Mental health training in Somaliland - Day 45

Tuesday 5^th November

Another early start, with the first stop being the beach! I have never seen the coastline in Somaliland, and it feels great to breathe the sea air. Then onwards to the mental ward once again. Today we spend time detailing what is available and what is happening on the ward, such as the numbers of patients locked in rooms, the numbers chained, trying to get some more sense of their diagnoses and the medications available on the ward. We speak to ward staff, who are mostly social workers with very little training in mental health. Many have only had three months training in mental health two years ago in Hargeisa and little since.

They all feel that they would benefit from further training. It is incredible really that they have all stayed on the ward for a number of years, despite not even receiving proper salaries. The ward administrator is very helpful and gives much of his time today to help answering questions about the general running of the ward.  It is interesting to find out how the ward runs, with so few staff. There are no trained nurses who work on the ward. Safety issues are striking. With so little staff and training, when patients become violent and wish to abscond, often they are left to go, as it is simply not safe to try and keep them there. Only two weeks ago, a watchman on the ward had boiling hot water thrown in his face as a patient tried to leave the ward. The watchmen have not had training in restraint techniques and so this clearly makes their job more challenging.

Though there is a doctor on the ward, we do not get the opportunity to meet with him today as he is away. He attends the ward from 7:30 am until lunch time each day. It is encouraging to see a system of clinical notes existing, though many are not written in any detail. I reflect on how challenging it must be to work here, without any senior supervision available.  The physical health of the patients remains a challenge, with very little input from doctors in the main hospital. They rarely come across to the mental ward whilst on-call, and so in emergencies patients are sent across to the main medical hospital. The patients only get their vital signs monitored on admission to the ward, and in an emergency. Their physical health is only assessed I am told, when the patients are noted to be unwell.  

We speak to a number of patients who report physical problems. It is clear that much could be done here to help both staff and patients. With better training, the staff would likely feel more able to manage the patients and also feel more empowered in their roles. I hope that we will be able to offer some input here in Berbera.

The journey back to Hargeisa from Berbera proves to be a challenging one. Rather than two and a half hours, we spend seven and a half on the road, and then end up back in Berbera! The road is flooded due to the rain running off the mountains and filling the rivers that the road crosses. We manage to cross two, though there is a real concern that if we try and cross any more, we may not make it across. We can see cars and trucks on the other side who have been impatient and ended up getting stuck in the sand. Many people are well aware of recent deaths when people have tried to cross, as often the waters rise and with such a strong current, cars get pulled downstream. We decide to turn back to Berbera to be safe, though then have to wait as the waters have risen in the rivers we have already crossed. We eventually get back and sleep soundly. 

Mental health training in Somaliland - Day 44

Monday 4^th November

Today we set off early as we are travelling north to Berbera. Berbera is situated on the north coast of Somaliland and as such has historically been an important strategic point due to its port. The drive up is beautiful and it is lovely to be on the road again. I adore being able to see some of the country as usually our movements are limited to between the hotel and places of work. We see many herders with their sheep and goats, lots of camels, including unfortunately those in trucks that shall apparently be exported to places like Yemen for people to eat and even wart hogs along the way. We pass through many villages along the way, with khat stalls still dotted along the way and people going about their daily business. We stop of at the Laas Geel caves on the way up to Berbera, a place I have wanted to visit for some time. These are a set of caves which feature beautiful rock art paintings, which are thought to be some of the best preserved in Africa. It was beautiful, we were taken up into the highest caves and I was amazed at just how clear the paintings were. There were paintings of people with their animals, including cows and dogs and even depictions of giraffes and pregnant women. The views from atop the caves across the arid land were stunning.

Onwards to Berbera and we stopped off briefly at a bakers, intimately tied up with a love poem written by a famous Somaliland poet. Then onto the most famous fish restaurant in Berbera, and home to many of the regions cats who were ready for any left overs.  We quickly checked into the hotel and then myself and film-maker Najaat went on to meet with the Regional health officer, Dr. Abdirahim. He was very helpful in giving us the details of the mental health service in Berbera at present. We join him on a visit across from the main hospital to the mental ward.

The psychiatric hospital is the only one in the whole of the Sahil region and Dr. Abdirahim tells us the population is about 220,000 people. There are no psychiatrists in the region and no trained mental health nurses. The work on the ward is done by ‘social workers’ who have been given some brief training by a medical doctor in how to administer medications and a doctor who spends each morning on the ward. There has been no formal mental health training in this region and the only doctor who was trained in the use of the WHO mhGAP approach has now left the region.

