"This is how they protect me."

October 11, 2015 9:16 PM

"Every society struggles to care for people with mental illness. In parts of West Africa, where psychiatry is virtually unknown, the chain is often a last resort for desperate families who cannot control a loved one in the grip of psychosis. Religious retreats, known as prayer camps, set up makeshift psychiatric wards, usually with prayer as the only intervention." NYTimes. Links contain upsetting images and video.

- Mental Healthcare in West Africa is often a product of luck.

“Here, if we had to wait for a psychiatrist, the people who desperately need treatment would never get it,” said Maxwell Akandem, the head of Presbyterian Community-Based Rehabilitation, the nonprofit that helps care for Ms. Ajadogbil. “The trained nurses we use can do everything: diagnose, prescribe, even provide some talk therapies.”

- Photographing mental illness with sensitivity.

For the first of two articles about mental health care in West Africa, The New York Times published several intimate photographs of people with mental illnesses in chains. Each one required multiple negotiations: one with the pastor running the camp where the person was being held; another with the person being photographed; still another with family members, if any were present. We worked through an interpreter, Samuel Kpavouvou, a pastor in Lomé, Togo.

posted by ChuraChura (6 comments total)

It's amazing that so many places have none of the cheap generics available. Even in the ridiculously price-rigged USA, a month's depot shot of Haloperidol or Fluphenazine costs around $15.
posted by meehawl at 9:48 PM on October 11, 2015 [1 favorite]

This is utterly fascinating; thank you for putting this excellent FPP together, ChuraChura.
posted by clockzero at 9:58 PM on October 11, 2015 [1 favorite]

The cost of the drugs themselves is far from the only barrier to access, unfortunately. We're talking about an area of the world where children still die of malaria despite treatment being only a few dollars. The health care system--such that it is, especially in rural areas--really is not capable of handling mental illness, and people have limited experience seeing mental illness as a treatable health problem.
posted by Kutsuwamushi at 10:35 PM on October 11, 2015 [2 favorites]

Odd timing as I spent the weekend working on screening protocols including mental health for high risk clients who are not quite as badly off, but have many of the same limitations. We have some access thankfully to psychiatrists and psychologists, but it's very limited so we have to prioritise. It was both interesting work, figuring out what screening would work based on what I knew could be translated appropriately, trained in usage and then applied reasonably well by our staff routinely, and looking for what had been used in similar settings with research support - for example the Pediatric Symptom Checklist 17 and the CRAFFT test for youth risk behaviours - and then writing out the protocols for what happens when the screening indicates a problem.

And it just feels somewhat - terrifying to be the person putting this together when I don't have the professional training in this, just field training and experience. I have thankfully trained staff who will review it, but there's a dilemma that keeps coming up in the whole "Where There Is No Psychiatrist" area - you have to train people before you can safely send them out to treat hurt people, and especially with mental illness, it's just hugely undersupplied.

WHO data shows that psychiatrists/population distribution is massively imbalanced - Norway has 29.69 per 100,000 (7 times their 4.28 physician density) and Afghanistan has 0.01 per 100,000 (0.03 times their 0.267 physician density). Basically it's enormously massively skewed, way way more than general medical infrastructure.

Like the screening protocol for drug abuse that we want to use which is pretty decent (we want to track and categorise drug use in our population) has a whole "refer to rehab, refer to this treatment center" and we had a good bleak laugh about that at the office because there is one rehab for adolescent drug offenders which is quite okay but super religious, and that's basically it. The other rehab places are such hellholes that you are better off recommending the client be released onto the streets currently.

The true cost of it is also hidden - that was a good line in the article about how the cost of psychosis isn't also accounting for the cost of the family members (probably women) who have to caretake the affected family members, and then the emotional distress and toll of the social exclusion on the entire family.

Thanks ChuraChura, a good read and good timing - good to see different approaches and ways to report such a complicated interesting subject.
posted by dorothyisunderwood at 12:34 AM on October 12, 2015 [14 favorites]

WHO data shows that psychiatrists/population distribution is massively imbalanced - Norway has 29.69 per 100,000 (7 times their 4.28 physician density) and Afghanistan has 0.01 per 100,000 (0.03 times their 0.267 physician density). Basically it's enormously massively skewed, way way more than general medical infrastructure.

The first article echoes this with some horrifyingly concrete numbers:

At last count, Liberia had just one practicing psychiatrist. Niger had three, Togo four and Benin seven. Sierra Leone had none.

The one thing that I wished these articles had mentioned (or if they did I overlooked it) is the difficulty and danger for mentally ill people living on the streets in places like West Africa. The articles talk about how care rests on the families, but in many cases families can't or don't provide that care (including when people have lost their family because of violence or resettlement). It's not easy being homeless and mentally ill anywhere, but options are particularly bleak in such poor countries with virtually no safety net, and reflects why families turn to the chains and camps that the articles describe.

(There is also a complex interplay between the violence of poverty and mental illness, as described by researches such as Nancy Scheper-Hughes, and of course the traumas of incredibly brutal civil wars and other violence, that are deeper than these brief articles can or should address, but that underlies what is depicted.)

I was glad that the Times included the piece on consent and photography. It is worth noting that the photographer is Joao Silva, who was badly injured by a landmine in Afghanistan in 2010. The transcript of his speech about the injuries and his work is well worth reading.
posted by Dip Flash at 3:16 AM on October 12, 2015 [3 favorites]

It's not just the cost of the drugs or the distribution of the drugs or the lack of pdocs - though those are certainly huge issues. Mental illness can be wretchedly difficult to treat even in places where those aren't barriers. Brains are weird, bodies change, cocktails that used to work don't anymore, or other weird side issues pop up (my wife is allergic to the coating on the 15mg Abilify. They have her alternating days, 1 10-mg 1 day and 2 10-mg the next day). Add in the barriers present here, and well.
posted by joycehealy at 7:46 PM on October 12, 2015