Mental health training in Somaliland - Day 29

Saturday 19^th October

Today I meet with Dr. Jibril, Dr. Zainab, Su’ed and Faduma on the mental ward at the hospital. We do a ward round together and use it as a learning experience. Dr. Jibril presents the new admissions that he clerked two days ago and together we all discuss the management decisions. We are trying to encourage an atmosphere where discussion together among nurses and doctors is usual and where each member of the team may ask questions related to management decisions, if they are not clear or do not agree with proposed plans. Though there is often a very clear hierarchy between doctors and nurses here, I am impressed with how the team works together. Dr. Jibril consistently empowers the nurses that work alongside him and values their importance.

One of our main discussion points again today is prescribing.  I realise just what a difficult position these doctors are in; working hard on the ward without any senior supervision on the ground. Though Dr. Jibril is supervised online by a number of international doctors and makes great use of this, there is nothing like having someone there, face to face to discuss things with. I wonder how I might manage if I were in his position. I have great admiration for them all.

I also begin to understand better why patterns like polypharmacy and high dose prescribing of antipsychotics become routine here. It is easy to say that it is wrong, though considering that there is no supervision available, very few staff available to work on the ward and very high risk patients, perhaps it is understandable why this is resorted to. Patients tend to be prescribed high dose antipsychotics and even depot antipsychotics on admission to the ward, when the diagnosis may still be unclear. Our discussion is very helpful and Zainab, who will be taking over from Jibril when he leaves for his upcoming residency also finds it useful. She will also be here with only international mentorship to help guide her management of patients. Again, I see photographs of patients who are now on the ward who have been chained. During the ward round, one patient tells us a story of how he was chained by his wrists/hands when unwell and chained to a tree, very high up, for 7 days. He was taken right out to the border of Djibouti and Somaliland and left there, like this. Now, the man was calm, coherent and very pleasant and I felt so sad that he could have been treated in this way simply because he had a mental disorder. Essentially tortured, as Jibril pointed out.

There was a very interesting case presented by Jibril, a new admission to the ward. The most striking feature was his substance misuse/dependence, his extremely traumatic history and his significant risk to others. In the UK, this man simply would not be on this type of ward. He would be in secure forensic services, detained under the Mental Health Act and likely the Consultants looking after him would be answerable to the DOJ. Here there is no Mental Health Act, no forensic services, no seniors to guide management. So this patient was being managed on the ward.

I was thrilled today as I had the opportunity to visit the community mental health service. Fadumo the nurse leads and teaches ten community health workers who are trained in mental health, child and maternal health. We visit the community in which they work in Borama. Jibril tells me it is one of the largest slums in the area and houses around 37,000 families. I am lucky to be able to meet with the community health workers who do such fantastic work in this area. They are all females, and have been selected as they live within the community. They are trained for 3 months and then work closely with Fadumo. They find people with mental illness in the community and encourage them to attend appointments in the community with the doctor, or Jibril visits them in their homes with the nurses. They do a lot of psychoeducation work, which they say they feel has spread through the community. This helps to reduce stigma surrounding mental illness and therefore to lessen practices such as chaining and they report that chaining has decreased in the area they work in the time they have been there. It is interesting to hear one CHW comment on how before she began her job she too would throw stones at people with mental illness, though now loves to see people get better with treatment and really values her role and job. It is so positive to see this kind of work happening in the area.