The staff manage on incentives rather than any formal salary and there are a number of watchmen on the ward. Though the ward is very positive in some respects, such as it having a large open area and shade structure, with electricity and running water available, it is clear that much could be improved. Patients are still chained, with five male patients seen to be chained to concrete pillars. The sanitation is poor and many patients are locked in their rooms, with waste draining from the rooms. Though it is very difficult to see, it is also easy to see the challenges faced by the staff here, who willingly dedicate their lives to helping those with mental illness, without proper salaries. With a shortage of trained staff, little in the way of money, a sporadic supply of medications and a rather challenging patient population when admitted to the ward, (often acutely psychotic or manic, with co-morbid khat use which often presents with aggression and violence) it is obvious that these people are trying to do their best under the circumstances. Though it is shocking, it is also positive to see that much could be changed and training would help immensely in order to effect this change. Tomorrow we shall visit the female part of the ward and speak to both staff members and the administrators to compile a comprehensive needs assessment report.

The day is wrapped up with a meeting with Najaat, who has been an incredible support during my time here, often tirelessly and enthusiastically shadowing me over the past 2 months, filming the work we do, so that the footage may be used to make a short documentary of THET’s work here in Somaliland. We work on the narration for the documentary, which she has asked me to do. 

Mental health training in Somaliland - Day 43

Sunday 3^rd November

Today is a day spent in the office, finalising the written report of the last two weeks teaching. Before this, I have breakfast with Mary-Jo and Eqbal and we all go to a local shop to search for camel bells to take back for friends as souvenirs. It feels rewarding to reflect on the last 2 weeks and in fact the last 2 months I have spent in Somaliland and I realise just how much I have managed to do in this time. I started by leading, with local colleagues, two TOT mental health skills training courses for interns and other health practitioners including nurses, in both Hargeisa and Borama. Then, with local colleagues, led revision teaching for the 6^th year medical students in both Hargeisa and Borama and simultaneously worked in partnership with local colleagues and both University Faculties on integrating further psychiatry into the medical students curriculum as a stand-alone clinical attachment. This included developing appropriate learning outcomes for the attachment and organizing suitable people to lead this project, both on the ground and also in UK, via the online learning platform Medicine Africa. This has now been accepted and shall start in November, which is a very exciting prospect as never before have the medical students had psychiatry as a clinical attachment.

The last month has been spent in Borama, and the past two weeks has been taken up with the annual teaching of the 5^th year medical students. Next stop, Berbera! Tomorrow we shall travel up north to undertake a needs assessment of the mental health services available there, in order to see whether THET might be able to offer any assistance with training and in other ways. 

Mental health training in Somaliland - Day 42

Saturday 2^nd November

Up bright and early to leave the hotel that has become my home for the past month. We say goodbye to all the wonderful and friendly staff, who have made our stay such an enjoyable one. The journey back to Hargeisa is beautiful, with the feeling of space all around us. Once back in Hargeisa, I meet with Mary-Jo, my great colleague and friend, and also nurse co-lead for the mental health group. It is such a great joy to see her here finally, as we have never yet been in Somaliland at the same time. She is leaving tomorrow, though we both feel lucky for having had the opportunity to spend at least a night together. We have a lovely dinner with the THET team and other friends.

Mental health training in Somaliland - Day 41

Friday 1^st November

Today was a rest day, and a day to round things up. I was lucky enough to be invited to a female student’s house for a wonderful lunch. Hayat had prepared a feast! We were joined by all the ladies who attended the course, which was a fantastic opportunity to get to know them better. It was a delight for me to have the opportunity to spend this time with my new friends. Later, myself and Mandip had a consultation with the sister of a student, who had epilepsy that was not well controlled and may also have had some anxiety. We were then joined by our friends and colleagues. Then the time came to say goodbye, until next time.

I have been so impressed by the warm welcome I have received from everybody in Borama, I really felt like part of a family here and know that I will return. Su’ed returns from Hargeisa where she will been doing a nursing TOT course with Mary-Jo who has now been in Somaliland for over a week. She is pleased with the course.  We have a very nice send off from all our friends and both Mandip, Jibril and I are thrilled with the outcome of the course and how it has all gone to plan.  Lastly we do a little work on Jibril’s presentations, as soon he is off to Mogadishu to present at a large health conference. It is an exciting opportunity to present all the incredible work he has done in Somaliland. 

