Programme was very well run, with the local staff ensuring we were all coordinated in our placements and maximising learning opportunities. They were very helpful with arranging extra learning opportunities too, and I always felt comfortable to bring up any issues or requests. Really appreciated the extra local experiences and tours, I feel it was incredibly enriching to learn about the social and historical context of Kenya. The house was very comfortable and we were incredibly well looked after, from the room cleans to the large variety of delicious food cooked for us daily. The clinics and outreach gave variety to our experience, loved going to new places, meeting new people and learning new skills. Safari was well planned. The guides we had were excellent, the accommodation much more luxurious than what I was used to/expecting!
A fascination with transcultural psychiatry was what initially set me on the path to want to become a psychiatrist, and an unforgettable six weeks in Kenya.
All through medical school I was determined to work in infectious diseases. This abruptly changed in my final year thanks to an elective placement abroad. I chose to study malaria with Shoklo Malaria Research Unit in a remote area of Thailand helping the Karen refugee population. Soon after arrival I found that the organisation was so good at its job, there was barely any malaria left. Looking for additional work, I undertook antenatal clinics where to my initial confusion, nearly every woman was reporting ‘chest pain’, ‘breathlessness’ but with no underlying cardiac or respiratory causes I could determine. Probing further, it became apparent that many women were suffering from prolonged severe stress, having survived a civil war with ongoing uncertainty regarding their futures. Many could have met the criteria for depression, anxiety, post traumatic stress disorder (PTSD). Their presentations however were completely different from that in my native UK, mainly favoring physical somatic symptoms. I wondered if they would be picked up on a standard diagnostic questionnaire, which invariably were created based on Western, Caucasian patients. This fascinated me. How could the same diagnosis present differently across different cultures and peoples? Is this the same for all mental illnesses? I learned that day a new phrase – transcultural psychiatry – the study of how social and cultural factors can create, determine or influence mental illness. I wanted to discover more about this nuanced and multifaceted specialty, to experience more countries and cultures.
After graduation and two relentless foundation years in multiple busy specialties, I was exhausted. I decided to take a year out before applying to specialty training and return to what made me first enjoy with psychiatry initially. IMA’s Kenya internship in mental health seemed the perfect fit. I wasn’t sure what to expect, but these last six weeks have both exceeded and challenged my expectations.
CPGH – GENDER BASED VIOLENCE RECOVERY CENTRE (GBVRC)
I had prepared for GBVRC by reading up on post sexual assault/rape guidelines beforehand, mostly geared towards adult victims. What shocked me on the first day was that 75% of the attendees are under 18. I was seeing children both male and female who were as young as 1 year old brought in post sexual assault and rape. Attendees had to undergo further rounds of an intimate examination, pregnancy test if necessary and a long course of HIV prophylaxis, coming back for counselling and support. I learned how to carry out an intimate examination with the help of the sister in charge, how to fill out a post rape care form, handle the evidence collected and prescribe prophylaxis according to guidelines. A lot of the survivors were unaware that they shouldn’t change their clothes, wash, etc after an assault, so in many cases there was no evidence to collect. A situation analysis of post rape services in Kenya found overall a limited awareness of what to do, where to go in the event of rape, with it generally not reported. (Kilonzo, 2003)
Gender based violence also includes domestic violence and its consequences. There was a young boy around 5 years old in the clinic and he wouldn’t stop crying. When I tried to engage with him, he suddenly started shouting at, punching and kicking me. His mother said that the father routinely beats her and the children; the day before when the boy was crying the father beat him until he stopped, then burned him with a cigarette. His face and torso were covered in bruises and there were circular burns on his shoulder blade. How could I blame him for his attack on me, when violence was what he knew? We tried to get the father arrested ASAP, and continue working with the boy in therapy, praying that this could break the cycle. These experiences with children have led me to consider seriously the subspecialty of child and adolescent mental health, where the patients are amongst the most vulnerable, and you hope that an early intervention can change the path of their lives.
Seeing how sensitively and calmly the counsellors dealt with the survivors and relatives, treating each person’s stories seriously and with compassion was a bright beam of humanity in what were often deeply upsetting accounts. Feeling some difficult emotions, I would try to verbalise and make sense of them after the survivor had left, and I appreciated then how important it was to have supportive colleagues to debrief with, for the sake of one’s own mental health.
