. Today we had no electricity from 6AM to 4PM—-I made tea just before 6, happily. Yesterday there was no power from 4-9PM. We skipped supper. It isn’t so difficult to skip a meal, actually. A bit of hunger for awhile and then it vanishes. Good for the pocketbook and the waistline. Sometimes we have a Green or a Malawi G&T with lime, if we can get tonic. Tonic water is often unobtainable in the entire country. Makes you want to stock up.

After morning clinic today I tailed Stefan and Alex to do three consultations (of 5 requested) on the wards.  Alex is a young doctor who wants to do a Psychiatry Residency. He is well-suited for it, having a quick, psychologically-adept mind and a lovely way with patients. He currently works in the Pediatric Emergency Department. Stefan is trying to persuade the Ministry of Health to fund Alex for the residency training, along with three other residents, starting in March. Given the mountain of trauma, depression and major mental illness here, it seems like a no-brainer to train some psychiatrists to lead the country.

I was concerned that the smells in this hospital would be overpowering, given the lack of staff and the crush of patients and the families attending them.  While the hospital provides food for the patients, the “guardians” attending them (Noting the conditions at some times, I see the need for guardians!), who lounge in the sun on the many, many lawns and dirt courtyards enclosed by and surrounding the hospital, often cook for and feed them. But miracle of miracles, the floors are scrubbed by uniformed teams at least twice per day and the hospital wards smell very neutral. I suspect they cannot afford much disinfectant, which fact improves the air quality.

Our first consultation was a 37yo woman who had a C-section and subsequent hysterectomy (multiple fibroids) the previous day. She awoke from the anesthesia combative and psychotic, terrified people were trying to kill her. She’d been restrained and sedated over 24 hours with chlorpromazine (Thorazine) and diazepam (Valium). She was sedated at first when we met her and her husband. He was able to tell us that she’d never been crazy or violent in the past. As we talked she gradually awoke and became more alert—-and calm. We removed her restraints and considered that she had a brief psychotic episode secondary to the anesthesia. Simple, our work was done for us. It may turn out that seeing a consultation 24hours after the request is submitted is not a terrible way to practice, given the resources.

Consultation #2 was on one of the male wards, an open affair with wings and probably 75 beds, all told. He was an unresponsive 23yo man lying on his side with a naso-gastric tube taped to his nose. He’d been violent at home and then swallowed keys and other metallic objects, which we could see on an x-ray film, traversing his g-i tract. His eyes were open and he followed movement but was otherwise catatonic. After futile attempts to talk with him, we took his mother to an exam room where she provided the following history. He was HIV negative in March, always a first step here. He had a history of cerebral malaria at 2yo and was unconscious and in hospital for a month, with consequent delays in locomotion and speech. He seemed to do alright with primary school but struggled in 4^th Form (high school) and dropped out. Described as friendly and liking to make music, last December his behavior changed abruptly, he became violent and after a week had a single grand mal seizure. He was put on phenobarbital (even the supply of Dilantin/phenytoin is insecure) and hasn’t had a repeat seizure. He was also on an unknown psychotropic for a few months but hadn’t taken them for the past 2 ½ months. On the day of his admission he had trashed their hut and broken all his electronics. It is unclear why he had a dramatic behavioral change and a seizure in December and it requires investigation with an EEG and a CT scan or MRI—the latter may not be possible until he passes all the metallic objects he swallowed. Stefan prescribed a small amount of iv diazepam and im risperidone, hoping to lyse the catatonia. We’ll follow up with him in a couple of days.

The last man, a 57yo farmer with a long history of well-treated Bipolar Disorder, was referred from a district hospital where he’d been discovered to have a tumor in his mouth. At QE he had the resection of a large squamous cell carcinoma from under his tongue and a skin flap rotated to cover the deficit. After surgery he became agitated and psychotic. Rather quickly, we realized that he hadn’t been given his antipsychotic, which he had taken religiously after spending a year in the Zomba Mental Hospital in 1996-7. His guardian, a maternal uncle, was very helpful with the history. Again, the Clinical Officer on the ward had given him some chlorpromazine and he was lucid and calm with us. He couldn’t speak much because of the surgery and, we sensed, because of privacy issues. The valproic acid supply is not reliable; lithium isn’t used because of the difficulty with monitoring levels. I haven’t seen tardive dyskinesia but I anticipate there must be a lot, given the broad use of (especially) first generation antipsychotics (Thorazine, Prolixin depot, Haldol).

