Great Expectations

I’ve just come back from the internet café, where I ran into Laura, one my fellow med students, as we headed out the door at the same time. She, like me, was in a bit of a self-acknowledged snit. As far as we could gather, internet service was apparently slow all over Malawi – not even the official café had anything resembling functional service, although they’ll certainly charge you for the five minutes it takes you to figure this out. A bit frustrating when you’re trying to do things such as pay your gas bills (me) or finish your looming applications for medical residency (her).

And I know, I know, this is Africa – heaven help the mzungu sucker who assumes (or worse, plans ) that any transaction will go smoothly or efficiently. Power outages happen during peak dinner cooking hours about every other day, ATMs regularly run out of money, scheduled car rides don’t happen. And in the clinic, of course, everyday drugs simply run out and don’t get refilled.

I’d say we only end up using about 10 drugs on a regular basis in the skin clinic: a few antibiotics for infections, some steroid creams and anti-histamines for itchiness, an antiviral for chicken pox, and exactly one antifungal, Griseofulvin, that we give out like candy to the many little guys that come in with tinea capitis – basically ringworm of the scalp. (This, for some reason, is way more common in scalps of African descent than European descent, both here and in the US. As my pediatrics attending once remarked, there’s a bit of a tradeoff – white kids don’t really get tinea capitis, but then, black kids don’t get head lice. Odd.)

So griseofulvin was available and plentiful last week, freely available to any patient we sent up to hospital pharmacy with a handwritten prescription. Easy peasy. And then, suddenly, patients started coming back down to us. The pharmacy was out. And that was the end of it. No one knew when more was coming, and the pharmacy itself was unreachable. From our point of view, there was no way of knowing if the hospital itself was even aware of the problem, let alone working on it. And there’s no real alternative to griseofulvin – for those kids who aren’t rich enough to buy the medicine at a private pharmacy, they’ll simply be stuck with itchy, rather unsightly scalps until the hospital procures more. It’s not life threatening, but it’s stigmatizing and irritating – and contagious. More infections for siblings on the way.

I had trouble figuring out exactly why I can’t just go zen about these sort of situations. I’ve been shot down enough times by now that I’d expect a total shift in expectations, but no – I still find myself naively planning for quick ‘n’ easy in a place that’s more slow ‘n’ convoluted. It was actually kind of a relief to find that Laura was feeling a bit of Malawian fatigue as well – she was a Peace Corps volunteer in Guyana back before med school, so the fact that she was still struggling with her own expectations made me feel a bit better.

The more I think about it, the more it actually seems like classic Pavlovian stuff. Our brains here are victims of inconsistent reward. If we were out in the rural areas, this wouldn’t be an issue at all – no technology or institutions to fail, so no letdowns. But in a place like Lilongwe, which has many of the trappings of developed countries but not much in the way of foundation underneath, the rug just keeps getting pulled out from under you. You see that internet and electricity and banking and gas stations CAN exist here, so you get repeatedly tricked into assuming that they WILL exist when you want them. This is the mistake. My western brain assumes all or nothing, when in fact the reality is somewhere in between.

And now, as I finish this, there is a line of waiting cars wrapping around the block from the gas station down the street, each waiting 2 to 3 hours to fill their tanks. Word on the street is that the country will be out of gas by the weekend, and everyone’s trying to store up. Guess we’ll be walking to the hospital tomorrow?