Author: Children Deserve Better

So much has transpired in the past week, I’ll have to abbreviate my descriptions.

The last night at the Bridgeview Hotel was not great. We both slept poorly. A mosquito was whining around and when I tried to shut the window it stuck and then slammed with a loud “crack”, awakening Linda. The mattress had been feeling very hard for the previous couple of nights. A regular PC volunteer (he’s recovering from pneumonia) mentioned yesterday that he moved to the Korea Garden Hotel because his bed here had no mattress. Eureka! We checked and, sure enough, we were sleeping on the bottom side of a box spring, slats and springs and all. No wonder my shoulder was so sore when I slept on my side! So, we asked them to put a screen in the window and a mattress on the bed; I suspect they have too few of each and rotate them from room to room until the next person complains. We are sure we had a mattress for the first week or two. My side of the bed then smelled foul, like sweat and urine, and I couldn’t imagine that came from me. I checked carefully and the mattress was scented with another’s perfume. Let’s get out of here.

Writing this in the lobby so as to get internet, I heard “George?”.  There was a young man, my height (short), with a buzz-cut and a very engaging smile shaking my hand. This was Stefan, my counterpart and boss, the only psychiatrist in Malawi and the Director of the Department of Mental Health at the College of Medicine. He is bright, warm, flexible, hard-working, and very friendly. He’ll become a good friend, as well as a partner in crime, as we plan together how to improve the provision of mental health services in Malawi.

As far as he knows, there is only one Malawian psychiatrist in the world. (Two are currently in training!) That one previously ran the country’s primary mental hospital (250 beds) at Zomba, of which you’ll hear more when I work there. But he decamped for Manchester, England. So our work with the advanced medical students and three psychiatry residents will be important. The lecturers and mentors will include the two of us, as well as a cadre of visiting psychiatrists from Scotland who come for a few months throughout the year, often returning the following. I’ll expand my repertoire to teach Old Age and Addictions and have some ideas about each of them. The students apparently love to role-play and the curriculum is being altered so that it is more interactive and less lecture-based. The students are supervised seeing patients in the clinic at Queen Elizabeth Hospital (“Queenie”) in Blantyre and they work with inpatients at Zomba during their 6 week psychiatry rotation. If this description is confusing to you, imagine what I feel!

Stefan asked me to accompany him to Kamuzu Central Hospital where we saw a government figure who was having a hypomanic episode, complete with sleeplessness, limitless energy, and paranoia. Luckily, he was with his wife and child and they helped him to listen and agree to a trial of medication (which has helped him in the past). Cultural differences aside, Stefan sees eating disorders, anxiety disorders including PTSD, depression, bipolar disorder, and schizophrenia, a similar spectrum to American or European mental illness. 
In any case, this promises to engage me and stretch me and be a lot of fun, especially with such an ally. He and I snuck out for a couple of beers that evening and talked about ourselves and our lives/hopes. He’s Austrian, raised and schooled in Vienna, and did his psychiatry training in the UK. His partner Lucy, whom I haven’t met, is a journalist who worked in Egypt setting up Al Jazeera.

Two days later we were sworn in at the Ambassador, Virginia Palmer’s, residence. It is a lovely sprawling home set on acres of gardens with a swimming pool and a 9 foot Steinway in the living room. Speakers included two among the GHSP volunteers, in English and in Chichewa, the Peace Corps Country Director Carol Spahn, the Ambassador, and the Minister of Health. It was very moving to hear Peace Corps (accurately, I think) described as one of America’s best foreign policy initiatives, now 55 years old.  Then wonderful snacks and a cake and talk and we left to change and pack and drive to our sites. We have now bonded and left others several times: our wonderful faculty and the Liberia and Swaziland volunteers in DC, the Uganda and Tanzanian volunteers at the airport in Addis, and now we Malawi volunteers are scattering to 4 different cities: Mazuzu (think “coffee”), Lilongwe (the capitol), Mangochi (near the lake, hot, mosquitoes and alligators), and Blantyre (center of commerce). I feel a twinge of sadness at the separations.

