Mental unhealth

By Jocelyn Edwards

The lone referral mental hospital  offers little respite for patients

Its just before noon at Butabika Mental Hospital and the patients are in the yard of the womens in-take ward. About two dozen patients are lying on the grass sleeping.  Many of those up and wandering around have droopy eyelids and seem to be in a haze.

The more alert ones seem excited to see a visitor in the ward; in ill-fitting hospital gowns they crowd together at the iron fence to greet me.  It does not take long before they are talking about their lives in Uganda’s only national referral mental hospital.  Im so tired of it here; Im so tired of it here, says one woman.  Im hungry.  One asks for a toothbrush, another points to her bare feet and says she wants shoes.

A patient with a particularly gaunt face comes up to the gate and wordlessly puts her hand out through the bars as if begging for food. The gate to the ward is open and a couple of patients wander out to sit beside me on a little bench underneath a tree on the outside of the fence.  Periodically, preoccupied nurses rush between wards.  None of them takes time to come up and question the presence of a visitor so clearly out of place.

Now at 750 patients, numbers at the institution have burgeoned in the past few years, according to the Assistant Director, Dr. David Basangwa.  As in the rest of the world, psychological ailments are on the rise in Uganda. One study suggested that up to 40% of people in post-conflict zones in Uganda, such as Teso, may be suffering from depression.  In the past, those suffering from psychological ailments in Uganda would seek traditional solutions but that is changing due to increased education. This is the reason that we are beginning to get more and more patients in our facilities, because people are becoming aware that mental illness is a disease that can be treated, Basangwa says.

Yet Butabika is failing many of these, according to those who have spent time there.  The complaints of the women at the gate only hint at whats hidden within the institutions walls.  Neglected physical needs are not the only concern for patients inside the hospital. Stressed out and under resourced staff often resort to physical abuse and overmedication to control patients says a source familiar with the institution.

Beatings most days

[Living there] sometimes you feel that your life is in danger, says Helen*, a former patient. Sitting at a cafe in downtown Kamapala, she chokes back tears as she talks about her experience.  Diagnosed with bipolar disorder, she has stayed at the hospital five or six times over the past ten years. Beaten, overmedicated and neglected by staff, her tale offers a window into the lives of patients at Butabika.

Now in her thirties, she often had to be restrained by staff during the violent manic episodes she experienced.  The methods  used to control her outbursts go far beyond reasonable use of force.  During one of her manic episodes, Helen recalls being strangled with a bed sheet and beaten by eight security guards.  After that, she was stripped naked and then taken to the seclusion room, where she spent the next 24-hours without food or water.  Hospital staff would often berate her during such incidents, she says. The insults that they hurled at you!  Stupid, useless, imbecile, lunatic.

What happened to Helen is not an isolated incident; physical abuse of patients at Butabika is a systemic problem, according to one former staff member.  Catherine*, who worked as a nurse at the institution for a period last year, saw staff beating patients most days at work.  Patients were beaten by staff as punishment over the littlest things.  If patients didnt take medication, if patients were disruptive when queuing up for meals, they were hit.  Catherine recalls one instance when a patient was beaten so severely by a security guard that her leg was broken.  I noticed this patients leg was swollen and she was crawling along the ground.  When asked her what happened, she told me the security guard had beaten her and placed her in the seclusion room because she had been crying.

Dr. David Basangwa is the assistant director of Butabika.  Sitting in his office in the sprawling campus of Butabika, recently renovated with African Development Bank money, he admits that sometimes he does get complaints about staff using excessive force.  However he maintains that such incidents are not common.  Thedisciplinary board fields complaints that result in action being taken against staff about once a year, according to the doctor.  More minor complaints are investigated about once a month he says.  “The patients in this hospital are people with human rights that have to be observed,” says Basangwa.  “We take that very, very seriously.

