Wednesday 2nd October
Today I visit the mental ward first
thing. The ward is extremely busy as today is a follow-up day for community
patients. There will be approximately 40 patients that have to be reviewed by
the doctors and nurses on the ward. This means that the whole team is busy.
Everyone has a role, from making little paper slips for patients to take away,
with their next appointment date written down for them, to finding patient
notes amongst files in the ward office, to sitting down with patients and
speaking with them and their relatives. I speak to both Mustafe and Dr.
Abdifatar on the ward and we agree that it might be better if I came back
tomorrow to see the in-patients. I spend some time on the ward interacting with
patients, some of whom I have met before and so they recognize me. I meet with
the manager of GRT, the organization that has done much to improve things on
the ward over a number of years.
Two years ago, all patients on the ward were
chained up and their living quarters was a block that contained nothing more
than tiny cells. Now no patients are chained and they all have a separate room
to sleep in, with beds and mattresses. The deputy manager from GRT spends some
time with me today, taking me through the history of the ward and it is clear
just how much they have done. Implementing change takes time, as does changing
attitudes and even small things, like moving the place of eating from bedrooms
to the open communal area, mean a real difference for patients, in terms of the
cleanliness of the ward. They seem to have an organized system for documenting
new admission case histories, a place to keep files of notes and a system for
monitoring statistics, including, number of admissions, number of discharges,
gender, age of patients, what their diagnosis is. All this is excellent to see,
as it will help inform change later on.
Epidemiological data is scarce in
Somaliland and it is great to see the ward staff diligently collecting this
each day. They have also implemented a programme of activities for patients and
have social workers who are on the ward to fulfill this. There is even football
scheduled for the male patients and I am impressed seeing female patients
taking part in sewing in a separate room with sewing machines in. There is a
separate small room with a simple examination couch inside, where patients may
have physical examinations carried out in privacy. It is clear to see that the
nurses and doctors here work hard taking care of the patients and they tell me
of their joy at seeing community patients recover and respond to medication
they prescribe. By counseling patients and their families at follow-up
appointments, not only are they able to tell them about their disorder and
inform them of what they should expect from medication, in terms of side
effects and beneficial effects, but they also get the opportunity to inform people
about mental illness. Many people here believe that mentally unwell people are
somehow cursed with ‘Djinn’ or evil spirits. As such people are usually taken
first to a traditional healer, rather than the doctor, which means patients may
have been unwell for a long time before they ever receive medical treatment.
Informing people about mental
illness and the possible causes is vital here as this propels the spread of
this information amongst their communities. Unfortunately, people are often chained
for many years as their relatives have little knowledge about mental illness,
no access to medication and beliefs about what the cause of their illness is.
This can lead to devastating consequences for patients, who, with a diagnosis
of schizophrenia, may well have responded to antipsychotic medication. Last
year, I met a man who had been chained for in excess of 20 years, as his family
simply had no knowledge about mental illness, he was violent due to his
psychosis and they felt they had no other choice. They did not want him to
escape and hurt anyone or himself. He was kept like this until he was
eventually found by Dr. Jibriil, a doctor in Borama, who diagnosed him with
schizophrenia. He was treated with antipsychotic medication and his psychotic
symptoms improved. Unfortunately he developed PTSD symptoms as a result of his
experiences and had difficulty communicating with people, having essentially been
confined to a cage for such a long time. Another man on the ward developed
severe leg contractures, so that now he cannot walk, as a result of having been
chained for many years. Outcomes like this are tragic, as they might have been
avoided if their disorder had been appropriately treated. Therefore, having the
opportunity to raise awareness about mental illness is a key part of the ward
staff’s job.
As I leave the hospital to go back
to the office, I witness the aftermath of a car accident, with people being
brought into the hospital on the backs of trucks. RTA’s are common here and, owing
to the severity of the mens’ head injuries, it is likely that these people may
not survive. It is a reminder to me of just how fragile life is and how lucky
we are in other countries to have a very organized system for dealing with such
emergencies.
The afternoon is spent with the 6th
year medical students. Today we practice OSCE scenarios of childhood mental
disorders including ADHD, which may well be, from people’s reports, common
here. In Somaliland there is no child psychiatry at all and so it is difficult
to know which disorders exist in the community. We concentrate on how to
explain the illness to a relative and take a history. We also practice an OSCE
station of an elderly male with memory problems and possible delirium. I stress
that organic disorders must be ruled out first, as often in Somaliland physical
illness, particularly infections, complicate the clinical picture.
The evening is spent meeting with
members of the Mental Health Group, a group we have formed collectively as
doctors, which includes previous mental health representatives and others with
an interest in psychiatry/mental health. This is exciting as it is the first
‘formal’ meeting of its kind. The idea is to share ideas, to think together
about how mental health may be developed further in Somaliland, to think about
the medical student curriculum and also post-graduate learning. I am joined by
Dr. Liban and Dr. Ayaanle, two Somaliland doctors who are currently undertaking
a Masters in Mental Health in Ethiopia. They will soon return to Somaliland and
will no doubt become leaders in the field of mental health in Hargeisa and
beyond. Dr. Layla also joins the meeting, a previous mental health rep, as does
Dr. Mariam who has recently assisted in the TOT mental health skills training
course in Hargeisa for new intern doctors. One of the new reps for this year,
Dr. Abdirahman also participates in the meeting. Dr. Adam, Dr. Gudon and Dr.
Abdirazak have given their apologies as they are unable to make the meeting. Dr.
Jibriil, another member, is in Borama, as is Dr Gurgurte. It is a very positive
meeting, with many ideas coming from all members. We talk about both the bigger
picture of mental health in Somaliland and also more specifically about
undergraduate training and the possibility of these doctors taking on a more
supervisory role within mental health education. The first agreement is that
the group will aim to meet regularly to discuss such matters and share
knowledge. It is so encouraging to see this group of professionals keen and interested
in bettering mental health in Somaliland and I hope the meetings continue.
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