The bus carried us for 5 hours through the Malawian countryside, which is dotted with beobab trees, huge termite mounds, the ever-present mud-brick kilns (a huge loaf of bricks with openings underneath in which to set and stoke fires), little villages of mud-brick huts with thatched roofs, and the strikingly steep mountains that jut up from the plain here and there. Occasionally we’d drive through one-street towns with shops—Howarth’s Panel Banger (ie, body shop)— and the ubiquitous open markets selling everything from gorgeous fruits and vegetables to tires, sacks of terrazzo grit, bales of used clothing being prepared for sale, and the famous Malawian delicacy, mice on a stick. So, a curved stick about 3 feet long has perhaps 10 mice skewered on it and then the entirety is roasted. I haven’t tried them yet. The seller stands by the road holding up his stick(s) like a phallus, seeking a sale. The bus carried all the luggage, 3 volunteers, and 3 faculty from the College of Nursing. We stopped in towns for the faculty to bargain for vegetables and fruit, considerably cheaper there than at home.  On both stops the bus was surrounded 3 deep by merchants selling chips, peanuts, cabbages, eggplants, cold drinks, and so forth.

Peace Corps is scrupulous about our safety and forbids driving between towns after dark. Just as darkness fell, we entered Blantyre, a hilly city with many trees and handsome houses behind tall brick fences topped with glass shards and/or barbed wire, each with a guard in front. In the dark we drove past Queen Elizabeth Hospital (1000 beds, old, one story) and turned down a quiet dirt road to discover our new homes for a year. We unloaded, looked around inside, had a beer, and fell asleep.

The house looks like a 50’s ranch, brick with a long covered porch in front with a sloping lawn. The house sits on about ¾ of an acre and has views over the city and of a sharp, tall mountain. The rooms are large, with three bedrooms, 2 ½ baths, a kitchen, dining room, and large living room with a—-fireplace?  This is winter and I’m comfortable in a tee shirt. In back is a patio with laundry lines and another smaller house for the help. So far the house comes with a guard and a gardener. We’ll likely have someone to clean, do laundry and cook a couple of suppers a week. Help is about $50/month. Overpaying them throws the system out of whack, incites jealously, and confuses people. Did the colonialists say the same thing? It does feel strange. Being a guard means sitting about all day (and night) by the front gate, walking the property occasionally. The property is fenced and the house has bars on all the windows, separate barred doors, keys and locks to everything, and, now, a mosquito net over our bed. The yard has guava, avocado, and frangipani trees, as well as a variety of others I cannot name.

There is a sweet open market with numerous stalls 5 minutes up the street where we can buy vegetables and fruits. We had delicious chips (French fries) in a little plastic sack with salt, vinegar, and hot chile, all for 55 cents. So delicious I think I may go for some now! Work begins Monday, when I’ll meet Stefan in clinic. The students are on break until 22 August.

I am reflecting on the aphorism, “You only begin to really live when you get out of your comfort zone.” Definitely getting out of there pretty quickly!

There are two more days of training here and then we are sworn in as Peace Corps employees by the Ambassador at her residence. I suspect there’ll be a lunch there (hoping) and then we load up and drive to Blantyre, 4 hours away. We’ll likely camp out in our house, reportedly 3 bedrooms with electricity and running water—hot andcold—and security bars.

While there isn’t much violent crime here, there is a lot of petty theft, robbery, and burglary. We have had many and excellent lectures, complete with vignettes from prior volunteers’ experience, about safety. Much of keeping safe means not walking in the streets after dark—always take a cab but smell the cabbie’s breath for alcohol first—and avoiding being isolated or intoxicated. Women, of course, are the most vulnerable, since men are the perps. What is it with us guys? Wars, violence. Anyway, being culturally aware is very important. Saying “No, no.” by a woman is seen as a coy invitation, by both Malawian women and men. “Choka” is a forceful “Go away”, whereas “Chokani” is a polite “Go away, please” and may mean “Don’t go away. I’m just saying this not to appear too easy but I really like your attention.” A woman without an escort in a bar at night is presumed to be a prostitute. And women are modest here, with long skirts and no cleavage. So dressing more skimpily is seen as an invitation. It’s good to know these things. And Peace Corps is very, very thoughtful and careful about it all.