As for Helen being left in the seclusion room for 24 hours, the assistant director stated that patients should only be left there for around six to eight hours, as long as it takes the medication to start working and them to calm down. Basangwa says he is not aware of any incidents of patients being left in seclusion rooms for long periods of time.  However, he admits, “I don’t know every single detail that happens on the wards.”Â

Other abuses

Physical abuse may be the most glaring example of patient mistreatment inside the hospital but other types of abuse also permeate the lives of patients, according to the former nurse.  The two dozen patients lying almost comatose in the in-take ward’s yard hint at another major problem in the hospital- over medication and incorrect prescription of drugs.  Medication is often left up to overworked nurses, according to Catherine, and ends up being dangerously haphazard.  “There were so many patients that you didn’t know who they were; so nurses would just guess which drugs to give them, which is pretty dangerous when you dealing with medication like anti-psychotics . . . I found myself on a number of occasions giving patients the wrong drugs simply because they were mislabeled and I mistook them for another drug.

Powerful drugs like valium were given to patients at significantly higher than the standard dosages The risk of giving too much of this drug can result in dependencies and overdose, says the nurse.

Dr. Basangwa admits that patients may be given higher dosages than normal, particularly in the in-take ward, to which patients may be admitted in acute condition. The dosages are slightly high to calm them down to keep them from escaping.  We sedate them a little bit so that they don’t kick and injure themselves.”

Dr. Basangwa shows off the private rooms of the hospital with just one or two beds and private bathrooms.  He admits they are for Butabika’s VIPs.  When it comes to regular patients, however, conditions of everyday life are a little less humane.  Helen says she often had to share a bed with other patients.  Food consisted of porridge, without sugar, and plain posho maize flour meal and beans for lunch and dinner everyday.  We would receive the same amount of food no matter how many patients we had, and this was never enough, says Catherine.  Patients who are too sick or heavily sedated to line up at meal times often end up missing out, according to the nurse.

Systemic problem

So what or who is to blame for the litany of abuse of patients inside the mental health system in Uganda?  Its impossible to understand without looking at the context of underfunding and under resourcing of mental health in Uganda.  There are just seven psychiatrists for all 750 patients at Butabika and Dr. Basangwa sets the nurse to patient ratio at one to 60 during the day and much higher at night. However, Nurse Catherine says that she routinely had around 130 patients to manage by herself; once she even recalls havi ng sole responsibility for 218 patients.

The heavy workload undoubtedly has an effect on patient care.  Dr. Margaret Mungerera, is a psychiatrist at Mulago Hospital and the president of the Uganda Medical Association.  Before rushing off to her own 10:00 am shift at the hospital, Mungerera explains the situation faced by psychiatric staff in Uganda.  With only 28 psychiatrists in the country and few medical students pursing the profession, “each psychiatrist [in Uganda] does the work meant for ten psychiatrists,” says the doctor.  Mungerera explains that the ratio of nurses to patients on properly staffed psychiatric wards should be 1:6 and even lower when dealing with severe cases.

Psychiatry just isnt an attractive profession for medical students in Uganda, explains to the doctor.  According to a 2010 study published in the International Journal of Mental Health Systems, only about 4% of health expenditure in Uganda was directed towards mental health.  And because of the lack of demand, doctors are unable to supplement their public sector income in mental health with private sector practice. This January, no psychiatrists graduated in Uganda; next year, only one is slated to matriculate.

As a result of the amount of work the few psychiatric staff in the country shoulder, theres a lot of burn out and just poor performance at work, says Mungerera.  In some cases, dealing with the demands of severely ill patients causes staff to develop health problems of their own.  The psychiatrist says she has seen professionals in the field with alcohol problems, drug problems and physical ailments, such as heart issues.  A lot of that is because of the amount of work they do, she says.

The psychiatrist readily admits that those problems affect patients.  When psychiatry staff members are dealing with exhaustion and stress of their own, They might make errors and they dont give the patients the amount of attention they need to give them, says the doctor.  Nurses who overmedicate cannot be blamed for doing so, she says.  With so many patients to deal with, sometimes it seems the only way to cope.  Instead of trying to calm patients down, [nurses] will resort to drugs.  The easy way out is to over sedate patients. How else can you manage?  Otherwise the patient will walk away and you will be blamed, says Mungerera.

With its less than desirable conditions, Butabika’s residents undoubtedly hope that their stays will be short ones. Unfortunately, without adequate staff to help them get well, the prognosis for mental health patients in Uganda isnt good.  Butabika has become a revolving door.  Patients come in and come out and then next month they come back, says Mungerera.  If you get sick in this country, the chances of recovery arent good, especially if youre poor.

****

* Names have been changed to protect sources annonimity.