Mental health training in Somaliland - Day 40

Thursday 31^st October

Today is the final day of the course. We spend the morning giving out exam feedback to the students and also feedback from the OSCE. The students have all thankfully passed, and in fact, many have passed with very high marks. We are particularly pleased with the progress many of them seem to have made since the beginning of the course. Many have much higher marks on the post-tests than they had on the pre-tests, which is great for us to know as teachers. They are a competitive group and despite very high marks, some think they could have done even better!

Today is a day of Somaliland Psychiatry and we are lucky to be joined by Fatima, the Dean of Nursing, who has been a truly inspirational figure here in Borama in very many different ways, but particularly in mental health. She gives a talk about the development of mental health services in the region and Dr. Jibril then presents all the work he has tirelessly been doing over the last 4 years. It really is incredible what this team have achieved. They have started mental health services from scratch, and integrated the services into primary care, maternal health care and child health. This makes sense for such a community, where most people visit traditional healers or sheikhs before they ever come to the attention of a doctor. The team has mobilized the community, including sheikhs, schools, even the prisons and police, to raise awareness of mental health issues. The Somali diaspora population connected to the area have also been involved heavily, particularly in the development and continued running of the mental health ward at Borama Regional Hospital.

I am astounded by the work that has been done here, much of it on a voluntary basis by Dr. Jibril. We hear of stories of him and Faadumo, walking all day in communities, just to go and find people with mental illness and offer help. We hear of certain cases in the region which really make one realise how crucial it is for change to happen. Dr. Jibril tells us of a family in which there were a number of family members with mental illness. They were ostracized from the community and due to being so poor could not afford food. Due to their mental illness, they were unable to work. Unfortunately three family members starved to death. This represents the extreme end of the picture, and we also heard very positive stories of similar families being helped by the community to live and eat. It was clear that much change was happening in Borama and this was a joy to hear. Finally, we give out the certificates to all the students and all the co-facilitators. The day ends early as the students prepare for the evenings celebrations, and we cannot finish the morning without many many photographs!

The evening is wonderful. As is tradition in Borama, my female students dress me up in traditional Somali dress. This year is a beautiful pink and purple dira (dress), and Hayat. One of the students spends time fixing me up an elaborate head scarf with multiple colourful scarves weaved together. As I walk past people I know in the hotel to go to the party, I am not recognized!

The celebration is a fantastic event. We are all at the University faculty, with the stage set outside and trees in the background. The students have decorated the place beautifully and it looks ornate. The evening is led by one of our female students Nasra, and many people make speeches, though I am touched especially by the student contributions. I had stated that I love poetry and had requested that one of our students, Jama, prepare 20 minutes of poetry for the end of the course, as he was an extremely talented poet. He recited a 6 page poem that he had himself written. I was stunned. He talked about a man who was apparently psychotic, about the challenges of mental illness and the loneliness it often results in, and went on to talk about the capacity people have to make change. He also talked about suicide and the issues related to this in the Somaliland context.  His recital was stunning, insightful, clever and also humorous in parts and I truly felt privileged to have been witness to this. We were also read another poem by a female medical student and even a song by one of our co-facilitators, Hodan. Her voice was incredible and you could have heard a pin drop when she sang. One of our students was in fact a Sheikh and also read a poem. He commented that as my name did not quite fit with the words of the poem, he would have to give me a Somali name.  This was ‘Cawo’ (pronounced Ao) which means lucky or luck. I felt absolutely blessed and lucky! What a gift to me this was! Finally the evening was rounded up with a wonderful traditional Somali dinner, which was delicious and then…..photos! The night was long and a happy one for all and one I shall never forget. The hospitality and the welcoming of everyone was just beautiful. 

Mental health training in Somaliland - Day 39

Thursday 31^st October

Today is the final day of the course. We spend the morning giving out exam feedback to the students and also feedback from the OSCE. The students have all thankfully passed, and in fact, many have passed with very high marks. We are particularly pleased with the progress many of them seem to have made since the beginning of the course. Many have much higher marks on the post-tests than they had on the pre-tests, which is great for us to know as teachers. They are a competitive group and despite very high marks, some think they could have done even better!

