Truly honoured
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 Micronesia is an archipelago of several hundred islands in
the Western Pacific, four of which make up the Federated States of
Micronesia (FSM). Pohnpei, the largest of the four state islands,
is 135 square miles of gleaming rainforest, mist-topped mountains
and mysterious mangrove swamp, and where I have been now for three
weeks as a volunteer.
The WHO Pacific Islands Mental Health Network
was established in 2007, and currently has 19 countries as members,
including the FSM. As part of this network, the FSM has
established a Substance Abuse and Mental Health (SAMH) council at a
national level and in each of the four states.
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My placement in the FSM has been arranged by the World Health
Organisation in collaboration with FSM’s SAMH project, led by the
administrator for the programme, Mr Kerio Walliby. Kerio comes to
meet me at the airport on the day of my arrival and almost
immediately whisks me off to a World Mental Health Day party at a
local restaurant in the bay, where they have roasted a pig in
honour of my arrival. Kerio is proving invaluable as a source of
much needed information, support and reassurance when I am having
one my many blips - those times when I realise for the hundredth
time that I know nothing of any relevance and have no idea what to
do next. Nevertheless it always seems to work itself out again, one
way or another, with Kerio’s calm, good humoured assistance.
"Does a bit of everything”
Each of the four states provides health care
to the population via a private hospital, and a state hospital,
with outreach health clinics, dispensaries and aid posts in the
communities. The state hospital provides emergency and elective
treatment, and is staffed by a number of general physicians.
I meet Dr Elizabeth Keller, the Director for Health, in my first
week here, and also the Secretary for Health at the government
buildings in Palikir, the capital of Pohnpei.
There are seven trainees with me for the next
three months – four from SAMH programme in Pohnpei and one from
each of the other three states – Yap, Chuuk, and Kosrae. They have
a range of job titles, including counsellors, outreach workers and
community workers, but they say that everyone “does a bit of
everything”. There are no psychiatrists on any of the islands, and
the patients who need to see a doctor are seen by the general
physicians in the State hospital on each island.
Mental Health care in the FSM is entirely
community based - there are no inpatient facilities for mental
health patients in any of the four states. Patients who are violent
or unmanageable are held in the local prison. Pohnpei and Yap
State have a “holding unit” – essentially a seclusion room – but
these cannot be used unless families are able and willing to stay
with their relative 24 hours a day and provide food for
them. Given this is usually impossible, the jail is much more
frequently used. Patients who are incarcerated in the jail are
seen daily by the SAMH workers to be given medication, and once a
week by one the doctors from the State Hospital. The decision that
the patient is stable enough to go home is taken by the doctor in
collaboration with the family, and there is no mental health
legislation in any of the states. We plan to go to visit the jail
and the clients there as soon as we can.
Tempermental jeep
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 All
the clients of the SAMH programme are cared for in the community by
their relatives. The church also plays a large role in
supporting families and the mentally ill. Families don’t have
the means to bring their relatives to the clinics in the towns and
so the SAMH workers go to see them at home, or they might be taken
to one of the local dispensaries, or community clinics. So several
times a week, and whenever a call comes in for assistance, three
trainees and myself pile into the temperamental jeep and bounce off
into the jungle. These routine reviews are mostly to
administer medication and check on how people are doing – patients
are seen on average once a month.
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On one of these visits we visit a family with
two adult sons, both of whom have a diagnosis of
schizophrenia. The father explains in Pohnpeian dialect that
the eldest sometimes experiences distortions of his face, with
tongue protruding and stiff jaw. When this happens, the
parents stop his oral haloperidol for a few days, but then he
begins to “act strange” again – angry and running off into the
forest and onto the neighbours’ land, chopping at their trees –
whereupon they start his tablets again.
We talk to the family about dystonia and the
importance of maintaining medication to prevent relapses, and leave
a prescription of anticholinergics to try. I am desperate to change
his medication to an atypical......but we don’t have any. The
only consistent supply is of Fluphenazine and oral Haloperidol,
which runs dry from time to time.
Later on, in the jeep, Stencer and Kehn, the
two Pohnpei community workers, tell me that there was another,
eldest son, who was found murdered in the mangrove a year
ago. They think he also had schizophrenia and was attacked and
killed in response to his bizarre and aggressive behaviour,
although no culprit was ever found.
The active caseload in Pohnpei is
approximately 75 with another 100 ”inactive” – this is in a
population of about 36,000. Inactive clients are those who are
known to have mental health problems but who have refused to engage
or take medication. The trainees tell me that frequently it is
often the families who refuse, not the patient. Families play
such a pivotal role here – no patients are seen without their
families consent; it is families who bring their relatives to the
hospital or clinic for help; families make decisions about
treatment.
“I cannot be happy unless my family is happy”
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I am touched by how welcome I have been made
since I came. Pohnpeians are warm and generous, and I am trying to
accept all of the many invitations that come my way. I am finding
that this is a great way to learn as much as I can about the local
way of life, and people’s ideas and beliefs about mental health,
what works and what is still needed here. I've learnt that the
reliance on family and community to support and help one another is
the natural way here – that clan is more important than
individuality. As someone says to me “I cannot be happy unless
my family is happy”.
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Suicide is an increasing problem here, with
FSM having among the highest rates in the world. But it is also a
taboo subject. Local people tell me that the majority of
Micronesians believe that talking about suicide will “put the idea
into the heads” of others – when I suggest reaching out to young
people and educating them about suicide, the trainees tell me that
parents would find this unacceptable.
I learn that local belief is that the spirit
of a suicide victim will “infect” others and cause them to kill
themselves too unless prompt action is taken – e.g. the tree
that is used by someone to hang themselves is burnt to the
ground. They tell me that “anger suicides” are rife – that young
people who are refused some latest gadget by their parents, or who
are jilted by a girlfriend or boyfriend, kill themselves as a way
of punishing their families.
A man in town I talk to tells me that he
thinks the problem is the decline of traditional values, respect
for the elders, and that the young people here are “lost” amongst
the conflict of local values with Western ideals. I wonder about
depression and the role it plays, but the trainees tell me that
depression as a concept is new and not widely held here, that
people who are suffering from emotional distress or symptoms of
depression are taken to the local healer and do not come to mental
health. The SAMH clinic seems to only access patients when
they become violent or chaotic. It is not a cultural norm here to
talk about your feelings, especially not to an outsider like
me.
Challenges
The trainees are enthusiastic, friendly and
well equipped with a good sense of pragmatism and humour. They
are keen to know more about how to explore psychopathology and how
to tell one major disorder from another; and they are quick to
come up with ideas as to how we can disseminate what we are doing
to others once training is done. They tell me that the biggest
challenges they face are to do with resources – human resources,
transport to access patients, medications that run out and don’t
get restocked.
There is so much for me to learn and to think
about. I knew I would be challenged a lot out here, but I am
utterly a novice, in so many ways. Three months is no time at all,
and we’re already a month in!
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