Anyway, we’ll have 4 days to furnish the house with the necessities; it is the assumption that pots, pans, silverware, dishes, glasses, towels, linens, etc. will all be gone when we get there. We get an allowance for them. And we’ll get hooked up to internet, which will hopefully be better than here in the Bridgeview Hotel. It is often very difficult to get on the internet and we use a variety of room numbers and strategies to do so, often going to the lobby where a different portal is available. The system is very frail and we can tell when others are on because it slows to a crawl. Forget streaming videos. I have a $10 “dumb” phone, as AT&T has failed to unlock my iPhone, despite the hours I put into trying to do so when I was in Maine.

We did some skits for our language teachers, demonstrating Malawian cultural practices that bewilder us. It was riotous fun and they all laughed a lot. The first topic was how public affection is forbidden between men and women; holding hands, even, is not acceptable. Yet men hold hands in public all the time. Even though homosexuality is illegal. Hmm. A volunteer is lying down, ill, trying to rest and is constantly visited by well-wishers who think that being alone is a terrible thing. That was a fun one. The teaching lesson with chombe—tea–, chombo—a commonly eaten fish—, and chomba—-locally grown marijuana, together with props and a quiz, cracked the teachers up.  They are a sweet and fun bunch and a great introductory resource to Malawi.

Linda is Catholic, her own take on it, as I guess everyone’s is pretty personal. Anyway, I go to church with her because she likes me to and because it isn’t a bad way to spend an hour a week, hearing a community of people being exhorted to be kind and generous and getting to sing together. We went to church today at the cathedral in Lilongwe and it was special. There were probably 1000 people there. Many, many incredibly cute little kids dressed to the nines, a choir of woman singing and shaking it to an organ, a guitar, a drum, and a tambourine, and a priest whose homily was about living consciously. He said, “A life unreflected upon isn’t worth living.” Wow! Did he do that for me, the psychoanalyst? English wasn’t his first language, so I think he was taking his cue from Socrates’ “the unexamined life isn’t worth living”. Or perhaps he knows ancient Greek and has the correct take. Anyway between the kids, the music, and the message, I was impressed, though I am still a non-believer.

After church we walked and walked—probably 7 miles all told. Midway we stopped at mausoleum to His Excellency Great Warrior former President For Life Dr. Banda. He lived 99 years and 350 +/- days and served to set the country on a peaceful path from colonialism to multiparty democracy, something the Middle Eastern countries didn’t have. A transition through strict, stable, even oppressive, rule to democracy. Apparently many long for the old days when things were more stable and predictable. Like many in the US longing for the 50′s. Seeing our own democracy in action this election cycle—and congressional behavior for the past 8 years—makes me wish for an enlightened dictator. Although I am convinced it is going to work out alright with our first woman president. Then we went to the old Capitol Hotel, which is elegant and has been expanded since Linda was last there in 1980, just after giving birth to her first child. (She recalls having “steak Diane”}. We had a lovely pitcher of Malawian coffee (Zuzu, from Mazuzu) sitting in a peaceful courtyard next to a reflecting pool.

Two further notes about our hotel. Plus side: We discovered it is run by Indians and even though they don’t serve beer (being Hindu), they make incredibly good Indian food with basmati rice and garlic naan for about $5/serving. We’ve generally eaten a buffet of ordinary Malawian food and only learned of their true heart’s cuisine this weekend. Negative side: My shoulders are sore if I sleep on one side or the other too long. I put it down to a hard mattress. Another volunteer noted correctly that there are no mattresses. We are all sleeping on box springs. Still, it is clean and quiet and conveniently located across from a money exchange which gives a great rate for dollars to kwacha (the country denomination).

We are all champing at the bit, wanting to dig into the tasks ahead. I’m already thinking about going to a conference in Goa about scaling up mental health interventions in resource-poor settings. I cannot wait to meet the medical students I’ll be teaching. Re-upping for another year might be in the cards. Getting engaged in global mental health efforts, at this time in my life, sounds like a tall order but one with great appeal.

