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The Royal College of Psychiatrists Improving the lives of people with mental illness

Zimbabwe

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16/01/2013 09:32:09

Harare

It’s a month now since I arrived in sunny Harare to take up my post as a Clinical Tutor at the University of Zimbabwe. I got my job here through the Institute of Psychiatry as part of the ‘Medical Education Partnerships Initiative’ (MEPI) for six months. King’s College London is one of the partnering institutions of the University of Zimbabwe as part of MEPI. This project, which is funded by the US, involves partnering African Medical Schools with institutions in the US and the UK with the aim of ‘improving medical education in Africa'.

 

In addition to teaching and helping with curriculum development for the undergraduates here, I have been working on the psychiatric inpatient ward and outpatient clinics at Harare’s main teaching hospital.

There had been a few weeks delay in my arriving in Zimbabwe due to issues with employment permits and the like, so I was pretty relieved to finally get on the plane. The sunshine and beautiful purple-flowering jacaranda trees which greeted me when I touched down made me all the more glad to have arrived!

Psychiatric wing of parirenyatwa hospital, Harare, Zimbabwe

I’m not sure what I had expected of Harare as I have never been to Zimbabwe before but I had prepared myself for more of a ‘third-world’ experience than I found. On my first day, I was very kindly taken by our project driver to the nearest Spar to pick up groceries. I hadn’t expected to go hungry in Zimbabwe but I was pleasantly surprised to find Marmite and Cadbury’s chocolate for sale round the corner from my house! My first impressions were in stark contrast to the media reports we receive in the UK which portray Zimbabwe as a dangerous country on its knees. People inform me however that things have only recently started to improve and that in 2008, there was scarce food on the shelves and rarely any petrol at the pumps due to the extreme hyperinflation at that time. The US dollar was introduced in Zimbabwe in 2009 and since then, I‘m told, things here have been steadily improving. Signs of the deep inequalities here are still to be seen on every street corner however and with the average annual income per capita of $460, it’s difficult to imagine many people are willing to spend $5 on Marmite (except me).

After a couple of days of settling in and meeting colleagues, I started working on the Psychiatric wards and in the clinic. Initially I was shadowing one of the consultants here but I have since started reviewing patients along with one or two SRMOs, our equivalent to House Officers. There are only 4 consultant Psychiatrists working in the government sector in Harare (5 in total in Zimbabwe so I’m told!). There are around 6 doctors on the MMed program here, which is the training scheme for psychiatry.

At each outpatient clinic, around 100 patients line up on benches along a very long corridor, spilling out into the car park. As such, most patients are seen by junior doctors here who are on a psychiatry rotation in their first year after graduation. The first thing that struck me, apart from the length of the line of the patients waiting, was that there are no notes. Patients are required to buy an exercise book where the doctor writes their notes, the patients then have to keep this book and bring it back each time. To my surprise, it’s extremely rare for them to forget this book and I wonder if I’m being cynical to imagine that this would be very unlikely to happen back in the UK. I’m grateful to be accompanied by an SRMO as most of the consultations would naturally take place in Shona, the national language here, although the majority of patients we see in Harare do speak good English.

'One of the more challenging aspects of the clinical work for me is managing epilepsy, which is included in the work of a Psychiatrist here'.

The clinical work is, in some regards, similar to the UK. Most patients attending are on antipsychotic medication and much of our role is trying to balance side effects with symptom control, the only difference is that here, only a small number of first- generation drugs are available for free, and the majority of consultations end with the doctor suggesting an alternative medication with fewer side effects which the patient cannot afford. The frustrating outcome of this is that you frequently end up prescribing medication which is causing severe side effects and may lead to long-term problems which cannot be reversed. This is particularly challenging for the doctors in training here as they have an impressive knowledge of psychotropic medication but they are unable to prescribe the drugs that they know would be more helpful to their patients. Luckily, another thing which I noticed straight away was the Shona trait of facing adversity with a smile; this applies to doctors as well as their patients. One of the more challenging aspects of the clinical work for me is managing epilepsy, which is included in the work of a Psychiatrist here, unlike in the UK. We are lucky to have an EEG machine here but after receiving the results of the first few I ordered, I soon realised that they all seem to come back with identical reports regardless of the presentation - another frustration - but like the other doctors here, I am learning to rely on my clinical skills instead of resorting to expensive tests which are so easily available in the UK.

'There are no provisions available for this child to go to special education classes -  and no support groups or centres for the family to attend for support or information.

