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Mental Health in Zanzibar. Where is Zanzibar?. Zanzibar.
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Zanzibar • Zanzibar is a semi-autonomous region of Tanzania in East Africa. It is composed of the Zanzibar Archipelago in the Indian Ocean and consists of many small islands and two large ones: Unguja is 60 miles long and 20 miles wide. Pemba Island is slightly smaller at 42 miles long and 14 miles wide. • The capital is Zanzibar City, located on the island of Unguja.
Zanzibar • Zanzibar’s main industries are spices, raffia, and tourism. In particular, the islands produce cloves, nutmeg, cinnamon, and black pepper. For this reason, the Zanzibar Archipelago is sometimes called the “Spice Islands” • The population is about 1.2 million people, most of whom are Muslims. The average annual income is £350. About half the population lives below the poverty line.
Mental Health Services • Services are run by the Ministry of Health in Zanzibar City • The services are based in Kidongo Chekundu Hospital in Zanzibar City. • There are male and female wards, a locked male ward, an occupation therapy department, outpatient clinics and a methadone clinic.
Cottage Hospitals • There are 2 cottage hospitals in Kivunge in the North and Makunduchi in the South. • HIPZ leases the hospitals from the Zanzibar Ministry of Health for a period of ten years. The statutory responsibilities of the State are not being replaced as the local staff, salaries, basic utility and other services are still provided by the Government.
Prior to HIPZ's involvement: • There was only one psychiatrist serving the whole of Zanzibar (1.3 million people) • Services were centralised at the psychiatric hospital (Kidongo Chekundu) in Stone Town with infrequent and overcrowded outreach clinics to surrounding villages. • Patients were frequently simply re-prescribed the same medication for life, because there was little time in the over-stretched service for symptom reviews or psychological approaches. • Despite this, there was a pool of un-tapped skill on the island, because many Zanzibari nurses underwent a year of psychiatry placements during training.
Cottage Hospitals • MAKUNDUCHI HOSPITAL • HIPZ has developed a nurse-led clinic model. Makunduchi nurse Pandu underwent a 6 month bespoke training programme, supported by HIPZ, before taking on the clinic as an independent nurse psychiatrist. • The clinic at Makunduchi has now seen over 160 patients with conditions including schizophrenia, depression, anxiety and sleep disorders. The clinic also treats many children and adults with epilepsy • KIVUNGE HOSPITAL • In April 2016, following the success of the Makunduchi clinic, a parallel clinic was launched at Kivunge hospital. HIPZ staff are now facilitating so many patients being treated closer to their communities, as well as giving them enough time in their appointments to receive more tailored diagnosis and treatment.
The Friendship Bench Project • Common mental disorders (CMD) such as depression and anxiety are a major cause of disease burden, especially in low and middle-income countries affected as these mental disorders are hardly recognized and combined with an under resourced medical system, result in a major treatment gap.
The Friendship Bench Project • The Friendship Bench Project aims to reduce the treatment gap by using a cognitive behavioural therapy based approach on primary care level to address kufungisisa. Kufungisisa, the local term for depression, is literally translated into “thinking too much”. Patients visiting the primary care clinics are being screened with a locally validated tool called the Shona Symptom Questionnaire (SSQ). When scoring above the cut off score, they are being referred to the friendship bench where they will receive individual problem solving therapy from a specifically trained lay health worker.
The Friendship Bench Project • A recently carried out randomized control trial showed that the Friendship Bench can deliver a successful, culturally acceptable and reliable treatment program for depression on a primary care level.
Primary Health Care Clinics • Patients from the outlying villages find it difficult to attend the 3 main hospitals. They have a long journey by Daladals to get there and back which takes all day • Most of the people seen in clinics are the parents of the patient. They cannot afford the Daladala fare to bring the patient (usually about 30p each way)
Primary Health Care Clinics • There are primary Health Care Clinics in isolated villages across the island. • These allow patients themselves to be seen in their local community. • The budget of the MOH is not sufficient to provide fuel and medication to visit the clinics on a regular basis.