Extreme poverty exacts its toll on the most vulnerable. These are variously defined, of course, but I think of children, mothers, and the mentally ill, especially, since I have experience with each group.

We just visited the Bwaila Psychiatric Unit in Lilongwe, a freestanding facility built in the 1930’s. It is the district government inpatient mental hospital for the area, and often draws from much more distant regions that have no such resource. It is a squat brick and concrete structure with a waiting room, an exam room, a nursing station, a men’s dorm of 14 beds, a women’s dorm of 11 beds, a courtyard for each dorm, and a small separate building used for multiple purposes. One of the latter is for the patients to watch the TV, which is fastened high on the wall in a welded protective cage with bars so thick ¼ of the picture is lost. There are two seclusion rooms, one off of each dorm, and steel-barred gates, as one would find in a prison, shutting the patients in their respective dorms. And bathrooms. And an open fire in the backyard where they cook the nsima and vegetables for the patients to eat at noon. Breakfast and lunch are brought from the hospital in the area.

While there are 25 beds, they often have 50-60 patients at a time. Staffing includes, per daytime shift, two psychiatric nurses, janitor attendants, and a clinical officer (equivalent to a physician’s assistant in the US, although with the responsibility of a physician) who is there some daytime hours. Patients have no occupational therapy, other than working in the very nice vegetable garden in the back yard once per week. There is no staff to conduct group or individual therapy, virtually all the patients are on medications (when they are available, which they may not be for months at a time), and they languish in their courtyard by day and dormitories by night. They are fed and kept safe. They are not bothering their communities at the moment. No physician or psychiatrist visits the facility.

Patients often try to escape, and succeed. During our visit one man was hoisting another on his shoulders so the latter could climb onto the high wall surrounding the courtyard. From there they walk to the lower wall surrounding the women’s courtyard and jump to the ground. Two male attendants shouted at them and they stopped their attempt.

Many are there for psychosis, mostly diagnosed with schizophrenia.  A few are labelled bipolar disorder. Some enter with depression and suicidal ideation, although rarely after attempted suicide. Suicide in the developing world is most frequently completed with the ingestion of organophosphate fertilizer, it being available in the agrarian environment and known to be very effective. Many of the patients, whatever their underlying diagnosis, come in having smoked chamba(marijuana) or in states of  alcohol withdrawal. There often is no diazepam in the pharmacy for several months, so seizures must be common. They are not routinely given thiamine on admission—“Their families buy it if they can.”—so I suspect Wernicke-Korsakov Syndrome is not uncommon. Although the HIV/AIDS prevalence is 10% of the Malawian population (and likely more in this subgroup), patients are not routinely tested for HIV on admission. If they are psychotic or have a delirium, they are treated with Thorazine and if they do not respond, HIV testing is done. If positive, the patients are put on anti-retroviral therapy and the nurses have noted that within two weeks their mental state usually begins to clear. Medically ill patients are referred to the nearby government central hospital; generally, they are sent back quickly as mentally ill patients are not welcomed there, according to our nurses. There is no capacity to do routine lab work at the mental hospital, other than a rapid malaria test. If lab work is needed, it must be sent to the hospital.

There is very little funding for much of anything, let alone mental illness, here. There are 4 psychiatrists in Malawi, reportedly all in Blantyre. I can see why our staff and instructors throughout the orientation here have told us just to observe for the first 6-8 weeks; there likely are good reasons for doing things as they do in a resource-deprived setting. We were encouraged by the examiner for the Medical Council of Malawi to mentor and correct bad practices, however.

Showing up on time and with regularity, lecturing, conducting teaching rounds with students and patients, having a hopeful attitude, being an entrepreneur in seeking small improvements to the care that is given, and self-care may comprise most of the year. It is bleak, in a way, and yet I feel excited to begin teaching and learning. It would be interesting to discover a self-care mechanism for staff and the medical students; that could be a valuable contribution and project for the year.

The circumstances certainly have the advantage of stretching my comfort zone!