Today is a day of Somaliland Psychiatry and we are lucky to be joined by Fatima, the Dean of Nursing, who has been a truly inspirational figure here in Borama in very many different ways, but particularly in mental health. She gives a talk about the development of mental health services in the region and Dr. Jibril then presents all the work he has tirelessly been doing over the last 4 years. It really is incredible what this team have achieved. They have started mental health services from scratch, and integrated the services into primary care, maternal health care and child health. This makes sense for such a community, where most people visit traditional healers or sheikhs before they ever come to the attention of a doctor. The team has mobilized the community, including sheikhs, schools, even the prisons and police, to raise awareness of mental health issues. The Somali diaspora population connected to the area have also been involved heavily, particularly in the development and continued running of the mental health ward at Borama Regional Hospital.

I am astounded by the work that has been done here, much of it on a voluntary basis by Dr. Jibril. We hear of stories of him and Faadumo, walking all day in communities, just to go and find people with mental illness and offer help. We hear of certain cases in the region which really make one realise how crucial it is for change to happen. Dr. Jibril tells us of a family in which there were a number of family members with mental illness. They were ostracized from the community and due to being so poor could not afford food. Due to their mental illness, they were unable to work. Unfortunately three family members starved to death. This represents the extreme end of the picture, and we also heard very positive stories of similar families being helped by the community to live and eat. It was clear that much change was happening in Borama and this was a joy to hear. Finally, we give out the certificates to all the students and all the co-facilitators. The day ends early as the students prepare for the evenings celebrations, and we cannot finish the morning without many many photographs!

The evening is wonderful. As is tradition in Borama, my female students dress me up in traditional Somali dress. This year is a beautiful pink and purple dira (dress), and Hayat. One of the students spends time fixing me up an elaborate head scarf with multiple colourful scarves weaved together. As I walk past people I know in the hotel to go to the party, I am not recognized!

The celebration is a fantastic event. We are all at the University faculty, with the stage set outside and trees in the background. The students have decorated the place beautifully and it looks ornate. The evening is led by one of our female students Nasra, and many people make speeches, though I am touched especially by the student contributions. I had stated that I love poetry and had requested that one of our students, Jama, prepare 20 minutes of poetry for the end of the course, as he was an extremely talented poet. He recited a 6 page poem that he had himself written. I was stunned. He talked about a man who was apparently psychotic, about the challenges of mental illness and the loneliness it often results in, and went on to talk about the capacity people have to make change. He also talked about suicide and the issues related to this in the Somaliland context.  His recital was stunning, insightful, clever and also humorous in parts and I truly felt privileged to have been witness to this. We were also read another poem by a female medical student and even a song by one of our co-facilitators, Hodan. Her voice was incredible and you could have heard a pin drop when she sang. One of our students was in fact a Sheikh and also read a poem. He commented that as my name did not quite fit with the words of the poem, he would have to give me a Somali name.  This was ‘Cawo’ (pronounced Ao) which means lucky or luck. I felt absolutely blessed and lucky! What a gift to me this was! Finally the evening was rounded up with a wonderful traditional Somali dinner, which was delicious and then…..photos! The night was long and a happy one for all and one I shall never forget. The hospitality and the welcoming of everyone was just beautiful. 

Mental health training in Somaliland - Day 38

Wednesday 30^th October

Today is the day for the OSCE examination. The students complete their post-course MCQ exam first thing and we leave the co-facilitators to collect papers, whilst myself, Mandip and Dr. Jibril, with the mental health reps Zainab and Abdirahman, go to practice the OSCE stations with the actors.

It is vital that we all standardize our marking, and also the acting, so that each student is fairly examined. We spend much time doing this and are pleased that our individual marks correlate with one another. We are joined by some 6^th year medical students who have kindly offered to volunteer their time to act as patients for the medical student exam. This is also good practice for them, as through acting, one often learns more about the OSCE, what questions are asked, what sound good in an exam scenario and so on.

The whole day goes impeccably, with Aidrous, one of the 6^th years, acting as the most important figure of the day- the time-keeper. The students all turn up on time and thankfully all goes to plan. The evening is spent as a team, with the co-facilitators, marking the examinations and finally inputting data to our spreadsheet. With 68 students, this is a mammoth task and we are so thankful for all the support and help. We all finally end the day with a dinner together at Ray’s. The certificates are written just before bed, which means a late night!