Report of Volunteer Visit to Kenya 01 September 2009 – 25 September 2009

Dr Megan Munro

INTRODUCTION

The visit was arranged by Dr Rachel Jenkins, Director of the Board of International Affairs at the Royal College of Psychiatrists.  I was based in the Department of Psychiatry at the University of Nairobi as a visiting lecturer/consultant psychiatrist.  Dr Caleb Othieno, Chairman of the department, had sent me a programme in advance and other sessions were arranged after I arrived.

CONTEXT

Kenya has only about 70 psychiatrists for a population of around 35,000,000.  The majority are based in the capital, Nairobi.  Some are in the employ of the government, some in private practice and some undertake a mixture of both.

The Department of Psychiatry is part of the University of Nairobi and is based on the Kenyatta National Hospital site, a little way from the central business district.  Dr Othieno acts as Chairman of the Department.  There are 8 lecturers/senior lecturers and a professor who contribute to the teaching programme.  Lectures and tutorials take place in the university lecture theatres and seminar rooms and clinical teaching takes place within the outpatient clinic, on the general wards and at Mathari Psychiatric Hospital.

The MBChB course lasts 5 years and there are approximately 250 students per year.  There is a comprehensive lecture programme throughout the 3^rd and 5^th year.  Third year students learn basic psychiatry and the 5^th years have a more intensive programme including a two-week clinical placement where they attend clinics, clerk patients on the wards, learn about ECT and attend tutorials.  Teaching is also provided in basic medical sciences for the pre-clinical 2^nd year students.

FACILITIES

The Department of Psychiatry is small, both physically and in numbers.  It is headed by Professor Ndetei, whom I didn’t meet.  I was responsible to Dr Othieno and I spent time with 7 of the 8 other teaching staff.  The department is supported by a full-time secretary and a technician/handyman.

The University Medical School occupies a large part of the Kenyatta National Hospital site.  There are 3 large lecture theatres, a number of labs and tutorial rooms.  The lecture theatres have no permanent equipment for lecture presentation and lecturers have to set up their own equipment each time.  A laptop and projector are available in the department but presentations can be confounded by lack of electricity.

The Medical School Library appears to have a reasonably comprehensive selection of psychiatric text books, although some of them are very old eg A Companion to Psychiatric Studies from 1974.  While I was in the university department the library had received a number of new psychiatric text books, mainly Cambridge University Press publications.  The librarian told me they were short of ICD10 and DSM4.

An outpatient clinic is held in Kenyatta National Hospital once a week.  It is attended by the Consultants/lecturers, MMed students (psychiatric trainees) who are not on rotation to specialties, MSc Psychology students and medical students, often in large numbers.  These clinics are also attended by the 5 Consultants/honorary lecturers from the Mental Health Division of Kenyatta National Hospital who take liaison referrals from the general wards.  Patients are also seen as emergencies in the Accident and Emergency Department.

Mathari Hospital, about 20 minutes drive from Kenyatta National Hospital, provides inpatient facilities.  This is an old hospital built on a pleasant site with trees and gardens but the buildings are in a very poor state of repair.  The wards are single-storey villas, each surrounded by a wire fence entered by a locked gate. The sleeping areas are dingy and gloomy. There are also some ‘amenity wards’, ie semi-private, which are in a slightly better condition.  The patients are mainly dressed in hospital clothing and spend their time in the yard during the day.  At the time I was there it was extremely dusty because of the drought.  Patients appear to be well cared for and well fed.  The nursing staff appear to be dedicated but their numbers are low.

The forensic unit, locally called “Maximum”, is also based at Mathari Hospital behind a high fence and wall.  The buildings here are also in a poor state of repair and some of the roofs leak during the rains.  Patients mainly sleep in 8-bedded dorms, which appeared quite bare.  There were hard beds with a blanket and a small locker for each patient but it didn’t look as if they had many personal belongings.  There are also single/seclusion rooms, which are used for more difficult or dangerous patients.  There is a small infirmary ward.  An occupational therapy department appeared to be under-used at the time I visited but patients are able to play pool and watch television.  The patients here are admitted from Court and each week patients are sent, sometimes in handcuffs and accompanied by armed prison officers, for assessment and report.  There is a Mental Health Act but I did not get a chance to see a written copy.

Mathari Hospital also has a small substance misuse rehabilitation unit.  There are a number of other rehabilitation units around Nairobi run by non-governmental organisations and, generally, with better facilities and higher staffing levels.