We awakened at 3:30AM to the sound of waves breaking on the beach. At 4 we were up and on the beach with cups of tea, watching the dawn break in Africa. Tiny lights from fishermen’s dugout canoes dotted the lake. Everything turned rosy, the slipper of moon faded, and, eventually, the red ball of sun began to rise. One by one 4 other GHSP volunteers spilled onto the beach, jogging and birdwatching. We saw an immense Sea Eagle which was being attacked by two falcons. And Lake Malawi stretched out like the sea; Mozambique, the other shore, was not to be seen.

We had spent the night at a beautiful upscale resort on the shore near Salima, a chance at renewal after 4 nights on the floor of a mud brick, thatch-roofed hut in a tiny village, Chisizema, north of Lilongwe. The latter was a wonderful, taxing experience. Our host family were Mwine Mwale and her husband, Mackiwell Nyilende. We stayed in a tiny two room hut in their compound which also had their tiny hut and those of two daughters and numerous grandchildren. Outside the fenced compound was a tiny bathhouse with a brick floor and a thatched roof and another mudbrick structure, the chimoze. The chimoze is a pit toilet capped with concrete and a raised center with a 6×6” hole in it for your business. Using it properly requires good aim. It was odorless and the entire compound was spotless. The dirt floor of the compound was swept each morning with a homemade broom by Mwine.

Mwine and Mackiwell were very gracious and welcoming.  We had bread fried in grease, bread with peanut butter, or bread dipped in egg and fried, all with tea, for breakfast. Nsima, steamed corn meal patties, with relish for lunch and supper. Often with supper there was meat, chicken or beef, or scrambled eggs and a vegetable dish of greens, onions, and tomatoes. All was served and eaten with our hands. Before and after each meal Mwine would place a basin under our hands and we would wash them with soap. The food was generally tasty, if lacking variety. The Peace Corps gave us each a loaf of bread and a jar of peanut butter for our use or to share. We gave it immediately to our hosts and then ate it for breakfast for the next 3 days. We might have done better to give it to them as part of our going away gift package.

Personal space is a very relative concept. Certainly in Malawi if you are alone, people feel sorry for you and sit with you. Since we were such unusual guests, people always gathered in our compound in the late afternoon and early evening to meet and visit with us. The difficulty was that our daily language lessons were just ramping up and most of the villagers spoke no English. Meals were pretty silent. Mackiwell actually knew a lot of English words but couldn’t make sentences. In the district there were nearly a million people and only three secondary schools. Girls, if lucky, get 4 grades of primary school. In any case, the children loved to visit and stare at us and then sit next to us. We taught them Twinkle Twinkle Little Star and they then would sing us a whole variety of their songs. We invented a game one evening with a two gallon water bottle, tossing it and two balls made of plastic bags filled with plastic bags to the children in a circle. Eventually 23 little children were involved and it got so wild and out of hand we had to stop it. But it cemented our rep in the community and as we’d walk to class a little voice would ring out from one of the houses, “Georgie” or “Linda”. The children were absolutely darling, if ever-present. Sometimes we’d just retreat to our room to rest, to be alone. But we could write in the courtyard and not engage with them and they would patiently sit for a long time, wanting to be with us and, no doubt, hoping for a little excitement.

We observed a netball game and a soccer game at the village field. Netball is a girls’ game and was it wild! Adolescent girls toss a soccer ball, wearing skirts and no shoes, to their teammates down the field, advancing it until, with luck, one of their team was underneath the hoop where she would get an unopposed shot. The hoop was a 3” strip of metal in a circle about 14” in diameter nailed to an upright pole. When a girl had the ball she couldn’t run with it, so they threw it with great force and often great accuracy. The leaps and abandon were remarkable and it was clearly wildly enjoyable to them and the spectators.  There was no net. The soccer game was fun to watch as well, but not novel. Serious athleticism and determination, however.

