Tuesday 22 May 2012

We concentrate on some challenging areas within Psychiatry - taking a sexual history and risk assessment. Sexual history-taking proves a real challenge for the students and they are simply not comfortable discussing such matters. We work through a number of different scenarios to enable them to think about ways in which sensitive questions and areas may be managed. Whilst discussing risk, it is clear to me how lucky we are in the UK, to have a functioning mental health act, secure wards, and clear protocols to work alongside. Managing risk in a country where no mental health act exists, and where there is a stark lack of staff available is another challenge altogether.

Wednesday 23 May 2012

Today is the students’ OSCE examination. Two cases have been picked and the actors are other medical students who have kindly volunteered their time. I examine alongside Layla and Peter is alongside Adan, with the reps carrying out the bulk of the marking, in order that they get a true experience of examining. The OSCE went smoothly, somewhat surprisingly, as it takes organization and strict time-keeping, to make it work. The reps had done a good job. The students demonstrated their enthusiasm and I was impressed with their progress after just 2 weeks of teaching.

Peter and I met with Faduma (the head of nursing) later that day. She requested that we interview a man, who was suffering from a manic psychotic relapse. He had a diagnosis of Bipolar Disorder and was on medication, though had not taken it during a recent reported incident of violence. Peter and I met with him in the company of Faduma, who translated for Peter. He was now taking Olanzapine regularly and was much improved in his mental state. He was wiling to be followed up by Faduma who was also supporting him financially as he was not able to work. Cases were brought to our attention, and we often interviewed people in the lunch breaks, even if only to offer advice or sign-post to a relevant person to follow-up the case.

Thursday 24 May 2012

We go through the post-course MCQ exam, and were pleased to see that some attitudes towards mental illness had changed positively from when we started the course. Small prizes were given out to the top scoring students and certificates were awarded to all. The students seemed pleased with their performance and we were delighted that all of them had passed the course. This is important as they cannot pass their final medical school examinations without succeeding in Psychiatry. It is a testament to how much further up the agenda Psychiatry has come since the teaching started, only a few years ago.

Then group photos, individual photos, team photos, university photos, class photos, friend photos, photos with reps, photos with tutors, photos on the grass and photos under the university sign…Somalilanders LOVE photos!! It was quite simply wonderful, and little did I know there would be a repetition of this later that night.

The two universities, Amoud and Hargeisa, had organised a dinner, for all the students and teachers, including the deans of the respective medical schools and various other academics. I was lucky enough to be dressed up in traditional Somalilander attire by two of the female students and attended dinner looking quite unlike my usual self. Many speeches followed, which made me reflect on just how important this teaching was and how appreciative the students were. I felt privileged to have been given the opportunity to be involved in such a trip.

Friday 25 May 2012

Our last day in Borama was spent inputting data and report writing. This is an integral part of any teaching trip, for without numbers, we are not able to reflect upon and ultimately improve our teaching for future trips.

DrJibriil and the reps joined myself and Peter to work on developing the final year medical student OSCE exams and to develop the written examination.

Saturday 26 May 2012

I bid goodbye to Borama and we make the journey back to Hargeisa. I get to see glimpses of Borama, a sleepy dusty town that reminds me of little villages in Kenya. It is early morning and as we get out onto the open road, I get a real sense of space.  I breathe the African air and feel happy to be moving, able to see life going on around us: herders with their black-headed sheep, women walking together, men steering their heavily laden donkeys along the road, the mountains in the distance, tortoises crossing the road, camels and baboons.

Somaliland blue sky sees us all the way to Hargeisa where we briefly stop by the THET office for a final de-brief and are on our way again, to the airport.

Soon we are on the ECHO flight, a small humanitarian aircraft that routes through northern Kenya. Back on the flight, I look out of the window and think about all we have achieved in the last two weeks, I think through all I have learned. I feel a great sense of achievement, and real joy in what I have done. It has truly been an incredible journey and I hope to return.