Epilepsy • Treatment of Epilepsy is included in Mental Health Services • Prevalence rates are 4.9 per 1,000 for epilepsy in Zanzibar compared to 9.7 per 1,000 in the UK. • Many of the patients seen in PMHC clinics are being treated for epilepsy. • Often common drugs are not available for many months due to shortage of funds • The inclusion of epilepsy in mental health services may derive from the belief that both are the result of possession by spirits.
ZAMHS • ZAMHS stands for Zanzibar Mental Health Shamba. Shamba is the Swahili word for Countryside. • ZAMHS is a small NGO that aims to support people with mental health problems in the rural areas of Zanzibar.
ZAMHS • We are working with Community Mental Health services in Zanzibar to pay for fuel for transport to far flung areas and medicines to be able to supply to those with Mental Health or Neurological problems who cannot afford to pay for them. • We also raise money to be able to provide much needed equipment such as Pikipiki (motorbikes) so staff can reach the remote areas of the island.
Comparisons of Funding • In the UK we can pay up to £15,000 per week to look after a single patient • Mental health funding in Zanzibar is £66,000 per year. • We can pay as much to treat one person in a month as they have to treat 1.2 million people for a year in Zanzibar
Traditional Healers • Most patients go to traditional healers (witch doctors). • Many of the rituals are tied up with their Muslim faith, for instance writing sentences from the Koran on the inside of cups and allowing the liquid to dissolve them. • It also includes making potions from roots and plants to drive away spirits.
Traditional Healers • in Africa and Latin America, paranoid delusions and hallucinations are often triggered by an intense fear of magical persecution and witchcraft. • These conditions are real within the cultures in which they occur – pain and physical symptoms are experienced – even though no physiological basis for them has yet been described.
The Twist • A WHO study was carried out over 25 years from the late 1960s in many sites in 10 countries in urban and rural settings, 2 studies showed that people in poorer countries had a less severe form of Schizophrenia, had longer periods of remission and higher levels of social functioning.
WHO Study • 40% of patients in in industrialised nations were judged over time to be ‘severely impaired’ • 24% of patients in poorer countries ended up similarly disabled • The nations with the most resources have the worst outcomes
Cultural Influences in Psychosis • Clinicians sometimes treat the voices heard by people with psychosis as if they are the uninteresting neurological by products of disease which should be ignored. Our work found that people with serious psychotic disorder in different cultures have different voice-hearing experiences. That suggests that the way people pay attention to their voices alters what they hear their voices say. That may have clinical implications. Tanya Luhrmann
Cultural Influences in Psychosis • …many of the African and Indian subjects registered predominantly positive experiences with their voices, not one American did. Rather, the U.S. subjects were more likely to report experiences as violent and hateful – and evidence of a sick condition. • Tanya Luhrmann
Cultural Influences in Psychosis • The more independent emphasis of what we typically call the ‘West’ and the more interdependent emphasis of other societies has been demonstrated ethnographically and experimentally in many places • Europeans and Americans tend to see themselves as individuals motivated by a sense of self identity, whereas outside the West, people imagine the mind and self interwoven with others and defined through relationships.
Cultural Influences in Psychosis • The research suggests that the “harsh, violent voices so common in the West may not be an inevitable feature of schizophrenia.” • Cultural shaping of schizophrenia behaviour may be even more profound than previously thought. • Tanya Luhrmann, Professor of anthropology, 2014
Crazy Like Us • In East Africa traditional beliefs in spirit possession help families accept schizophrenia and reduce social stigma. But Western ideas have the effect of stripping away the local beliefs that in practice can make people feel better.
Rwandan Prescription for Depression • “We had a lot of trouble with western mental health workers who came here immediately after the genocide and we had to ask some of them to leave. They came and their practice did not involve being outside in the sun where you begin to feel better, there was no music or drumming to get your blood flowing again, there was no sense that everyone had taken the day off so that the entire community could come together to try to lift you up and bring you back to joy, there was no acknowledgement of the depression as something invasive and external that could actually be cast out again. Instead they would take people one at a time into these dingy little rooms and have them sit around for an hour or so and talk about bad things that had happened to them. We had to ask them to leave.”