Parirenyatwa Hospital, Zimbabwe

One or two cases come to mind when I reflect on my first few weeks of clinical work here; one is of a mother who came for help in managing her 9-year old son. She told us that he had had problems learning since he was a baby and had delayed developmental milestones. He has never been to school and spends his days by his mother’s side at home. She brought him to clinic as he is increasingly head-banging and biting his hands when he gets frustrated.  As a result, she ties his hands behind his back at all times to limit how much harm he can do to himself. I attempted to dredge my child psychiatry knowledge back into the front of my mind and started trying to explain the ABC approach to behaviour management to the child’s mother and the SHO I was with.  Both were looking increasingly bemused at my explanations and seemed disappointed that I did not plan to increase the low-dose antipsychotic already being given to manage the behaviour. The patient had already been seen by the psychologist here but was told that they couldn’t help in this area and that the family would have to see a private psychologist, which they cannot afford. The child’s medication is being paid for by the family’s pastor as both parents are unemployed.

'One of the things we take for granted in the UK is the high level of multi-disciplinary teamwork and the breadth of expertise available within the National Health Service.'

There are no provisions available for this child to go to special education classes and there are no support groups or centres for the family to attend for support or information. There was some discussion amongst the doctors about the possibility of rare genetic abnormalities as the cause for the child’s presentation but I couldn’t help but feel frustrated that the need in this case was for some basic support and education for the child’s parents as well as some provision for special education or stimulation of some kind for their child.

 

One of the things we take for granted in the UK is the high level of multi-disciplinary teamwork and the breadth of expertise available within the National Health Service.

These sorts of experiences raise big questions for our work on revising the undergraduate curriculum here.

 

Most doctors will spend at least some of their time working in rural settings in Zimbabwe with little support from other senior colleagues and will be expected to manage all patients who present, without specialist input. The question is; do we attempt to teach them to be doctor/OT/nurse/psychologists all-rolled-into one? Or do we train along the lines of a more western model, which assumes that a well-functioning health service is in place?

 

Many of the doctors trained in Zimbabwe, will unfortunately go on to work in higher income countries and it seems reasonable that they should expect their qualification and skills to be transferable. I’m working closely with the Zimbabwean faculty here to try and make sure that any changes we make are appropriate and sustainable. I’m hoping that as I learn more about Zimbabwe over the next few months, I will start finding the answers to some of these questions.

 

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24/01/2013 13:43:23

3 months on...

I’ve been in Zimbabwe for three months now and feel far more confident in my clinical work now than when I arrived. I am getting more used to seeing lots of patients in each session and prioritising which patients still need more time within a busy clinic or ward round. I sometimes think that all clinicians should be required to spend some time in a low-resource environment as the sheer volume of patients and presentations you see here offers excellent clinical experience and is a very steep learning curve.

 

There are certainly things that I have learnt in Zimbabwe that I hope I will take back to the UK with me; whilst it’s clear that patients here are worse off in many ways than those in the UK, there are ways in which they are better off too. One of the striking differences for me is that here in Zimbabwe, nearly all of our patients are accompanied by (and often many) members of their families and that their families usually attend the twice-weekly ward rounds, sometimes waiting for hours to see the doctor. It’s rare for a patient’s family not to take them home and there are often members of extended family involved in supporting the patients when their immediate families aren’t able to. Unfortunately, in my experience in London, this is often not the case and patients will rarely be accompanied by relatives to appointments and social isolation is a huge problem. I think that this support network means that patients here in Zimbabwe seem to do better after their acute episode has subsided than some of our patients in the UK.


"One of the striking differences for me is that here in Zimbabwe, nearly all of our patients are accompanied by (and often many) members of their families and that their families usually attend the twice-weekly ward rounds..."

 


 

 

HIV clinic at Parirenyatwa hospital

The role of the church is also extremely important here, with the church community often acting like extended family when a person is in difficulty. I think that we can learn a lot from Zimbabwe in terms of these valuable support networks which often seem to be absent in our communities in the UK.

 

There are also challenges for psychiatrists in regards to the different models of community support here. As in many other countries across the world, a traditional healer is often consulted before a doctor or a nurse. This is particularly true for psychiatric and neurological conditions which are commonly thought to be due to evil spirits or relating to unresolved problems with deceased ancestors. ‘Goblins’ are also thought, by many, to be the cause of mental illness here. A skill which I have been learning from the other doctors in Zimbabwe is how to work alongside these beliefs in our patients and their relatives. I have learnt that it is not always necessary to challenge these beliefs, but rather incorporate them into our explanations of illness and advice on staying well; for example: ‘it may be that your son’s epilepsy is due to unresolved issues with ancestral spirits but these pills will stop his seizures and enable him to live independently’. Whilst the church and the church community are also invaluable as a source of support for many people here, we quite frequently meet patients who have been advised by a faith healer that they should demonstrate their faith in God by stopping their medication, often unfortunately resulting in relapse.

