Medical students and the rebuilding of psychiatric services in Sri Lanka after the Tsunami
Like many developing countries Sri Lanka has suffered from chronic underinvestment in psychiatric services. The need for locally based services was made all the more apparent amid the devastation of the Boxing Day Tsunami of 2004. Mehrunisha Suleman, Matthew Fittall and Justin Loke spoke to two doctors about the process of reform, and the role that medical students have played in the wake of the tsumami.
Neuropsychiatric conditions represent 12.3% of the global burden of disease and over one-third of all years lived with disability [1]. As so many years of economically active life are lost it seems strange that for many developing countries the spending on mental health services forms less than 1% of the total health budget [2]. Dr Nick Rose is an Oxford consultant psychiatrist who has worked extensively with developing world psychiatric services. According to him “one of the problems is that psychiatric illnesses are stigmatised in almost all cultures. This means it is usually of a very low priority. In this country [UK], however, there has been media driven publicity highlighting psychiatric patients who may commit murders and the alarmingly high suicide rate since the1990s. This caused the British people and politicians to become more interested in financing psychiatric services. This is not true in the third world. It is difficult to address this problem. There is very little money to spend in such areas, where do you put it: HIV? Immunization? Malaria?”
With such limited resources Dr Rose faced the challenge of reforming Sri Lankan mental health services that had not seen change for over fifty years, “The strategy we adopted was to build on to the existing structure. This involved training current staff to recognise psychiatric conditions and to also familiarize them in ways to teach non medical staff to help manage psychiatric patients”. This has been underpinned by fundamental changes in medical training, Dr Kremlin Wickramasinghe, a newly qualified doctor from Sri Lanka told us that “before 1995, medical schools didn’t even have psychiatry as a final year subject, but now in our final year paper it is one fifth of the component so medical students have to take it seriously and they have to study the same as for medicine and surgery.”
The benefits of this new training became acutely apparent amidst the devastation of the Boxing Day Tsunami in 2004, when Dr Wickramasinghe saw psychiatric services stretched to their limit. “Medical students who had graduated but were waiting for their internships were trained by consultants so that they could screen people and identify whether they needed further psychiatric support. Then we took one or two consultants and some junior doctors to run a clinic to which these students could refer patients. We also could go to some houses in villages as well but obviously we couldn’t reach everyone. For medical care there were enough doctors but for psychological needs the care that I coordinated filled the shortfall. With the available resources that was the best option.”
The effort to make the most of untapped resources was continued by local students involved in tsunami aid, who realised that the education of local communities could be the key to promoting better care. As Dr Wickramasinghe explained, “now we are involved in community based programmes which enhance the capacity of a community. In this programme we teach them the basics of first aid - dealing with snake bites and burns - and sexual health, but under this programme they also talk about identifying psychiatric conditions. They can then be told how they can access care. We can also tell them about dealing with alcohol, drugs and smoking addictions, how they can help someone in their family if they are affected but again how to get help if they need it. This programme is run through the medical school under the core group of disaster management [formed after the Tsunami] but this is not mass care. They take medical students out to one community and run a one day programme. The students take over a local centre and run lots of education stations which small groups come past at a time. The community likes this very much and often we can’t handle the numbers that turn up but we can’t turn them away. The students like it also and it’s a good programme but we don’t have much funding because we need money for transport and refreshments for those that come. We can only really run three or four sessions a term seeing about 150 people each time.”
Funding these projects which can only currently reach a few is a problem but even when people are aware of the nature of their illness they may be unwilling to seek help. “In the University [of Colombo] we have a counselling service but very few students go for it. After the Tsunami and when classmates died in the war, people have never thought about counselling or seeing a psychiatrist. When you go and see a psychiatrist you are labelled as a ‘psychiatric patient’ which could be bad for you. Generally in society people just want to avoid being labelled. [In the UK] the perception is different, going to see a psychiatrist or telling someone that you have been is not a problem but in Sri Lanka a lot of prejudice remains.”
As had been suggested by Dr Rose and others well before 2004 reform without additional spending is best targeted at the local level, training existing staff to recognise mental illness. The disaster of 2004 led hardworking local medical students to put this principle into action. Even these small scale projects can make a difference but with further funding and more students involved perhaps people will become aware of the new services springing up and be less afraid of the stigma of mental illness.
Matthew Fittall, Mehrunisha Suleman, Justin Loke
Final year medical students
University of Oxford justin.loke@green.ox.ac.uk
matthew.fittall@medschool.ox
mehrunisha.suleman@green.ox.ac
[2] World Health Organization. Atlas: country profiles on mental health resources 2001. Geneva: WHO, 2001
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