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Bangladesh
4/25/2012 9:43:12 AM
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The major focus of this week was a visit
to Pabna hospital, only 200km from Dhaka, but a hair-raising 8 hour
journey on the bus. Pabna is the largest mental health
hospital in Bangladesh and has been open since the 1950s. I
had heard numerous rumours about Pabna, mainly circulated by
persons that hadn’t been, so I did not know quite what to
expect. The Chairperson of the BSMMU, Professor Mullick, had
worked there previously and recommended that I visit. The
hospital is centred in around 120 acres of land, just outside the
town of Pabna, and the initial approach, I guess is not too
dissimilar to some of the older larger mental health hospitals in
the UK, reminding me a little of Middlewood in Sheffield. The
staff had arranged for me to give a presentation on both psychiatry
in the United Kingdom and transcultural psychiatry (delayed a
little by a power cut!) which started the day.
I guess I was pleasantly surprised by the
setting. Lots of green space, a theatre hall, a mosque, a
garden area – much more tranquil than the hospitals in
Dhaka. The staff were keen to point out the positives of the
unit in terms of being an ideal environment for recovery. I
understand several weeks before I arrived, the unit had been
portrayed in a negative light on national television, with a
documentary piece talking about locked wards and old-fashioned
treatments – the staff were clearly unhappy with what they
considered to be an unfair representation.
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I understand that there are 18 wards,
around 2/3 male with one substance misuse wards – I was able to see
6 of the wards – with a total of around 490 patients. The
majority of patients’ care is funded by the government, with a
smaller separate paying unit. Yes, the wards that I saw were
locked – the staff informed me that the wards are generally locked
in the mornings, with activities and more freedom in the
afternoon. The staff said that the wards were locked for the
safety of the patients – there were clearly a large number of very
ill individuals with a variety of illnesses, and a variety of
ages. The average stay is around six weeks, although some
patients have been here for much longer. Often the difficulty
is finding suitable onwards care if families have disowned
individuals.
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The staff informed me that they utilise the government formulary
(that I had previously seen in the National Institute in Dhaka)
which has a reasonable selection of psycho-tropics from different
groups. The staff I spoke to seemed very enthusiastic, but
were a little upset that more doctors are not interested in working
there – there are only 4 psychiatrists and a few other
non-specialist doctors covering both the hospital, with a huge
outpatient clinic, also. Few of the senior psychiatrists wish
to leave Dhaka (I understand mainly due to family and private work
commitments). On a positive note, I met my first mental
health social worker since coming to Bangladesh, and I understand
that there are three individuals who use an Occupational Therapy
model, as well as one psychologist. Interestingly, I was
informed that sometimes the patients take part in psychodrama in
the theatre.
This part of the Royal College Link was more for my own
experience. There were clearly a lot of positives about the
environment, the setting, the enthusiasm, knowledge and skill of
the staff. The wards are locked, and I did see several
patients who had bindings on. (admittedly these patients did appear
very agitated). Visiting the unit, I could understand this in
the context of not enough staff to effectively manage and treat the
patients in a more open ward environment. There may be
potential for future doctors under the Royal College volunteer
programme to do some more work at Pabna hospital - the team
informed me that I was the first British psychiatrist to visit the
unit in many years and were supportive of the idea of a possible
future link.
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4/10/2012 10:29:35 AM
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The volunteer link is nearing the half-way
point, with a huge amount left to achieve over the next few weeks.
I have been working on an interesting project looking at
establishing an early intervention service in psychosis at the
BSMMU. Essentially the task is to ascertain whether it is feasible
to set up such a service without any further resources (feels like
in the UK…), and to establish whether there is an evidence base for
such a service in a low income country (I am yet to find such
information…)
As I have spoken about previously, there are
no mental health workers in the community here. Despite this,
however, the team at the BSMMU believe that an early intervention
service could be replicated, with biological interventions provided
by a specialist clinic, psychological interventions, i.e. CBT and
family therapy, provided by the psychology department, and social
interventions provided by the extended family network that pretty
much each patient seems to have – i.e. in-house occupational
therapy and rehab training for families. There is clearly a
potential demand – a range of individuals with psychosis present to
the outpatients department– the challenge is, however, that often
they present later on in the time-course of illness, and it is
actually the traditional and spiritual healers who are providing
early intervention services currently.