Since it is the dry season there is no real farmwork for Mackiwell to do, so he mostly hung around. The land he farms—maize, groundnuts, cassava— is a 45’ walk each way for him during the planting and growing season.  Our hosts let us know a couple of times that drought and flooding had left them without enough food or money to get through this year, clearly hoping we’d pony up. But when we didn’t, they were still warm and friendly. It would be so easy to drop $100 (76,000 Kwatcha) which could make a great difference to them. But we have been told it would set a precedent and might create difficulties for them in their village. We are giving to Malawi in another way, as medical and nursing volunteer faculty, and will do well to stick to that. It is difficult, however, to imagine them hungry in January and February, the “hunger months”, when crops are planted but not ready for harvest and last year’s maize has run low or out. An estimated 6-8 million Malawians are facing famine this year.

As part of our village stay we visited a district health center. The Clinical Medical Officer, the equivalent of a Physician’s Assistant in the US, is the ranking professional. He sees between 300 and 400 patients per day, serving a catchment population of 47,000. Since some of his patients come from as far as 28 kilometers away, pregnant women are asked to come in their 8^th month and wait until they go into labor. They sit outside the clinic on the ground, cooking, and talking with other mothers each day. There are one midwife and two “community midwives” (1 year of training) to deliver over 200 babies per month. And the clinic formulary is so limited the Clinical Medical Officer can only treat malaria, HIV/AIDS, and some STD’s. They sometimes have Valium if someone comes in with a seizure, but sometimes they do not. An ambulance to the District Hospital generally takes 4-5 hours to arrive.  Talk about stretched resources.

We also visited a Traditional Healer. There are Spiritual Healers, who use masks and drumming and potions but ours was basically an herbalist. It was difficult to assess the scope of his practice but I think he treats cancer patients. He had an old wine bottle with a large plastic pigeon inside it—I couldn’t imagine how he got it inside!—that he uses as a diagnostic tool. He stated, “It’s my xray machine, my MRI.” Hm.

Then, the day before we left, we had a ceremony with speeches, presentation of certificates of completion to the host families, and wild drumming and dancing. The latter included two cross-dressing men who did remarkably lewd dances. A good time was had by all.

Sadly, we didn’t get to say goodbye to Mackiwell the next morning. In the middle of the night he had to locate a vehicle to take one of his daughters to the hospital with a probable breast abscess. It brought home, again, the precarious circumstances of these lovely, smart, generous people who depend on the weather for their livelihood. People everywhere want food and job security, decent and affordable health care, and freedom from violence. It doesn’t seem too much to ask, really.

We are being eased into the experience to come so carefully, thoroughly, and intelligently. Today we leave for a 4 night homestay.  The sixteen of us will be distributed into 15 homes—Linda and I are the only couple—in one of four tiny villages. They have been working for 5 months to assure that standards of safety and hygiene are adequate. Each house will have a pit latrine separate from the house; we’ll all bring a covered pee bucket to use at night so we don’t have to encounter critters in the dark at our time of need. There will be a hand-washing station outside the latrine. We’ll spend evenings and meals with our host families, who are apparently very excited to meet us (as we are them). During the day we’ll study language and culture in a hut equipped with chairs and a white board. No public affection, women wear long skirts, Malawians are confused when we cry if we are other than sad, and so forth. The teaching crew here did some hilarious skits about cultural differences. Everyone washes their own underwear, generally when they bathe; don’t hang it up on the line outside unless you also cover it with a chitenje, the ubiquitous piece of colorful fabric used to wrap and carry everything from bananas to babies. And so forth.

Our trainers, the language trainers so elegantly dressed and so thoughtful, the security crew, the country Peace Corps Director, and our wonderful Seed Global Health (SGH—acronyms abound here and Peace Corps  (PC) program leaders are remarkable people by any measure.

The US Ambassador to Malawi came and spoke to us yesterday. A large, animated woman, we all fell in love with her. She is brilliant, filled with the necessary subtlety earned by a state department career, and with an astounding grasp of the facts. My image of an ambassador was that the job went to a ruggedly handsome political friend who wore a blue blazer well and could charm you at a cocktail party This woman was charming but for all the right reasons. She loves Malawi, despite its many issues that might drive others to hopelessness and gin, and is determined to use her influence to improve conditions for people here.

