Over kinderen, hun psychische problemen, hun ouders en hun behandelaars.

A day in the life of a visiting child-psychiatrist in Addis Ababa – part 1

Henrikje Klasen took six months leave from her job as Head of Training in Child Psychiatry in The Hague, Netherlands, to move to Ethiopia with her family. There she supports the Psychiatry Department of the University of Addis Ababa in the development of their child mental health services. This week, she tells about some of her experiences in three posts on De Kennis – Blogs.

Landkaart-EthiopieDaylight hours are precious in Addis, so we try to get up around 6:00 AM as morning dawns. The city awakes with barking dogs, cocks crowing and the sun slowly cutting through the rising morning mist. It is still quite cool and we clearly need our fleeces as we leave the house around 7:20 to walk our daughter to school. Just outside our house we are held up by a herd of sheep, asking ourselves where in this vast and busy city they might find a suitable grazing ground. It is easier for the five young donkeys that are well established at the roundabout next to the new, huge, condominium blocks we pass soon after. We cross a river, where a few men and women are already busy washing themselves and their clothes, before we reach the lovely oasis of the German School, set in beautiful gardens.

Our daughter is greeted from all sides and quickly disappears amongst her friends. The open-air cafeteria of the school serves a delicious “makiato” (macchiato), an Ethiopian specialty ever since the Italian occupation in the 1930’s and 1940’s. We treat ourselves to a cup before embarking on my least favorite part of the day. I need to catch a mini-bus to the hospital and as it is already almost 8 am it is about the worst time of the day to take public transport. The air is thick with dust, smoke and exhaust fumes. Most mini-busses are full already; every now and then there is a free space and the conductor (usually a young boy) shouts the destination from the window. However, I am usually too slow to catch the empty seat and the door slams in my face. After a quarter of an hour, as the next bus approaches a middle aged woman who had been observing me, takes pity and resolutely pushes away the crowds to get me a seat. I breathe a sigh of relief as I crouch down in a little space above the tire and quietly thank the woman, who gets on the bus with me.

Ethiopia and the hospital

Ethiopia is a land-locked country with a population of about 96 million from more than 14 ethnic groups; almost half (44%) of the people are younger than 15 years. The ancient Ethiopian monarchy maintained its freedom from colonial rule with the exception of a short-lived Italian occupation from 1936 to 1941. In 1974, a military junta, the Derg, deposed Emperor Haile Selassie (who had ruled since 1930) and established a socialist state. Torn by bloody coups, uprisings, wide- scale drought, and massive refugee problems, the regime was finally toppled in 1991. A constitution was adopted in 1994, and Ethiopia’s first multiparty elections were held in 1995. A border war with Eritrea late in the 1990s ended with a peace treaty in December 2000.

“Yekatit 12” is a big academic general hospital with a vast array of buildings in incongruous styles and colors. Everything is overshadowed by their newest acquisition, a huge ten-story white building, which still needs to be inaugurated. Psychiatry only has an outpatient service, which serves the local adult population, but also has a supra-regional function as the only specialist child and adolescent mental health service in the country. All psychiatric specialist trainees rotate here for a few months of child and adolescent mental health (CAMH) training, as do some junior mental health nurses. Medicine and psychology undergraduates regularly come to observe and there are advanced plans to start some clinical research, such as an adaptation of assessment tools and treatment packages. Unfortunately the child psychiatrist (one of two in the country!), who has been working here, was a victim of his own success and now leads the university’s psychiatry department, leaving no specialist child psychiatrist working here.

Little space

Despite my morning adventures I am the first doctor to arrive, so I have some time to talk to the nurses and psychologists, who are there already. Two of the mental health nurses have recently completed a psychology degree – one at master level, but despite her qualification as clinical psychologist, she is not given much appropriate work and feels under-utilized. Part of the problem is that she is among the very first psychology graduates in the country and has yet to find her role; the other problem is space, as the staff – two general psychiatrists, one or two residents, two psychologists and about five mental health nurses and medical officers – only have three rooms to share and see patients. As is often the case, psychiatry is housed in one of the scruffiest buildings of the hospital; with the shiny new building just being completed we hope to be rehoused soon. There is little or no hope we will get into the new building but we have been promised 10 rooms in a lovely bungalow at the back of the hospital, which would be a great improvement. Apparently the plastic surgeons, who are there now, want to keep their old ward as well as some extra rooms in the new building; tough negotiations are ahead. The psychiatrists fear they don’t have a chance against the surgeons, let’s wait and see. Some things appear to be universal after all…

The teaching session

Soon the first year resident and his supervisor, 
a newly qualified consultant in general psychiatry,
 arrives. We start with a teaching session. The 
resident reports the case of a 23-year-old 
female waiter he saw the previous day. For the
 past few months she had suffered from bouts
 of excessive daytime sleepiness, often just
nodding off for a few minutes, whenever she sits
down. She sleeps well at night and reports no 
psychosocial stressors. The young consultant
 asks me if I have any questions and I ask quite
 vaguely about mood, epilepsy and the nature 
of the sleep episodes. As I finish, the young
 consultant takes over the questioning. Quickly
and systematically she drills the resident on the
 gaps of his presentation: personal history, social
 history, drug and alcohol use, thought disorder,
 timing, frequency and muscle tone during the
 sleep episodes, hypnagogic hallucinations,
 sleep terrors, formulation, differential diagnosis,
 further investigations, suggested treatments…
 Wow! It reminds me of my time as a trainee at
 the Maudsley. It seems that the resident had 
already decided on the diagnosis of narcolepsy
 and in the absence of sleep laboratories and
 stimulants in Ethiopia, had started the patient on
 imipramine, which – so he informs us – suppresses REM sleep, which typically occurs too early on in the sleep cycle in narcolepsy. Quite impressive knowledge really, but the young consultant recommends further history and EEG when the patient comes next to exclude other diagnoses, in particular epilepsy, depression and substance abuse. After all, as every doctor learns, common problems are common… and rare ones are rare… I must say, I can only admire the quality of the teaching – it was an excellent training session – also for me!

This article was also published in IACAPAP Bulletin 40 (February 2015).

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