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I continue to work along-side the junior
doctors at the BSMMU and every day am seeing large numbers of
interesting patients, including many conversion cases, which are
difficult to treat, as again individuals present at a later stage,
via the alternative healers, and then usually via large numbers of
private clinics, all of which perform a multitude of physical
investigations first (often repeated several times) which seems to
reinforce the belief system of many of the patients. (Including one
who said he had spent £5000 on investigations, a huge amount of
money here). Also, although there is no direct evidence base to
support it, I am beginning to believe that there are larger numbers
of individuals presenting to the services who could potentially be
diagnosed with personality disorders but are not, maybe due to the
necessary speed at which patients are seen in the department. A
last observation is the continuing input from the drug companies –
no different form the UK several years ago, but noticeable,
nevertheless.
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Mental health has been well-represented in the
media over the past few weeks – Bangladesh lost to Pakistan in the
Asia cricket cup, and the local media linked the result to seven
suicides. The papers seem to have a weekly suicide report. This has
previously been criticised for being sensationalist, rather than
providing useful information on how to access help. Perhaps
surprisingly, I am not encountering much suicidal ideation or
behaviour here (compared to the UK) which is slightly at odds with
the media reports – local attempts have been made to raise
awareness, with suicide being the major topic of a day seminar by
the Association of Therapeutic Counsellors here in Dhaka – a very
good day topped by a cultural evening in which all of the doctors
took part.
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Ending on a positive note, the staff tell me
that times might be starting to change a little in terms of
recognition of mental health - the daughter of the prime minister
is a psychologist, and mental health has been discussed at several
political meetings (which is new here). I understand that the
department is due to move into larger premises in a year or two,
also, with more space.
If you would like to post a response to Adrian's blog, please
email your message to the Website Manager, who will be
pleased to upload it to website. 4/4/2012 8:22:26 AM
The placement is progressing quickly - It
is about time to talk about some of the expected outputs from the
RCPsych link. The first part that I have been working on with
Professor Mullick is a research project to culturally validate life
stressor rating scales for both adolescents and adults in
Bangladesh. This has been identified as a local priority area
– stigma surrounding mental health is huge here, but people do seem
to understand the role of life stressors, and placing mental
illness in this context can help individuals understand.
There is a huge respect for qualifications in
Bangladesh, and perhaps more importance is placed on these than
outright experience – because of my Msc in Transcultural psychiatry
I have been judged the right person to write the research protocols
for the adolescent and adult rating scale validations - which I
have just sent to local research and ethics for
approval.
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To summarise, the research will be of
mixed methodology and comprise of focus groups and a survey phase.
The current life stressor scale commonly used was designed in the
states in the 1960s and has less relevance to Bangladesh today. A
large number of potential life stressors need to be added that are
culturally appropriate here - eve teasing, dowry stress, effect of
siblings getting married, to name a few. The research will continue
after I have left, but it is hoped that a validated rating scale
will be produced by the end of the year which can be utilised in
Bangladesh and possibly in areas of the UK with larger Bangladesh
communities
The curriculum for the mental health
trainees in Bangladesh is a mix of that in the United Kingdom, the
States, and Canada, and is being re-written at the moment. A
lot of the buzz words familiar to those trained in the UK are
becoming topical here – competency based learning is in the process
of being introduced, with a slight shift from purely relying on
knowledge. I have been working with the curriculum designers
here to improve the curriculum a little (although it is already
very comprehensive) and will be working on an OSCE programme for
the trainees over the next few weeks. The other project just
starting is working with the doctors here to establish whether an
early intervention service would be feasible.
There clearly isn’t any more budget, and
there isn’t any community psychiatry, so the work centres around
whether such a service could be re-created at outpatients to cover
pharmacological and psychological interventions, and by the use of
the family to provide some of the social interventions.
Patients here usually have the benefit of a stronger family network
than compared to the west. Watch this space.
