Wednesday, 9 October 2013

MMed training in Zambia - a new arrival.

My name is Dr. Katie Williams and I am three weeks into a three month “Out of Programme Experience” (referring to my UK training programme), in Lusaka, as part of the MMed Psychiatry programme.   Back in the UK, I am based in Nottingham and I am a Specialty Registrar in General Adult Psychiatry, in my final year of training. When I heard of the exciting opportunity to spend three months working with the MMed psychiatry programme in Zambia, I thought it was too good an opportunity to miss, and so here I am!

My main base whilst I am here is Chainama, the main mental health hospital in Zambia, where the trainees gain a lot of their clinical experience.  There are clinical officers working at Chainama, who are trained for only 3 years in mental health but are not trained nurses or doctors.  They are expected to take on a lot of duties, such as deciding which patients should be admitted, clerking patients, making diagnoses and prescribing! There is a lot of difficulty recruiting doctors into psychiatry (same as in the UK), and at the moment there are only 7 doctors in the whole of Zambia doing postgraduate specialist training in psychiatry. My main role during my time in Zambia is to be involved in mentoring the first year MMed trainees in their clinical work, by providing ward and clinic-based teaching and tutorials.  

At Chainama, I am based on a male acute ward, which has about 30 patients per firm. You enter the ward through a padlocked iron gate, and unsurprisingly there is usually a gaggle of patients hovering at the same door trying to leave.  The ward reviews are slightly chaotic, as many patients wander in and out as you are trying to review somebody else, shouting, singing, praying, or becoming agitated and asking to go home.  Usually the patient you are trying to see sits there quietly, as others join him uninvited, sitting next to him on the bench, as if there is no reason they shouldn't be there.  The nursing staff try their best to encourage these patients to leave the room, however it doesn't take them long until they're back.

We have a lot of patients admitted due to alcohol problems, mostly withdrawal problems - delirium tremens, and also "alcohol induced psychosis", which I haven't previously come across in the UK.  There is a big drinking culture in Zambia, especially for those with low incomes, and the local brew is apparently very strong.  As well as the patients with mania, schizophrenia, and alcohol-related problems, we recently have had a patient admitted following a high-profile suicide attempt.  He had climbed up one of the telecommunication towers in the city centre planning to jump, and had been rescued by the fire service sparking a lot of media attention. He had stated that he was going to jump because he could not get a job and needed better housing, and the government had taken interest in this, sending victim support counsellors to Chianama to follow him up. His story was a genuinely sad one. He was a man in his 30s, the sole breadwinner, with a heavily pregnant wife and two young children already. His permanent job had ended a few months back as the company had folded and temporary jobs were getting more difficult to find. He had reported to the local government to seek advice and support, as he had no money and no food for his family. After attending again and again with no offer of a solution, he eventually started to feel hopeless about the future, hence impulsively climbing the tower with the thought of killing himself.  Since being on the ward, a social worker and clinical psychologist have visited his one-roomed family home and were appalled at the squalid and bare conditions, and the lack of food for his wife and children.  There have been some donations of baby clothes for when the new baby arrives, and the social worker is going to provide the family with some basic food, also using money from donations. There is no benefit system in Zambia, and I am told if you don't work, you don't eat. People in this situation often then rely on extended family to help them out financially; however, this man's mother had also joined them asking to be provided for by him, adding to the pressure of the situation. We are hoping that the ward social worker will be able to help with his social circumstances, which would have a significant positive effect on his mental health.

Another of the key aims of the programme currently is to support each MMed trainee to complete an audit, with the goal of directly improving patient care locally. There are different ways of doing things here, such as rapid tranquilisation, and there are some clinical areas which would greatly benefit from interventions to improve patient safety and service quality. Once these audits are completed, we hope that the trainees will present and publish their results both at a national and international level.  I am also involved in teaching medical students of the University of Zambia during their psychiatry rotation, both on the wards and in tutorials and lectures.  I understand that recruitment into psychiatry in Zambia is a challenge, similar to the problem we face in the UK, so our intention is to stimulate an interest in psychiatry at an early level, so that they may consider psychiatry as a future career. With World Mental Health Day on the 10th October, we are arranging events for spreading awareness and education about mental health disorders, including designing informative posters, arranging a film club with a psychiatry theme, a medical student essay competition, and a carers meeting.

Finally, since arriving I have been most struck by the friendliness and politeness of the Zambian people.  Zambia itself seems to be a diverse and fascinating country, from the modern malls in Lusaka to the natural beauty of the national parks and of course the Victoria Falls, which I am looking forward to visiting at some point during my trip.  I am very grateful to all of the MMed trainees, Dr. Ravi Paul and all of the THET staff for such a warm welcome to Zambia and I am looking forward to a productive and rewarding few months ahead.

Katherine Williams with nurses and clinical officer students, Zambia.