Dr Lauren Gavaghan

CT3 Psychiatry trainee

Thursday 17 May 2012

We begin each morning of teaching with a re-cap session. The students were enthusiastic and keen to learn and one question would lead to another. A ‘terminology’ board was utilised and proved very useful, in order that students felt able to ask about aspects of psychiatry that confused them or words they did not know. I present a talk about psychosis and again, I am reminded that what is appropriate, especially on a national unit in the UK, is often not relevant to a medical student learning about psychiatry in Somaliland. Forget about Clozapine and Lamotrigine, for they are not even available here. We are back to the typical antipsychotics, Haloperidol and Chlorpromazine, because they are available and importantly, cheap(er). Newer atypical antipsychotics have started to trickle through in Somaliland, and are now being used more often. Unfortunately these antipsychotic medications are more expensive and many patients simply cannot afford them. One really has to think about these matters in a country where no National Health Service exists.

Friday 18 May 2012

Each day, students meet with patients, who have kindly agreed to being interviewed. The students enjoy this part of the course, some of them have never had the opportunity to speak to someone with severe mental health problems and the experience gladly seems to change many of their preconceived ideas about mental illness.

Today it is Somaliland Independence Day, which marks the 21’st anniversary of Somaliland’s independence from Somalia. The students request an early start and finish to teaching, which we respect, allowing them to return to friends and family to celebrate.  

"There was a general consensus that those with conversion disorder were indeed somehow ‘faking’ their symptoms, so I found the job of unravelling such beliefs interesting."

Saturday 19 May 2012

We explore somatisation and conversion disorders today. This is an interesting and very relevant topic here in Somaliland. Somatisation is common. We hear some of the stories from the students and it is fascinating to find out a little of their own experiences and views. We are told of placebo drugs and IM analgesic injections being given to ‘cure’ paralysis. There was a general consensus that those with conversion disorder were indeed somehow ‘faking’ their symptoms, so I found the job of unravelling such beliefs interesting.

We also worked on a more taboo subject, alcohol, and how one might take an alcohol history from a patient. Alcohol, though available, is banned in the country and its use looked upon with shame. Religion plays a hugely important part in people’s lives here and therefore trying to broach such subjects, bridging both religion and medicine can often be a challenge.

Sunday 20 May 2012

Organic disorders and psychiatry are discussed today. In a country such as Somaliland, organic disorders are extremely important and we get the students to work in small groups, discussing cases they have brought to the teaching. We also get them to role-play cases and practice under examination conditions to prepare them for their future OSCE exams.

Adan, one of the mental health reps, leads a discussion about psychiatry in Somaliland, concentrating on khat use. This is such an important topic here and one that the students need to be familiar with, as often, the psychotic presentations they see will be related to khat. Khat intoxication can lead to a psychosis that is similar in presentation to a schizophreniform episode. The students are familiar with this area and they teach us a great deal about local practices.

Monday 21 May 2012

Today, as we explore the vast area of child psychiatry in one morning, I role-play the part of a 7 year old hyperactive child, teaching how one might advise a parent of a child with a possible diagnosis of ADHD. This was popular with the students, and something they were not familiar with, as child psychiatry is even further down the agenda than adult mental health, perhaps understandably due to the scarcity of resources. Interestingly however, some of the cases that Peter and I saw were children and it is clear that this is becoming a growing area for focus internationally.

Layla the second rep gave an incredibly insightful talk about mental illness in Somaliland. She concentrated on the links between religion and health beliefs, and I began to appreciate just how important religion is in Somaliland and how such beliefs can impact upon peoples health beliefs, both positively and negatively.

I am currently a CT3 core Psychiatry trainee, working at the Maudsley Hospital, South East London. I have always had a passion for global mental health, having grown up in Kenya. I was lucky enough to come into contact with Dr Peter Hughes at a trainee conference in 2011. He put me in touch with Dr Susie Whitwell, the mental health lead for the King’s THET Somaliland Partnership (KTSP) mental health group. By coincidence, there was a teaching trip due to go out to Somaliland in May 2012, which I keenly volunteered myself for. I was lucky to come full circle and accompanied Dr Peter Hughes on this trip to teach undergraduate medical students in Boroma, Somaliland. Below follows a blog of my experiences there...

May 2012 Teaching Trip to Borama, Somaliland

Monday 14 May 2012

The trip begins with a meeting in Nairobi, the capital of Kenya. Peter and I plan the initial stages of our trip at the Nomad Palace Hotel. It is situated in Eastleigh, a region of Nairobi termed ‘little Mogadishu’ due to its significant Somali population.