An interesting aspect of being at the clinic was how I learned through the survivors about some of the wider social issues. Poverty meant many patients could not continue to attend counselling, that young poor girls were exploited by older men giving them money or a meal in exchange for sexual contact. The nurse in charge Saida would give all the girls counselling on the importance of staying in education, but when young girls became pregnant (and there is a high rate of teen pregnancy in Kenya with a national average of 18% according to the Kenya Demographic and Health Survey 2014), they mostly dropped out of school due to lack of resources to support them. There was also the tension seen between the generation of young Kenyans who wanted to have casual relationships, go out drinking alcohol and party, and the older generation of the clinic staff who still taught celibacy before marriage. Some of these issues were universal to other countries such as substandard sex education, but knowing about others more specific to Kenya, such as the tradition for early marriages, helped explain why so many teenagers were seen.
Port Reitz was yet another learning curve! I saw patients mainly in outpatient clinics, clerking them for admission as necessary then reviewing them on the ward. There was also an opportunity to sit in on counselling sessions with the psychologists and take part in occupational therapy. Highlights of the occupational therapy included being taught by a patient how to use a hoe to garden and taking the patients for a therapeutic seaside walk.
The very concept of a mental illness was very different in Kenya compared to what I was used to. Patients and relatives would often have spent years trying prayers or traditional healers before attending the hospital. It is more considered a spiritual disorder e.g. due to possession or witchcraft rather than a medical condition and a hospital attendance was often the last resort. There are innovations being trialed for delivering community based mental health care in Africa such as collaborating with traditional healers, establishing relationships with Muslim leaders to facilitate identifications, which I will follow with interest.
The presentations were also different. There was high prevalence of psychoactive substance use such as khat/mugoka, bhang/cannabis which lead to psychotic symptoms. Psychotic patients would present with symptoms ‘talking too much’, ‘wandering’ – these presenting statements I have never heard uttered in the UK.
The psychotic patients tended to present more with visual and auditory hallucinations rather than thought disorders, which was also found in a worldwide study of schizophrenia in different cultures (Sartorius et al., 1986). Interestingly, they seemed less concerned by auditory hallucinations than patients I saw in the UK were. An anthropological study by (Luhrmann, Padmavati, Tharoor, & Osei, 2015) has found that voice hearing experiences of people with serious psychotic disorders were shaped by local culture. The African and Asian participants were more likely to report rich relationships with their voices compared to American participants who tended to describe the voices as a sign of a violated mind. A possible explanation posited is that Europeans and Americans tend to see themselves as more individualistic, whereas outside the West people see themselves as more interwoven with others. I learned to be more flexible in seeing how different mental illnesses present, and not make assumptions about the person’s own interpretations of their symptoms.
Comparing the scarcity of the resources available here compared to the UK was sobering. Staffing levels were low, with so few psychiatric nurses, clinical officers, and only one psychiatrist for the whole county who was retired. I could choose between only about four antipsychotics due to limits of cost. The patients were mostly poor so I found myself grappling with wanting to help my patients but they were unable to afford medications, admission, therapy, or even follow up attendances. At home in the NHS, I was used to working within the limits set by a nationally funded healthcare system. However, at the point of contact with patients all services were free. Here I found it difficult deciding which of the three medications the patient needed was the most important when she could only afford one, how to best manage a patient as an outpatient who would otherwise have been admitted but the family could not afford it. Instead of ‘best practice’, it became ‘good enough practice in these circumstances’. This can sap morale at times, so I suppose that is why when one of the patients I first clerked got discharged completely well, I was extraordinarily happy.
There were many instances which were cause for admiration. I was surprised at how many people attended with the patients. It was common to have a brother/sister, father/uncle, neighbor/friend all present, and patients are often living with an extended family. The care shown was humbling; an elderly father who travels 4 hours from home and back every day to visit their child in hospital; family members washing and helping toilet a young man who had been too psychotic for a month to self care. In the UK, it seems like a greater proportion of the psychiatric patients I’ve seen are living alone and have little to no family support. The role of the family and community support cannot be underestimated and has long been seen as a positive and protective feature in mental illness. There is a hypothesis to suggest that schizophrenia has a better outcome in developing countries, however the WHO studies with this conclusion have many limitations and there have been studies questioning the findings since (Cohen, Patel, Thara, & Gureje, 2008). What is clear to me is that the level of family and community interconnectedness is higher in Kenya and can be a significant resource in a patient’s improvement.
As beautiful as the landscapes of Kenya are, I will leave with the greatest impression of its people. The extraordinary resilience of the psychiatric patients, clinic survivors and the clinical staff living and working in circumstances that are often limiting are an inspiration. I am encouraged to continue down the path I have chosen and will hopefully be able to help more sexual violence survivors and psychiatric patients in the years to come, as a better doctor than before I started six weeks ago.