One night Anna, a GHSPL Family Medicine physician completing her year in Mangochi (and who has signed up for another year) took us to Ad Lib, a little restaurant a few blocks from our hotel. We arrived as darkness descended and sat at a long table made of many smaller, sipping a “Green” (Carlsberg beer, the only brewery allowed in the country for the past 50 years) or a MGT (Malawi Gin and Tonic). We listened to the band in the back room playing a mix of reggae covers and Sarah told us about a couple of cases. A South African man, on holiday with friends and drunk, went off a 60 foot cliff. Among other injuries, he fractured his pelvis so that bone was sticking out and his rectum and bladder were both opened. He was brought in at night, and Anna had to call all the help she could get into the little district hospital. He had nearly bled himself dry and they were only able to give him two units they obtained from themselves, there being no blood bank. They stabilized his pelvis by wrapping it tightly in a chitenje (see, used for anything and everything) and tying it very tightly. It turned out he had insurance and a plane was soon landing to take him to S. Africa. Apparently after several surgeries, he is alive and was very pleased to have completed a divorce from his wife! The other case was a man who was totally bruised after being attacked by a rock python. He was delirious and febrile and his real problem was that he had cerebral malaria. And on and on. We listened, walked back to our hotel in the dark a few blocks, alert to our surroundings, and went to bed. I suspect we all were imagining feeling frightened and overwhelmed at some of the medical problems we’ll encounter. I know I did.

Stay tuned.

The crepe myrtle is in bloom everywhere in this city, from lily white to shades of pink, lilac, lavender, heliotrope, and royal purple. Extravagant scarlet canna lily blossoms frame walkways. The trees have fledged and walking along the Potomac or among the ancient townhouses of Georgetown in the evening heat is a marvelous segue from cool Downeast Maine to equatorial Africa.

We’re in DC, having completed the first 5 of 8 days of orientation. It has been well beyond expectation. In preparation for our assignments in Liberia, Uganda, Malawi, Tanzania, and Swaziland, the 59 of us have had 8AM-5PM lectures about everything from tropical dermatology (have that one after, not before, lunch) and personally avoiding malaria to pedagogy and learning our (local) language. Mine is Chichewa. Zikomo gambili (Thank you very much.) We are taught by renowned experts in each field. Our curriculum has been carefully—dare I say, lovingly— constructed and we’ll be as prepared as one can be.

The Global Health Service Partnership is a 4 year old joint effort between Seed Global Health, Peace Corps Response, and PEPFAR. The latter is the President’s Emergency Program for AIDS Relief, a magnificent effort conceived of by John Kerry and Bill Frist and enacted by GW Bush. President Obama has continued and expanded it. It has been a game changer in Africa, which carries the largest burden (70%) of HIV/AIDS in the world. The incidence—rate of new cases over a specified time period—and prevalence—the amount present in a population at one time—have dropped remarkably over the past ten years through the efforts of many courageous and hard-working people. (See, I was not dozing in class. I can listen better with my eyes closed!).

We’ll serve a year and then consider, and be considered, for re-enrolling for another year. It is difficult to feel like much more than a medical tourist if you don’t work in the country for at least a year, from my experience. The brilliance of this program is that it builds health care capacity in-country and deters the brain-drain from each country served. Over 20% of US doctors were trained in developing countries. I can understand their desire to come to the US for what they imagine is a better way of life and a better chance for their children to move up the ladder. However, it just devastates a poor country, which is already terribly understaffed with medical personal, to go to the expense of training them and to have them leave. So we’ll be training medical and nursing students and residents in situ, hoping they’ll stay at home.