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Aside from the above, I have been giving
weekly talks at the journal club, up to now on transcultural
psychiatry, the royal college scheme and early intervention in
psychosis, and am hosting more informal teaching sessions each week
for the trainees on a variety of practical-experience-based topics,
including treating early onset psychosis and presenting a lecture
(trying to think about what I was taught on training the
trainers….) I spend a large proportion of the week working
directly with the junior doctors seeing patients on the ward, and
at outpatients, which I am finding the most rewarding, including a
very interesting steroid induced psychosis case on the medical
ward, which we had to assess in the corridor surrounded by about
twenty people holding their drip bags above their heads as the ward
was being fumigated for bed bugs.
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I have a few interesting visits lined up
for the next few weeks – I shall be going to Patna, the “tertiary”
referral centre I guess, which is the largest inpatient unit in
Bangladesh and is around five hours away. I don’t want to end on a
negative point, but have heard a few “rumours” about conditions
there, and, I guess, want to make up my own opinion. Afterwards I
will be going along with the WHO to one rural Upazilla health
centres to look at the work they are doing educating primary care
staff in mental health.
If you would like to post a response to Adrian's blog, please email
your message to the Website Manager, who will be
pleased to upload it to website.
3/14/2012 11:42:22 AM
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Time to report back
after a somewhat busy first week. Work here begins at
between eight and half past, and after a quick cycle- ride (I have
bought a bicycle, much to the amusement of the local doctors, and
have become quite adept at constant bell-ringing whilst cycling)
and ascent of eleven flights of stairs (also amusing to the local
doctors, but better than waiting twenty minutes for the BSMMU lift)
I arrive at work.
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The day generally starts with junior doctor reviews of the
inpatients, followed by a split into ward round or outpatient
reviews. After this follows the special clinics, such as
psychotherapy or child and adolescent, then teaching for the junior
doctors and more patient reviews. The junior then tend to
spend the latter part of the afternoon pursuing research
interests.
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The RCPsych volunteer scheme talks about the bilateral
exchange of knowledge, skills and experience – I am certainly
receiving my own share of all three. During the first clinic
I saw more patients with conversion disorder than I have seen in
total in my previous training. Clearly one of the most common
conditions here, it is skilfully diagnosed and managed by doctors
of all grades. The outpatients is extremely busy.
Around 30 patients are seen by each doctor over a three to four
hour clinic. Most are new patients, and severity and
diagnosis varies greatly. My initial thought was that the
doctors diagnose and treat with medications too soon… but that is
from a western perspective. Given the vast pressure of
patient numbers, and the likelihood of a lack of follow-up, or
“watchful waiting” doctors have to treat here, and patients expect
medication.
Inpatients is much calmer than the clinics, and
patients receive a comprehensive clerking (with a proforma that is
better than any I have seen in the UK) and a strong academic focus
to investigations and management. There is a broad range of
patients in terms of diagnosis, and turnover is swift. To
provide a flavour, I have seen a 16 year old girl with treatment
resistant bipolar, conversion disorder ranging from seizures, to
paralysis to head-aches and head tremor, liaison patients including
acute lupus psychosis and yet again more conversion disorder.
Relatives stay with the inpatients, providing much needed support
(and staffing) on the ward.
The confidentiality issue struck me initially, in that the
next patient in the queue (and their family) at outpatients gather
round whilst the doctor is seeing the preceding patient.
Also, at ward round, the doctors are usually joined by an
interested group of patients and relatives. This is in part
due to space constraints at the BSMMU (psychiatry is due to move to
a larger ward in the next few years) but is also, not dissimilar to
the situation that occurs in Bangladesh anywhere – the bank, the
train station, buying cha (tea), and although bizarre to myself, is
not seen as strange here. A counter argument that has been
explained to me by the doctors is that the support generated by
such a crowd is actually beneficial in patient recovery – perhaps
an interesting qualitative research project?
