Editorial: Mental Health Services in Southern Sudan - a vision for the future
Major mental illness exists all over the world with a remarkably similar prevalence. This includes the major psychoses such as schizophrenia, bi-polar disorder and major depression. These place a huge burden on the individual, their families and the economy. Southern Sudan is no exception. Mental illness may be less visible than physical illness but the suffering is equally great.
St Mary’s Hospital, Isle of Wight – Juba Teaching Hospital Link
St Mary’s Hospital on the Isle of Wight, UK has a health education link with Juba Teaching Hospital (JTH), which started about 2 years ago - see page 10. I was privileged to visit JTH for three weeks in October 2008 with little knowledge beforehand about the mental health service there.
Juba Teaching Hospital
Ward 12 is the in-patient facility, which also admits sleeping sickness patients. The lead clinician is a very experienced medical assistant with one deputy. Nurses do not have specialist mental health training and rotate from other areas. They work on a medical model to the best of their ability.
Accommodation is clean but basic with no therapy/meeting areas. Psychotropic drug supply is limited and irregular. Families can buy newer antipsychotic drugs if they can afford them. Patients are not fed which is a major problem for those without families. Records and observations are minimal. There is no mental health legislation. The families carry out most of the care and family bonds are strong.
Outpatients are seen in a nearby small building. The staff has just one room to see patients with their families and to use as their only office. None the less I observed excellent therapeutic relationships. The two medical assistants are assisted by nurses and a trained counsellor / social worker.
Many of the acute psychiatric patients come in through the general outpatient department and the medical wards. There is often co-morbidity with cerebral malaria and other tropical diseases. Suicide attempts and completed suicides are regularly seen. Often violent methods are used or the swallowing of toxic substances.
The central prison has separate buildings for male and females incarcerated through mental illness and not criminal offences. The male wing is much larger. The family and a magistrate have to agree on the need for incarceration on grounds of public and personal safety.
Accommodation is extremely basic and most inmates appeared severely ill. Physical health suffers in this environment with malaria and dysentery prevalent. There is no alternative location for minors. The prison governor and health staff agrees that there is an urgent need for an alternative health-led facility. They are very aware of the inappropriate placement in prison for some adolescents with severe psychosis.
It is difficult to establish the prevalence of mental morbidity in the community. Certainly the Non Government Organisations deal with much minor illness and religious leaders have an invaluable role in counselling and bereavement work, etc.
A recent study based in Juba showed a high level of post traumatic stress disorder after the war. This may increase as people return from internal and external displacement. Drugs and alcohol misuse are emerging problems. There is a generation growing up minus one or both parents.
Key Mental Health Staffing
As in much of Sub Saharan Africa skilled medical assistants or clinical officers take on the medical role. The mental health medical assistants in JTH have completed a three-year mental health training in Khartoum in addition to their previous training They carry out the functions that a psychiatrist would carry out in the UK. The student medical assistants are trained in Juba at the Health Institute and at least four said they wanted to specialise in mental health.
St Mary’s Hospital, Isle of Wight / Juba Teaching Hospital Link is a charitable organisation allied to The Tropical Health Education Trust. There are several other UK mental health links to countries in Sub Saharan Africa such as Malawi, Uganda, Ghana and Somaliland, and so there is a growing network within which to share experiences.
The Royal College of Psychiatrists has an international forum that also networks. They have an international volunteer scheme whereby the host country funds a local salary for accommodation and basic needs and applies for an experienced psychiatrist who will work for six months to one year with the local service.
The Way Ahead
The Government of South Sudan is aware of the need to develop mental health services as well as all their other major priorities. The Ministry of Health plans to appoint a Director General with a brief for the development of mental health services. It will then be much easier to establish the needs and priorities for strategic planning. In the mean time we need to build relationships. It is essential the Link concentrates on major mental illness.
As time progresses more opportunities will exist:
- The introduction of mental health modules in medical student teaching now that the medical school has returned from Khartoum to Juba
- Similarly mental health modules in nurse and midwifery training
- Psychiatric modules for continuing professional education for junior doctors and trained nurses
- A priority will be the mental health modules for medical assistants at the Health Institute. They are a skilled, talented and committed group of young people who need support and training for their chosen speciality. In the future medically qualified doctors may wish to specialise in mental health but the priority at present is to establish mental health training for medical assistants.
- The other priorities are to relocate the prison mental health unit and develop community psychiatry.