I’ll join the Department of Mental Health, College of Medicine, University of Malawi in Blantyre, the commercial hub of the country, located in the south at about 3000ft elevation. It is in the Shires. It was settled by Scottish missionaries and is the oldest European-founded city in E, W, or S Africa. It is about the size (a million, give or take) of Malawi’s capitol, Lilongwe. Malawi was formerly a British colony called Nyasaland and is a peaceful democracy. The country is known as “the warm heart of Africa” because of the kindness, gentleness, and generosity of its people. It is a poor, agrarian society, heavily dependent on the rainy season being cooperative (enough, evenly distributed), and was ravaged by AIDS.  It is very beautiful, according to Linda who lived there fresh out of nursing school for 2+ years  with Peace Corps.  She lived in a small village, got malaria, and had a black mamba living in her back yard. “They are very timid; they’ll get out of your way.” Reassuring? (The puff adder who was in her kitchen didn’t and needed to be removed by the gardener. A bite from either of those pets will send you down for the count.)

Yes, I am anxious. I anticipate the workload may be a lot and I worry that there will be so much unaddressed trauma, let alone malnutrition and disease, in kids that it may get me down. The inevitable bouts of diarrhea aren’t enticing, either.  But I know I can be of help and accompanying the anxiety is excitement. I suspect it will be a tremendously positive learning experience for me and in ways I cannot anticipate.  It will be a remarkable shakedown cruise for our new relationship, as well.

As a psychiatrist and psychoanalyst with a subspecialty in child and adolescent psychiatry, I’ll have to get the lay of the land before I teach much. Respect, curiosity, and humility are a fair start for the medical students I’ll teach. I’ll gradually learn what mental illness means and how it is traditionally viewed and treated. Certainly depression, suicide and both physical and sexual trauma will be common. Since medications are in short supply, I can focus on the therapeutic relationship, listening at multiple levels, and basic concepts common to us all like transference, countertransference, defenses, anxiety, and the unconscious. It will be so much fun I can hardly sit at this computer! And we are told that the students are incredibly eager to learn, bright and hard-working. It represent something quite amazing for them to become doctors, I think, emerging as many do from dire poverty and being at the vanguard of a large expansion of health care services in their country.

John Kerry, came by Thursday evening with inspirational well-wishes for us. His daughter, Vanessa, is the co-founder of Seed Global Health and an incredibly energetic, approachable, and far-thinking physician leader  She is rightly proud of what she has accomplished and wanted to show us off to her Dad! I feel extremely privileged to be able to join this party.

[I plan to write this blog frequently so you can sign up here (I hope) to have it delivered to your email if you wish. A more geographically accurate photo will grace future editions.]

I am healthy and active with no sign of cancer.  I sit in my cottage on a little island in Penobscot Bay in Downeast Maine, looking over a sunny meadow to a very calm harbor.

I have joined the Global Health Service Partnership, a joint venture between Peace Corps Response, Seed Global Health, and PEPFAR, the President’s Emergency Plan for AIDS Relief. On July 10, I’ll fly to Washington DC for orientation and on July 21 fly to Malawi where I’ll spend a year in Blantyre, the commercial center of the country. I’ll be teaching psychiatry and child psychiatry at the College of Medicine of the University of Malawi.

I shall mostly be teaching 4th and 5th year medical students in small groups as they do their psychiatry rotations. I think that principles of compassion, patience, and curiosity—listening carefully at many levels— will be of use to them in gathering medical histories and working with patients generally , even though the vast majority will not go into psychiatry.

I’ll also have the opportunity to teach the few (3, I believe) psychiatry residents who are there, supervising their work in clinic.

I’ll undoubtedly provide some direct clinical services, as there is a great shortage of mental health workers in the country (as well as in all of the developing world). The United Nations World Health Organization estimates that mental illness in developing countries, especially depression, is the major cause of ill health and inability to work in the population. Suicide, especially among farmers whose crops fail because of weather (drought/flood), is a major problem in the developing world where life is very hard, food security lacking, and hope can be difficult to sustain.

I expect I’ll learn more than I give, of course. It has been a dream of mine to do this for a long time and this seems like the perfect opportunity.

Malawi is called “the warm heart of Africa” because of the kindness and generosity of its people. It is a small but very beautiful country in eastern Africa containing the 3rd largest lake in Africa. Lake Malawi occupies a third of the area of the country. 85% of colorful fresh water tropical aquarium fish come from Lake Malawi.

I plan to start a separate blog to chronicle my year. I’ll leave instructions to access it here when I know them.