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I have found it difficult as an overseas doctor to understand
the vast variance in services between different parts of the
country. I spoke last time about the private and public
split. I do not want to sound critical of any part of mental
healthcare in Bangladesh, it is what it is, with huge financial and
logistical constraints. The reality is that there are around
150 psychiatrists in Bangladesh, and with a population of around
150 million - 1 per million people. The BSMMU is producing
psychiatrists every year, all of whom have been through a very
rigorous education programme, and the total number of psychiatrists
is growing slightly. However, this is countered by a “brain
drain” of trained psychiatrists to other countries (I guess
including the UK) Because of the financial and logistical
restraints, huge parts of the country are without any psychiatric
input at all. I have seen several people at outpatients who
have travelled up to eight hours to get there, not ideal if you are
being monitored for clozapine/lithium, etc!
That brings me to the question of what is my role in the link
is. It is tempting to decamp into the rural areas where there
is no psychiatry and see patients to prevent them having to travel
so far. The reality is, however, that any similar attempts
would only be temporary. There is already a WHO programme
training community workers in mental health to improve
capacity. The BSMMU is a fantastic place to start due to its
key role in training the doctors of the future. Identified
aims of the volunteer scheme link include 1) a collaborative
research project to culturally validate rating scales 2) An update
of the curriculum using my experience of training through the royal
college version 3) Teaching sessions in transcultural psychiatry,
early intervention and crisis intervention, 4) The establishment of
a mock OSCE for the junior doctors (who have just started OSCES and
quite nervous having never been through this type of
examination)
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Aside from work – over the last week I have been improving my
cultural competence through attending a local wedding and going to
the Bangladesh Premier League Cricket final – weddings and cricket
being two of Bangladesh’s favourite passtimes.
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If you would like to post a response to Adrian's blog, please
email your message to the Website Manager, who will be
pleased to upload it to website.
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2/28/2012 9:39:35 AM
Day Four – 26 February, 2012
Bangabandhu Sheikh Mujib Medical
University
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The official start to the working week at the
Bangabandhu Sheikh Mujib Medical University (BSMMU) is eight thirty
in the morning on Sunday - the traffic outside where I am staying
is already at a complete gridlock and I am at risk of being late on
my first full day. Taking a cycle rickshaw seems to be the
only option to navigate the traffic and my driver takes great pride
in navigating towards the BSMMU on time. Dhaka is reported to
have 250,000 cycle rickshaws, which is not hard to believe when
attempting to cross the cycle rickshaw lane. On first
impressions one can feel uneasy considering the low pay, long hours
and difficult conditions the drivers have to endure. The
counter-argument is that the rickshaws are a major employer and
drivers’ pay compares well to jobs of a similar skill level.
In a city where noise and traffic pollution rate amongst its
greatest difficulties, the quietness of the cycle rickshaws (well,
aside from the constant tingling of cycle bells) and their green
nature do appeal to the environmentally minded amongst us.
The BSMMU certainly is a huge hospital.
It comprises of four blocks, each up to 17 stories high, with a
range of inpatient and outpatient facilities for the majority of
medical specialities. The department of psychiatry is on
floor 11 of block C. The BSMMU is the primary medical
university in Dhaka for postgraduate teaching and qualifications,
including training for both MD and MPhil in psychiatry, and the
links it has across the country mean it is a great starting point
for setting up a Royal College Volunteer Scheme link.
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Professor M Mullick is the man in charge of
the psychiatry department, the lead contact for the link, and I am
sure will be mentioned again in the blog. The doctors
at the BSMMU have a wider range of clinical interests than I
initially expected. The first doctor I speak to properly is
Dr Ahsan, who tells me about his desire one day to gain experience
at the Porterbrook psychosexual clinic in Sheffield. (without
knowing where I am based!) There is definitely a strong interest in
collaborative working. I think the next three months are
going to become very busy.
When we did the previous scoping work looking
at mental health services in Bangladesh, the need to start by
establishing similarities between health systems, rather than
differences, became apparent. The BSMMU provides inpatient
(both paying and non-paying) and outpatient services.
Patients are recommended to attend outpatients by a community
doctor or can self-refer – the model is generally recognisable with
the UK. There is, however, no real community psychiatry, and
more limited availability of psychotherapy - the BSMMU does have a
psychology arm, however. There are several other government
hospitals in Dhaka, as well as a variety of private inpatient and
outpatient services, accessible to those with greater
finances. There is a specialist child and adolescent service
at the BSMMU, although other specialities are less developed.