It is an experience to walk onto a large ward where every bed is surrounded by between 1 and 4 relatives attending to each patient. Colorful chitenje’s cover the blanket on the bed, there is chatter and nsima with relish being devoured, and it feels a bit like a party, despite the fact that some of the patients are desperately ill and will die soon.

The consequences of severe head injuries from motor vehicle-pedestrian or motor vehicle-bicyclist interactions are commonly seen on the medical wards. For many people, I suspect, “Progress” has meant a degradation of their lives. Certainly degradation of the environment.  Lots of plastic bags by the roads, all small and a nice azure blue, looking like flowers. There is a BMW dealer in town.

I was thinking, since this major hospital in Malawi is named Queen Elizabeth, perhaps I should write a note to Her Royal Highness (though some of her kids seem determined to make it Lowness) requesting a modest sum to improve things. If any of you readers have her ear, please let me know.

Three of us travelled to Zomba today to visit the primary mental hospital for the country. The little town of Zomba is pretty, sitting at the foot of the escarpment leading up to the Zomba Plateau. Zomba Mental Hospital sits across the street from the Zomba Central Hospital; at the apex of the triangle is the Zomba Prison. Quite a triad in very close proximity.

Zomba MH is a 400 bed hospital, of which currently 155 are occupied. This is divided between men and women, about 2:1 and between Acute (av. 14 day stay) and Rehabilitation (av. a month). There is also a small Infirmary, largely for the severely developmentally delayed, many of whom were picked up wandering and cannot say where they are from. So they may stay for years.

We first met with the Director, a bright, sophisticated nurse with some years of experience. She was very welcoming and served us mango juice and cookies as we talked. She and Stefan discussed the issue of medication procurement; the funds have been set aside for a modest, basic formulary but the wheels of bureaucracy just turn very slowly. It is somewhat of a crisis, however, since most hospitalized patients are psychotic for one reason or another and require medication. The small mental hospital in Lilongwe (4 hours away), Bwaila, has been transferring patients to Zomba because they are have out of medications. And if the two central hospitals are out of meds, the district health centers and district hospitals surely won’t have any.

We met one of the three Clinical Officers who showed us around. He was bright and informed, having worked there, basically as a psychiatrist, for 6 years, evaluating patients, doing physical examinations on all of them, prescribing medications, giving electroconvulsive therapy to those profoundly depressed who don’t respond to medication, deciding upon the dates of discharge, etc. Both ECT machines are unfortunately broken at this time.

The hospital is remarkably clean and has a neutral smell—neither of cleaning agents nor bodily secretions/excretions. It is on a gradual slope, all one story with many connecting cement corridors. Some windows were broken and the ceiling tiles were missing in many parts of the buildings, clearly because of leakage during the rainy season. There are 8 beds in each room, 4 rooms per ward, and separate courtyards for each section. There is apparently some occupational therapy and there are TV rooms. We walked through the courtyards among the patients and some approached us while others seemed indifferent to our presence. None were threatening. It was eerily quiet and no staff were interacting with patients, other than to redirect them away from us. Everyone seemed subdued, as if by Thorazine. Hmm. As we walked out after our tour, music was being played for a dance class.

We had lunch at African Heritage, a very pleasant outdoor café with a gift shop and then went with Stefan to check on the house the Scottish Mental Health Foundation rents for their volunteer psychiatrists. It was up on the base of the escarpment, a four bedroom home with a front verandah overlooking the large garden below (mangos, avocados, papayas, frangipani) and the entire valley with mountains beyond. $180/month.

I think I am slipping into accepting the limits of psychiatric treatment here. It’s not that I won’t attempt to press for improvements. It is just that it will do no good to anguish over it. It is pretty astounding, however, to think that the major mental hospital in the country cannot keep its extremely modest formulary stocked. There is a lot of perspective to be gained here. And a remarkable opportunity to train residents and medical students about relationship, rather than the manipulation of neurotransmitters.