Day fourteen - Stick out like sore thumbs

We hang around doing paperwork and emails although Uganda has terrible internet access, or at least for me. We go to a restaurant near the airport and spend a few hours working. Erin and I go to a beach club. We are the only non-Ugandans there so stick out like sore thumbs. But that's not a problem as people in Uganda are laid back.

Days fifteen to seventeen - Frantic days

These are the last frantic days of the workshop. We are trying to desperately catch up on any lost time.

As expected, the first few days in the previous week took a while to warm up. Now there is pressure to finish the design document in time...or at least the main body and budget. It's frantic during the day and frantic at night as we get all design products trimmed and ready.

At the last day of workshop we have actually got something that looks good and we can be proud of. It is a Ugandan document. As outsiders we have been able to advise and honour the donor requirements but not take over.  There is a photo opportunity and final prayers. Then my colleagues fly off while I have another day to go before I catch my flight

Days eighteen - Chimpanzee sanctuary

I spent the morning watching chimpanzees. There was one chimp looking a bit isolated and miserable. It looked at the leaflet and saw that there was indeed a chimp who suffered from depression. This day was taking me to a whole new world of mental health –chimp mental health.

I write this on my last day in Uganda at Entebee airport. I can’t say I have endured any hardships here even if power and internet is unreliably. Uganda is a beautiful country and is secure. The people have been kind and gracious hosts. They are committed to improving mental health. Nodding disease is becoming a real concern and time will tell what happens with this bizarre disease and its increasing cases in the North district.

This morning I walked down to the lapping shores of Lake Victoria. This is an idyllic place. The weather is warm and really perfect.

As I walk down the corridor in the hotel, in front of me is a typical view.  There are about five small groups working mostly in French on domestic violence, agriculture, Malawians with fisheries, Bangladeshi soldiers. We have had a weekend of pentacostalists at the Hotel. Its NGO land in this hotel...and Russia.

So this blog is not about “exciting” clinical work or training but about being stuck in a classroom effectively talking through paperwork and money. It doesn’t sound exciting. However I think that because we have participated in such a tight design document  the project has a great chance of success and will really make a difference to Uganda. The idea of the user groups being such a core part of the project was a real surprise to me and seemed really interesting and translatable.

The other thing I learned about was interpersonal therapy which I had never really understood before. It has significant evidence base. A practitioner explained it to me and all those I spoke to who use it in Uganda seem to love it. Patients love it. It is used for depression primarily. In Uganda mainly it is used as group work. It was a big take home message for me in CBT UK. 

It was a pleasure being part of this process and I thank the Ugandan Ministry of Health, World Vision Australia, WHO and all my professional colleagues for this experience - I learnt a lot from them. Take home messages I got were the value of careful planning of projects, user groups, interpersonal therapy and the value of a strong mental health advocate in the Government.

I'm both fascinated and confident that this project will be a success.

Day five - Desk review

Desk review - this was something new! It's similar to preparing a review paper. You assemble information related to health in Uganda at all levels and then prepare a report based on this.

This was beyond tedious! I wondered whether this would be helpful or not.

From discussions, I do now realise that this is an important part of the process which fleshes out the background for the task ahead and feeds into a formal report. It helped me understand Uganda's health needs. It also helped me participate in a workshop.

This is hard, dry work but useful.

Days six and seven -  Entebbe

Desk review continues each day as it is an ever expanding task. I'm sent papers from all sides to incorporate into the desk review.  At the end I feel like I have something that is reflective of the information I have...although some of the data seemed out of date in 2012.

Wondering around Kampala: Mark from WHO Geneva is a welcome addition to our group. Over the last few years, I have been in contact with Mark about mhGAP and different projects. It was nice to spend time with him in person rather than email. I learned a lot from Mark about international work and WHO. He's a master of technical knowledge as well as very nice company.

On Sunday we travel to Entebbe. Entebbe is either a very tiny place or I missed most of it. There are a few roads and little traffic. Bizarrely the hotel seemed populated by lots of Russians as well as the expected NGOs.

I expected mosquitoes and got none -  instead I had lake flies.On arrival at the hotel I had so many lake flies in my hotel room -1000s if not millions that I slept in the bathroom. It was literally a carpet of insects by the morning. I have never seen anything like it.