Of course, "Dhaka is Dhaka" as I have heard several residents say,
and the availability and set-up of services varies greatly across
the country- I hope to be able to explore rural psychiatry later in
the placement.
Briefly back to the link….As this is a new
link, the early priority is establishing clear and achievable aims
and objectives….More on this next entry….
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2/23/2012 9:40:39 AM
Day One – 23 February, 2012
I shall begin by providing an introduction to
Bangladesh and its capital, Dhaka. I am lucky enough to have
visited Bangladesh two years ago, with colleague Dr Ashique Selim,
when scoping for partners for the RCPsych link. Despite
this previous trip, nothing quite prepares you for the colour,
noise (and traffic) that hits you after landing – certainly a
dramatic wake-up call following an overnight flight. Dhaka is
a vibrant, energetic and rapidly expanding city, currently home to
around 12.5 million of Bangladesh’s 160 million population.
With an area the size of England and Wales, makes Bangladesh the
fourth most populated country (after the city states of Monaco,
Singapore and Malta), and is set to rise to 180 million by
2015. The rapid expansion, of course, leads to challenges in
areas such as future health-care and social provision. Another
major topic of conversation when discussing Bangladesh is
water. The geography is dictated by the great Himalayan
rivers that pass through Bangladesh – the Brahmaputra and Ganges,
the delta of which forms the majority of the coast-line.
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Bangladesh has both a rich cultural history,
and a turbulent political history. The majority of the
population is Muslim, with smaller pockets of Hinduism, Buddhism
and Christianity. In Dhaka itself, the influence of the
various cultures and religions is perhaps best physically
demonstrated within the old town. Ancient Mughal forts and
mosques lie along-side Buddhist and Hindu temples. More
recent history is dominated by Bangladesh Independence in 1971
following the Liberation War and despite many political twistings
and turnings over the past 40 years, Bangladesh is undergoing a
period of relative stability, under the Prime Minister, Sheikh
Hasina government.
The Bangabandhu Sheik Mujib Medical University
(BSMMU) is a major Government training institute for post-graduate
doctors specialising in mental health. It is located within
central Dhaka and my placement there commences
tomorrow.
In the next entry I shall describe the BSMMU
in more detail as well as look at the provision of mental health
care in Dhaka and Bangladesh as a whole.
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2/22/2012 10:15:38 AM
RCPsych Volunteer Scheme Link with the Bangabandhu Sheikh Mujib Medical
University, Dhaka, Bangladesh.
Welcome to my blog.
Over the next few months I hope to provide an insight into the
Royal College of Psychiatrists Volunteer Scheme link with the
Bangabandhu Sheikh Mujib Medical University in
Dhaka. I will be the first volunteer to take part in the
scheme and will be flying out to Dhaka on 21 February 2012 for
three months. The blog aims to cover the background to the
link, experiences along the way, and hopefully act as a
catalyst for those interested in the volunteer scheme and who may
possibly take part in the Bangladesh link in the future.
The first official blog entry will follow shortly!
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About this blog
Dr Adrian Phillipson is an ST5 in general adult psychiatry,
based in South Yorkshire. He is currently part way through a
year out from his training rotation, utilising the time to pursue
research and travel interests. Adrian is the first
psychiatrist to take part in a new Royal College of Psychiatrists
Volunteer Scheme Link with the Bangabandhu Sheikh Mujib Medical University in Dhaka,
Bangladesh. He hopes that this blog will provide good insight
into the link, and will encourage others thinking of taking part in
the volunteer scheme.
Adrian’s attraction to
transcultural psychiatry
stemmed from a chance encounter with a local practitioner in Malawi
in 2003, where he witnessed a traditional healing ceremony for
psychosis. He has further developed his interest through
completing a masters degree in Transcultural Mental Health Care at Queen
Mary, University of London, as well as through further overseas
exposure. In 2010 Adrian made an initial scoping visit
to Bangladesh to look at mental health services and help establish
a sustainable link. A report from this project can be found
here.
Archive
February 2012 (3)March 2012 (1)April 2012 (3)
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