Tuesday 15 May 2012

Our flight has been re-routed through Mogadishu, something not too uncommon when traveling in Africa. The in-flight magazine ‘African Business’ has an article entitled ‘Mad money in Mogadishu,’ describing the place as ‘having a reputation as one of the most dangerous places in the world.’ I am struck by the beautiful coastline of Somalia as our plane waits on the runway. We are soon on our way again and landing in the capital of Somaliland, Hargeisa. After paying a three dollar entry fee, we are allowed to enter the country.

We receive a warm welcome from a smiling and friendly Somalilander. We are driven by Faisul to the central THET office, based at the Edna Adan University Hospital where the local team await us. Ms Edna Adan is in her office as we arrive and Peter drops in to say hello. A remarkable lady, awarded the French legion of honour in 2010, and who has tirelessly worked to implement and improve the healthcare in Somaliland.

A security briefing takes place, and we are made aware that the situation in Hargeisa is at present calm. There existed a 20:00 hours curfew in Hargeisa and a 19:00 hours curfew in Borama which are were expected to keep to as foreigners.

We head out to Borama setting off in convoy in 4-wheel drives, passing stall after stall painted with the now familiar picture of a green bundle of what looks like spinach. This is khat, as much a staple in Somaliland as tea is in England. Khat is part of the culture here, chewed at specific times of day, in a stereotyped fashion.  It is important in terms of mental illness as it contains a substance not dissimilar to amphetamine, which, when chewed in large amounts, can lead to a schizophreniform-like psychosis.

..."we will be teaching using ‘mhGAP.’ This is a mental health manual, formulated by the World Health Organisation and used to aid diagnosis and management of mental health conditions in low-income countries. This, as far as we know, is the first time it has been used as a foundation for undergraduate teaching in psychiatry..."

The land is dry to begin with, with thorn trees dotting the landscape and as we head out further towards Borama and Ethiopia, the land becomes greener. Road blocks exist between districts, most of them simply ropes traversing the road, with men in green army gear stood by the side, waving vehicles onwards.

We arrive at the comforting Ray’s hotel and Dr Jibriil is awaiting our arrival. A now near celebrity in his homeland and famous amongst the THET team in the UK, Dr Jibriil was once taught Psychiatry as a medical student by Peter himself, and now works as a doctor who has tirelessly dedicated his time to ensuring that mental health is on the agenda in Somaliland. Dr Jibriil organises much on the ground, and is currently busy setting up the first psychiatric in-patient ward in Borama.

We are joined by this year’s mental health reps, two interns who are selected to take up the position, and who will be leading on the teaching with us.

It is the aim this year that the reps will lead on approximately 40% of the teaching and take a much more active role, which is crucial as it ensures that the job can be continued when we leave.

Another important difference in this year’s teaching is that we will be teaching using ‘mhGAP.’ This is a mental health manual, formulated by the World Health Organisation and used to aid diagnosis and management of mental health conditions in low-income countries. This, as far as we know, is the first time it has been used as a foundation for undergraduate teaching in psychiatry, which is an exciting prospect.

We plan the teaching timetable for the next two weeks. Due to Somaliland Independence Day happening on Friday 18^th May, our timetable is shortened. We make the necessary changes. Flexibility is key to international work. Computers don’t always work, things crop up that one does not expect, and a little creativity goes a long way in ensuring things get done on time. It is a late finish to a long but satisfying day of travel.

How can one get the balance right, between ensuring the teaching is culturally relevant and also ensuring that the students receive an ‘international’ education, in order that they also learn about practice elsewhere? Our local representatives Adan and Layla were to prove indispensible in this area. For they knew the culture inside-out and could pick up where we left off, to make the teaching more culturally relevant.

I talk about professionalism within medicine and psychiatry, talking about the duties of a doctor, documentation in medicine, teamwork and ethical issues within psychiatry. The session ends with exercises where various ethical scenarios are discussed amongst the class. We talk about issues as diverse as doctor-patient relationships (colleagues in distress and the issue of chaining) and violence against mentally ill patients. The groups were honest in their views and it inspired an interesting discussion.