We had a buffet at the hotel - this was a place we began to hate!

Days eight to twelve - Workshop

This was the meat of the trip and a new type of process for me. Designing the mhGAP project in Uganda may have been long and sometimes exquisitely tedious, but by the end I realised how this would ensure that the project would work.

This is a Ugandan project that World Vision sponsors - WHO provides technical advice and the owners are the Ugandan health services and ministry. So there was a variety of stakeholders at the meeting including psychiatrists, psychologists, ministry people, NGOs representing epilepsy and psychosocial work. My role was a bit less clear in my mind. I was there to share my modest experiences of mental health in international primary care work. 

There were new terms for me to learn and understand: log frame, detailed implementation plan, monitoring and evaluation as well as budgeting. The workshop day begins with prayers and end with prayers.

Ugandans like to talk and there's lots of participation. Chairing was a challenge and I did my share. There was lots of enthusiasm and ideas. Log frame means the logical framework. This was the core of the workshop which is about the skeleton of the design. It consists of a table  featuring goal, outcome, output, indicators, and assumptions. This took the bulk of the whole workshop and is the base for the implementation. We ended up with a goal and several outcomes. The workshop fleshed these out with input from all stakeholders.

Detailed implementation plan is a plan to role out the outputs and outcomes with a time line. The budgeting discussions were predictably  difficult. As normally happens the initial budget goes well over budget and then needs to be painfully trimmed down.The end result was a design which was scaled down, realistic, achievable but still valuable for patients with mental, neurological and substance use problems in Uganda.

What was very interesting was the input on user groups. This became an important part of the discussions and became a structural part of the design. User groups would be able to combat stigma, publicise and market clinics. They would drive the momentum for the service to continue. My own feeling was that epilepsy would be a key condition that could generate its own market. The community will see the benefit of treatment and insist on treatment continuing long into the future. Something I had seen previously in Chad.

By day five I was so shattered that I realised that doing direct clinical work or training –the “exciting” stuff - is actually less exhausting.

Day thirteen - Day off

This was a great day. Dr. Mugaga was our wonderful host who took us sightseeing. We saw waterfalls and were taken to schools with unbelievably well-behaved school children. We also went to the source of the Nile in Jinga District and had a boat trip. Dinner was with Word Vision in Kampala then back to Entebbe.

Day one - London

I leave London Heathrow in Emirates new Airbus A380. Those who know me will know exactly how delighted I was be to go on this for the first day. And it didn’t disappoint. This is the only way to fly – even down the back.

Day two - Kampala

Arrive in Entebbe airport and I'm carted off to Kampala which is about an hour’s journey. The hotel is huge and incredibly dark.

Kampala seems like a nice town to me. Warm weather. Gentle hills. I just can’t see many people around. Unlike other places I go to it is amazing to be able to go outside without security briefing and a security guard. It is a really safe place apart from petty crime - although there has been some East African terrorism here in the past year.

Then I meet Erin from the partner and donor organisation to the project -  World Vision. World Vision is a huge worldwide, non-governmental organisation. They are one of the few who work in mental health. I hadn’t realised how enormous they are and even in Uganda they are a huge operation. They are children focussed and Christian, but are clear about never evangelising and are open to beneficiaries of all backgrounds.Erin is in her twenties and leaves me speechless with her mastery of the NGO world, policies and ability to synthesise varied and complex concepts in a concise way that even I can understand. They are a very impressive organisation.

A pleasant supper in the almost dark dining room that evening.

Day three - Kampala

I meet with the formidable and delightful Dr. Sheila. She works in the Ministry of Health and is lead for mental health in Uganda.

I had met Sheila once before in Italy at a conference on mhGAP. Sheila is a Public Health Physician and has a background in mental health work. She has a remarkable drive and vision on mental health in Uganda. In Africa it is so important to have key people with a commitment to mental health. This whole project would have no beginning middle and end without the backing of Sheila. I know that she can make the project work.

My job was to gather background information on mental health and health systems in Uganda. It was a struggle to keep up with Sheila’s pace as she is so passionate on the subject and knows it from the ground up.

