THE ART OF MEDICINE
by Jack Allison (Malawi 1966-69)
“I think music in itself is healing. It’s an explosive expression of humanity. It’s something we are all touched by. No matter what culture we’re from, everyone loves music.” — Billy Joel
I was immersed in seeing countless patients in my baby clinic when I was politely interrupted by Mr. Chitowe who requested an emergent consultation: “Jack, I have a most interesting patient to share with you.”
“A woman has refused to be seen by me, demanding to be evaluated by the white doctor,” he explained calmly. “She claims that there’s a snake in her vagina, Jack.”
“So what am I supposed to do, Mr. Chitowe? I may be white, but I’m no doctor, as you well know, sir,” I pleaded.
“Please perform a basic pelvic exam on her, if you will. Otherwise, I won’t be able to continue see the remainder of the patients waiting in my clinic,” he insisted.
“But I’ve never done a pelvic before!” After a brief pause, I tried a bit of nervous humor: “The are only two things I know about a vagina — it is warm and it is moist.”
Mr. Chitowe smiled faintly and guided me into his side of the dispensary.
My Malawian counterpart was a medical assistant, comparable to a physician assistant in the USA. My paltry “paramedic” training was based upon discerning whether children were well or ill. In PC training we had been taught that ill children were not to be inoculated. Period. Only well children were to receive the immunizations I provided: DPT routinely, measles occasionally and smallpox infrequently, based on what was available through the Ministry of Health.
The consult involved a thirty-year-old woman who had been awakened the night before when she had felt a snake crawl into her vagina. Today she had walked three miles to have it removed. The woman insisted vehemently that I be the one to extract it. Mr. Chitowe obviously wanted off the hook.
After procuring a kerosene lamp from his home next door, and clearing a space in the dispensary’s closet where he kept his medicines, Mr. Chitowe asked the patient to disrobe and to lie down on a sheet on the floor. Then I was invited to examine her. I was incredibly nervous. There was neither an examination table with stirrups nor a speculum in order to get the job done properly.
With Mr. Chitowe’s guidance, I slowly examined the patient by parting her labia majora and labia minora with both hands, then gently probed her vagina with the fingers of my right hand. I shared with both the patient and Mr. Chitowe that the snake was no longer present.
They were most appreciative. As I went to wash my hands, Mr. Chitowe filled out forms so that she could ride free on a bus to be further evaluated by Mr. C.’s boss, the principal medical assistant (PMA) at Ntcheu Regional Hospital which was located twenty-five miles north of our facility.
That evening we met briefly after work. I pondered, “I’m curious, Mr. Chitowe. Why did you refer the patient to the PMA in Ntcheu?”
“Because we were not able to provide a proper female examination. The Ministry of Health guidelines require referral to the regional hospital for any clinical matters we can’t handle,” he answered, and went on to explain that
her diagnosis involved at least three possibilities: a round worm had crawled out of her anus and entered her vagina; she had a psychiatric problem; or maybe even both. I was appreciative of his explanation. The question I was too embarrassed to ask was why he had invited me to perform an exam for which I was most definitely not qualified? Acquiescence to the patient’s demand? Providing me with some additional clinical exposure? I’ll never know.
What happened next was extraordinary, documented in a courtesy letter Mr. Chitowe received four days later from Ntcheu Regional Hospital in response to his referral:
The PMA received the patient graciously. He listened intently to her story, then had a nurse put her up in stirrups. He examined her vagina with a speculum and declared that he saw the snake. He then wrestled it from the deepest refuge of her birth canal, threw it to the floor, stomped on it until it was annihilated, called in a janitor to sweep it up and put it in the incinerator, and quietly informed the patient that she was cured. The woman was tremendously relieved and incredibly grateful.
My sarcastic comment to Mr. Chitowe was, “The PMA broke both of his arms patting himself on the back.” Mr. C. laughed because he was familiar with the PMA’s flowery English. I then asked, “What does ‘Conversion Reaction’ mean?” — the final diagnosis that the PMA concluded?
Mr. Chitowe responded, “It’s a psychiatric diagnosis. Something to do with how a person copes with a problem. I’m confused because that diagnosis usually involves a pseudo coma, blindness or some other neurologic symptom which this person did not have. Interesting. I’ll have to ask the PMA the next time we see each other. Stop by my house tomorrow and let’s look up conversion reaction together.”
We did just that the next day. As I read that section in his medical textbook, I had to keep asking Mr. Chitowe to translate medical words and related terminology, and although Mr. C. had been correct in challenging the diagnosis of conversion reaction, I still had another question: “Why did the PMA make a psychiatric diagnosis?”