The 5 psychiatrists from Kenyatta National Hospital run a number of clinics including Child and Adolescent Psychiatry.  A large part of their work seems to be with ‘gender violence’ and they have a cohort of trained counsellors who do trauma counselling.  They also run a psychotherapy clinic, work with people who have tested positive for HIV and carry out liaison consultations for patient referred from the general wards.  They also run a number of groups for patients with gender violence, HIV and schizophrenia.

Availability of psychotropic medication is limited and apart from some basic drugs such as Amitriptyline, Chlorpromazine and Haloperidol, patients have to buy their own medication, in which case some atypical antipsychotics and selective serotonin reuptake inhibitor antidepressants are available.  (While I was there ECT was unavailable because of power cuts at Mathari Hospital)

There seem to be a reasonably large number of psychologists and counsellors working in a variety of mental health services.  It is difficult to ascertain the exact number because many work for the non-governmental organisations.  There are specialist psychologists and counsellors within the mental health services at Kenyatta National Hospital, many working in the gender violence programme and in some of the voluntary counselling and testing services for HIV.

PSYCHIATRIC PROBLEMS ENCOUNTERED

It appeared that the majority of patients admitted in Mathari Hospital and attending the outpatient clinic suffer from schizophrenia or bipolar affective disorder.  Hypomania was a common presentation.  Alcohol and drug abuse are major problems.  The predominant drugs of abuse are bhangi (cannabis) and miraa (khat).  Other presentations now not commonly seen in UK are encountered such as depressive stupor and major degrees of somatisation.  The majority of referrals from the general wards are for organic psychosis.

HIV and mental health is high profile.  HIV/AIDS is openly talked about on television.  Posters are commonly and prominently displayed.  These encourage people to find out their HIV status.  A number of the psychiatrists and psychologists are interested in the links between HIV and mental health.  In the hospital and around town there are many voluntary counselling and testing facilities and these are widely advertised.

ACTIVITIES UNDERTAKEN

• Lectures to 2^nd year medical students in basic medical sciences – generic topics such as communication skills and compliance with medication.
• Lectures to 3^rd year medical students relating to psychiatric emergencies, some of which were later demonstrated clinically.
• Tutorials/clinical teaching with 3^rd year students concentrating on history-taking skills and mental state examination.
• Tutorials for 5^th year medical students, case presentations and revision for exams.
• Tutorials with MMed students on a number of topics, including ECT, Forensic Psychiatry, Early Intervention in Psychosis, Clozapine, side effects of medication, community psychiatry and stigma.
• Tutorials with MSc Psychology students covering a number of topics, including community psychiatry and stigma.
• Talk to general nursing students on psychiatric placement at the Mathari site of Kenya Medical Training College.
• Attendance at case conferences and research dissertation proposal meetings.
• Attendance at outpatient clinics.
• Accompanying psychiatrists from Kenyatta National Hospital on liaison visits to the main hospital.
• Accompanying psychiatrists on assessments of forensic patients and review of reports written by MMed students.
• Visits to drug and alcohol rehab (NGO) units.
• Attendance at a meeting of the Department of Psychiatry to review the MSc Psychology curriculum.

PROBLEMS ENCOUNTERED

There were no major problems and all members of the Department of Psychiatry and Mental Health Division at Kenyatta National Hospital were extremely welcoming and supportive.  The minor problems encountered were not really under their control.  These included other people using lecture rooms and tutorial rooms which had been allocated for Department of Psychiatry use, power cuts, very large groups of students and occasionally very small groups of students when their transport broke down.  Another problem was because of the drought there was red dust everywhere, including in the lecture theatres.

COST

This was not a cheap trip.  It cost over £1600 inclusive of flights, visa, vaccinations and accommodation with the latter being the biggest expenditure  While this was not personally a problem, it might deter others from offering to volunteer in similar circumstances.

THANKS

• Dr Rachel Jenkins, Director, International Board of Affairs, Royal College of Psychiatrists, for arranging my visit.Dr Caleb Othieno, Chairman, Department of Psychiatry, University of Kenya, for organising my schedule.
• Drs Kigamwa, Kuria, Mathai, Obondo, Kathuku and Owiti of the Department of Psychiatry, especially the latter who took me under his wing and introduced me to Mathari Hospital and ‘Maximum’.
• Drs Kanyanya and Omondi, Mental Health Department, Kenyatta National Hospital.
• MMed and MSc Psychology students at University of Nairobi for stimulating tutorials/discussions.
• Florence, the department secretary and Alfonse, the department technician, who helped me to keep track of what I was doing/where I was going and supplied me with cups of coffee.
• Mrs Sylvent Otieno, Acting Principal, Kenya Medical Training College.

Megan Munro

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DR M A MUNRO

CONSULTANT PSYCHIATRIST