New hope at clinic of ‘last resort'
Ethiopian doctors and Canadians improve
conditions for mentally ill
22 May 2006
The Globe and Mail
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ADDIS ABABA -- Here's the good news: next
month the number of qualified psychiatrists in Ethiopia will nearly double,
thanks to an innovative mental-health program supported by Canadians.
Here's the less-good news: when the seven
newly trained doctors take up their posts, they will bring the number of
psychiatrists in this country of 78 million people to a grand total of 18.
Ethiopia is on par for most African
countries: in the already minimal public-health system in this desperately
poor country, mental illness has long been stigmatized. Private-practice
psychiatry is almost unknown, so promising medical students see no future
except poorly paid work in the country's one mental hospital, still commonly
referred to as the asylum, or “the mad people's place.”
But a pair of dedicated Ethiopian doctors,
drawing on a long friendship with a University of Toronto professor, are
determined to change all that.
Twenty-two years ago, Clare Pain was a
physiotherapist working here as a volunteer with polio-affected children; she
had just begun to fall in love with Ethiopia when she had to return to England
in the violent events after the overthrow of Emperor Haile Selassie. She
couldn't come back until the collapse of the communist regime that replaced
him, in the early 1990s.
By then, she had emigrated to Canada and was
a practising psychiatrist, but she maintained an interest in Ethiopia. One
day, when she was in Addis Ababa, she knocked at the door of Amanuel Hospital,
on a hill in the capital. It was the start of a long, warm friendship with the
hospital's then medical director, Mesfin Araya, who with his colleague Atalay
Alem was trying to modernize the facility.
Prof. Alem described his hospital as the
destination of last resort. “The first stop is the local traditional healer.
They go from one to another until they have exhausted all means, and as a last
resort they come here. But our patients are just the tip of the iceberg. Very
few have access to this hospital,” he said. “Many are chained at home,
restrained, until the disruptive phase of their illness is over, then they are
released and become vagrants. That is the general fate of the mentally ill in
The last few years have seen dramatic
changes. “Amanuel has moved from a real asylum to a 21st-century mental
hospital,” Prof. Pain said from Toronto. Back then the wards were caged,
patients were fed sitting on the floor and were cared for by cleaning staff.
There were no psychiatric nurses; electro-convulsive therapy was prescribed
for almost every ailment.
“It was terrible, really,” Prof. Alem said.
“Today we know it is still far below standard, but compared to what it used to
be . . .”
To really change the place, he knew they
would need more staff. At that point, the handful of Ethiopian medical
students who expressed interest in psychiatry were sent abroad to train, since
there was no one to instruct them at home, but half of them never came back,
lured by a life and a profession so much easier outside of Ethiopia. They
needed a residency program in Addis, but there were only two professors of
psychiatry in the country.
Prof. Alem wrote one day to Prof. Pain. “It
was kind of Martin Luther King-esque,” she said. “He said, ‘I have a dream, a
crazy dream, we want to open a residency program. But we have two faculty. Can
you from your Canadian end give us supplementary faculty?' ”
His request came just as Ethiopia's political
climate was opening up, favouring such collaboration, and the University of
Toronto's medical faculty was seeking to broaden its educational relationships
in other countries.
Together, Prof. Pain and Prof. Alem designed
a program in which U of T faculty come to Addis Ababa three times a year to
instruct residents in specialties such as forensic, child and geriatric
psychiatry and substance abuse, fields of expertise which are unknown in
Ethiopia. They are accompanied by a U of T resident, who teaches the students
basic clinical skills, such as how to work an emergency room. The first
Canadians came in 2003; the first graduates qualify next month.
The hospital is still enough to horrify a
Westerner at first visit. There are grubby patients in torn flannel pyjamas,
some of them shackled, bobbing, muttering, or rolling in the bleached yellow
sunlight in the courtyard.
Yet the larger atmosphere is one of
compassion, often the first empathy that patients, brought in bound and tied
by frustrated family from all over the country, have experienced.
“The atmosphere there is better than some
psychiatric hospitals in Canada: there is a respect for poverty and distress
that has nothing to do with the assumption you haven't worked,” Prof. Pain
said. “I have to teach residents here how to be empathic — in Ethiopia, they
understand about hardship and suffering and pain and compassion and
generosity. That sounds very romantic, but it's true.”
Staff at Amanuel have only 11 drugs to use —
most of them invented at least 20 years ago — and there are ailments here,
such as a trance state called zar, that Canadian doctors know nothing about.
There is no word in Amharic, Ethiopia's national language, for depression. And
yet the Canadians find there is much they can offer.
Said Hassen, 47, is one of the newly
qualifying psychiatrists. A general physician since 1984, he finally got the
chance to enter the world of mental health thanks to the U of T partnership.
“Psychiatry is built on skill — you can't use machines for investigation, it
depends on skill and knowledge,” he said. “This program is only possible
because we have had the Canadians. Although our environment is not like
Canada, our materials and trainers have given us training as if in Canada.”
The collaboration with U of T will go on for
at least three more years, and Prof. Pain emphasizes the two-way nature of the
exchange. Half the patients she sees in Toronto were born outside Canada, she
noted; the experience in Ethiopia helps the Canadians come to grips with the
diversity of experience their patients at home may have had, Prof. Alem added:
Today, Amanuel has outpatient and
rehabilitation departments, and nurses have been trained to run 55
mental-health units at district hospitals around the country, to supervise
patients who go home and to refer those who need serious help to Addis Ababa.
And along with the physical changes at the hospital has come a shift in
attitudes to mental illness: The government is committing new resources to the
“People have started realizing this mental
illness is like any other illness,” Prof. Alem explained. One consequence of
that change, however, is that the hospital now draws many more people. “So
we're still unable to provide enough of the necessary care and service,” he
said. “Seven more doctors is of course a very small number. But it will help.”