“Remember, Jack, he did perform a pelvic exam which did not reveal a snake in her vagina. That’s when he went through the necessary steps in our culture to cure her and relieve her obsession.”
A week after returning to her village, the appreciative patient invited Mr. Chitowe and me to come to her home for a celebratory feast to honor us for relieving her misery and for saving her life. The poor woman had had a cow slaughtered and roasted, and had paid a local brew-master to brew up a fifty-gallon drum of village beer. This party was more festive than any other I’d experienced in Malawi, whether with Americans, Malawians or both. I could feel the genuine excitement in that village for our patient had been cured, and she and everyone else were most appreciative.
As the sun was beginning to set, a small bonfire was lit. I also finally learned the patient’s name — Lovinesi Ulemu — although she preferred to be called by her mfunda [clan name], Anachisale.
While Mr. Chitowe and I each savored a gourd of mowa [village beer] as the villagers gathered for the feast, he observed, “What a lovely evening, Jack! These people are quite happy.”
“I agree. I just hope that we don’t drink too much so that we’ll be able to ride our bicycles the three miles back home without crashing in the dark,” I said half-kiddingly.
Anachisale approached us. It’s customary for a woman to say Odi [May I come in/approach], or at least Zikomo [Thank you/pardon me], crouch on one or both knees, proffer her extended right arm while touching her right forearm with her left hand, shake hands with each guest, and finally say Moni [Hello] to each person separately. She was a gracious, polite host. Passing moni doesn’t begin until guests are seated. Since Mr. Chitowe and I were provided the only two chairs in the village, the ceremony had begun.
Chief Salomoni greeted us warmly. He also squatted beside us as he, too, sipped mowa. After every adult had casually ambled over to greet us, it was around 8 o’clock when the speeches began, starting with the chief.
Anachisale delivered an impassioned oration that extolled the clinical prowess of Mr. Chitowe and me which contained zikomo [thank you] numerous times.
When Mr. Chitowe was asked to speak, I realized that I would be next. I was always reluctant to speak Chichewa in front of Mr. Chitowe. His Chichewa was crisp and proper; mine was elementary and mistake-ridden. I was more comfortable speaking Chichewa with villagers, for they were patient and forgiving of my errors. Tonight, I decided to relax and do my best in expressing my gratitude for such a wonderful, celebratory feast, and for Anachisale’s having been cured. Each speech received an enthusiastic round of applause. We had so much fun!
We finally began enjoying the roasted beef around 9:30. The food was delicious and probably even more so because we were ravenously hungry by then. The revelry lasted well into the night.
As Mr. Chitowe and I slowly peddled our way back along the pathway to Nsiyaludzu Village, he waxed philosophic: “I love practicing medicine, Jack. I simply enjoy helping people get well.” I listened to his dedication to his profession, marveled at how people in surrounding villages admired him, and reflected on what had transpired with Anachisale, from her presentation to our dispensary through tonight’s celebration.
Although I quietly accepted all of this graciously, I had learned a tremendous lesson: the PMA had been masterful in knowing what that woman had needed, and went about casting out the demon with true professionalism. And even though it was he who had cured her, I also learned that grace is something you receive when you don’t deserve it.
As an avid observer and an equally eager participant, I was experiencing a plethora of raw clinical medicine in such an isolated rural medical dispensary! I had joined the Peace Corps in part to afford me the time to sort out whether I should become a physician or a pastor. I recalled how I had agonized over that decision during the time I was also not sure if the Peace Corps was going to be right for me. Now this unique series of experiences definitely helped me to decide unequivocally to apply to medical school and therefore forego the seminary. What a relief! I was finally sure of what I wanted to pursue professionally.
From forthcoming memoir The Warm Heart of Africa: Three Years of Peacekeeping, Love and Music by Jack Allison
Jack Allison (Malawi 1966-69) presently serves as Professor Emeritus of Emergency Medical Care, College of Health & Human Sciences, Western Carolina University, where he teaches, performs research, and spearheads faculty development.
In 2012 he volunteered during the month of February with Medical Teams International in Kenya and Somalia where he provided both emergency medical care and public health education to Somali refugees; and in October he volunteered with Marion Medical Mission on a public health project in Malawi and Zambia where he helped to install 112 shallow water wells.
Allison’s avocation is singing/songwriting. He has written over 100 songs and jingles, and recorded over 80 of those. Since 1967 he has raised $150,000.00 with his music, and he and his wife, Sue Wilson, have given away all of these monies to various charitable organizations, including $30,000.00 to help feed Malawian children who have been orphaned because their parents have died of AIDS