In the end, I felt that I knew more about the health service in Uganda than the health service in the UK. There is a very well structured tiered layer of health clinics running down from national and regional centres. The health centres feed into a volunteer village level - the Village Health Team. There are two national psychiatry centres close to the capital Kampala.

Sheila, I believe,  is actually the most important part of the project as she has been with mhGAP from its launch in WHO. She really drives the mental health agenda in Uganda. Uganda is lucky to have such a dynamic force.

Day four - Kiboga district in the west of Uganda

Today's task was interviewing health workers on their services. Armed with my notebook and my WHO copy of mhGAP manual, I headed to a rural area in the west of Uganda. This was a three hour drive from Kampala along mud roads past villages with no water or electricity. The poverty was overt.

We met a health worker who was clearly committed to her work but struggled to understand concepts of mental illness. When I asked about schizophrenia she talked about referring to an ear specialist for hearing problems. Yet when I left the little corrugated roof building, I soon saw a homeless man who was clearly psychotic and homeless.

The next practice was in a much better building and supported by Irish Aid. Here there were two skilled health workers. Yet here they said they didn’t see any mental illness. Just before I started to speak to them I saw a young Ugandan lady with four children. She looked depressed and sad. They told me she attended frequently with physical health problems. They had never asked her about depression. However, when I talked to them about it and showed them the manual I could see that them make the connection. I know they will ask her about this next time and maybe think a bit more about mental health. I hope in the future all these areas will have access to mental health information. In the meantime people are referred on for further advice through the layers of health services.

At this stage I felt this was real volunteer work - going to clinics, seeing front line workers and getting my hands dirty.

March 2012

However, after some rumination and discussion with colleagues, I thought maybe it would be good to show the more mundane part of international development work. I love doing direct clinical care, training and training of the trainer, but this was work was almost entirely paper-based. Also I was stuck indoors in a giant eight day meeting.

I have always said that if you are doing international work right it is probably somewhat dull. I wouldn’t describe my experience  in Uganda as dull even though it may sound dull being stuck in workshop for eight days. It was actually a fascinating experience and I learned a huge amount of how to do this work right.  

February 2012

As Idi Amin is no longer President of Uganda, some of the Asians he drove out are coming back. Uganda has been at peace for about seven years now which is why many are incensed at Joseph Kony,Lord Liberation Army, who gave the impression that Uganda is still at war.

Tackling AIDSs has been an astounding success but the rate is increasing again. People are highly aware of HIV and prevention is though a multi-pronged campaign of education.

Uganda is known for its homophobia but is probably not much different to many other countries in the region. I know that there are those in UK who  feel that we should not support Uganda because of this. It is a tricky area. At least in mental health we' re committed to designing programmes which are non-judgemental, where there's unconditional respect for all patients and carers.

One of the big challenges facing Uganda at the moment is the increasing rates of the bizarre,chilling  and unexplained Nodding disease in the north of the country. In this condition, children between 5 to 15, developa  nodding motion when faced with food and stop eating. They eventually die. In Uganda it falls under mental health. It appears that the disease has been spread by hysteria but there are more conventional medical cases. It is also found in South Sudan and a few other countries and is currently the subject of an international health investigation. Our health ministry colleagues were very preoccupied with Nodding disease and it'll be a big challenge to a poor country.

In February 2012, WHO contact me (out of blue) to ask if I would be interested in doing some work in Uganda based on the mhGAP. After about 2 seconds I said yes. I am passionate about the mhGAP approach, especially incorporating mental health into primary care.

In case anyone still hasn’t heard me talk about this - this is the WHO approach of addressing the inequality of mental health provision in low and middle income countries. It means that mental health is brought to primary care level and health workers are trained to identify and treat basic mental health problems. They refer on any that are in any way complex. It is a double system of primary care mental health clinics with secondary referral systems for complex cases. There is a manual that is a guide to management. Coupled with this are training materials and supervision systems. It is a way of scaling up mental health in places that wouldn’t have access to any service otherwise. Conditions covered are the MNS conditions  – mental, neurological and substance abuse. So the anomaly, for a western psychiatrist, is that epilepsy is part of the mental health system.

This can work as long as there is a political, training, supervision drive and a robust secondary referral mechanism. So with all this in the background I was proud to be asked by WHO to be part of the design planning of a programme to scale up mhGAP in parts of Uganda.