"Goblins’ are also thought, by many, to be the cause of mental illness here. A skill which I have been learning from the other doctors in Zimbabwe is how to work alongside these beliefs in our patients and their relatives."

The psychiatry doctors during a ward round

Most of the work we do here is treating patients with severe mental illness and as such most patients we see are suffering from psychotic illness. I have been struck at how similar the presentations of mania and psychosis are across different cultures and countries. We do seem to see more cases of florid mania here compared to paranoid schizophrenia, which is perhaps commoner, in my experience, of adult psychiatry in the UK. This is probably, at least partly, explained by which patients get to a psychiatric hospital, i.e. those with mania draw more attention than patients with paranoid or predominantly negative symptoms.

 

HIV also accounts for much of the illness we see here; as a direct consequence of the virus on the brain as well as opportunistic infections and the effects of anti-retroviral medications. This is quite new to me, although I had some experience in this area in my liaison post back in London. HIV medicine was a very small part of my undergraduate education and I have been relying a lot on the junior doctors here who are extremely knowledgeable and up-to-date. Ten to fifteen years ago the prognosis for people who were HIV positive in Zimbabwe was extremely poor, with millions of people across Africa dying from AIDS. Since anti-retroviral medication has become widely available, HIV is now an illness which people live with and need not reduce life expectancy significantly as it used to. Whilst things have changed dramatically for the better in Zimbabwe, in terms of HIV, the effects of the pandemic are still profound. As part of my work here, I am starting to go the HIV clinic once a week to offer some psychiatric support and training for the staff there. They inform me that mental health input is something they have been lacking for some time. Of particular concern is the large adolescent population living with HIV, who have often acquired the virus vertically, i.e. at birth from their mother. The psychological impact on these adolescents is huge as many have been orphaned and have to live with a chronic disease and the burden of taking medication regularly, in addition to the usual stresses and strains of adolescence. The staff at the clinic tell me that many of these adolescents are showing high viral loads on their blood tests, demonstrating that they are not adhering properly to their medication. The reasons behind this are likely to be complex, but staff at the HIV clinic feel that mental health support for this group is particularly important.

 

Another exciting part of my work here is teaching the 4th year medical students who started back last week. We have managed to prepare some new components to their curriculum using different teaching methods. We delivered a Team Based Learning module on self-harm and suicide this week and received good feedback from the students. We were lucky enough to have Dr Matthew Goldenberg visit from the UK in December, who has experience in developing TBL modules as a faculty member in the US. With his help we were able to adapt a module for use in Zimbabwe. The premise of TBL is that students read some materials prior to the session and work in teams to complete exercises, applying the knowledge they have learnt from the reading materials. The exercise provoked a lot of healthy discussion and debate and we felt that the students engaged well with the exercise and gave some very thoughtful answers. It’s the preparation required that is the biggest challenge for using TBL and for that reason we were extremely grateful for Dr Goldenberg’s support. The plan is to develop a new TBL module in substance misuse over the next few months.




"We delivered a Team Based Learning module on self-harm and suicide this week and received good feedback from the students."

The college of Health Sciences, University of Zimbabwe

 

 

 

Although there are significant challenges in working here in Zimbabwe, it’s also very exciting to work in an environment where things are changing and improving so rapidly. I have been very inspired by the doctors working here already. I mentioned in my previous entry the problem of ‘brain- drain’, common to many low income countries, whereby many doctors leave to higher income countries after they have been trained. Those that remain here show a deep and inspiring commitment to their communities and country. This is despite the fact that salaries here remain extremely low. For those working in the government sector, a doctor-in-training’s salary is not really enough to live on, particularly if you have children to send to school and university. All of the doctors here are either relying on a spouse to support them or do a small amount of private work or have other small businesses outside of their government work. I am more and more appreciative of our regular NHS salaries and the fact that we only have to have one job to sustain ourselves back home! It’s also somewhat frustrating that although the project that I’m working on here is valuable in terms of capacity building and supporting local staff, it will not provide salary increases meaning that most doctors will continue to be required to juggle locum shifts etc.  in order to support their families.

 

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About this blog

Dr Angharad Piette

 

 

 

 

 

 

 

 

Dr Angharad Piette completed her core training in London, UCLP scheme in July this year and is working as a Clinical Tutor on the IMHERZ project in Zimbabwe for 6 months before applying to higher training, hopefully starting in August 2013.