Mental Health Nursing Visit November 2012

Proposal for the Development of a Mental Health Service in the Republic of South Sudan by Bob Marks

Current situation
There is an urgent need for the development of a modern mental health service in South Sudan. Other countries in the region have underdeveloped services but most do have inpatient units/hospitals and a specialist mental health workforce including some psychiatrists and importantly run ongoing training programmes. South Sudan lacks psychiatrists to develop and lead services. The current Ward 11 at Juba Teaching Hospital is totally unsuitable both in facilities and trained professionals to deliver effective and safe acute mental health treatment. Furthermore follow up of discharged patients by maintenance treatment and relapse prevention is minimal.
Individuals who could recover given appropriate support and treatment remain a burden to their community and are non productive. The incarceration of the most ill patients in Juba Prison is ineffective, inhumane and leads to much suffering and does not befit the values of a new nation. The incidence of serious mental health conditions in the world does not significantly vary between countries. The very small numbers of people in Southern Sudan receiving treatment indicates that the mentally ill are largely untreated and either ostracized or confined in family homes. Self treatment with alcohol and other substances is an increasing problem.

Following the war South Sudan has serious problems arising from Post Traumatic Stress Disorder which was documented in a study in Juba. To address these problems countries such as Sierra Leone have established child soldier projects which provide counselling and support to children traumatised by war,. In the Congo women who have experienced violence attend listening houses where women can talk through their experiences in a safe environment. These projects can only be delivered as part of a mental health strategy for South Sudan which at its core has a properly functioning mental health service.

Health professionals are acutely aware of the large numbers of people with untreated mental health conditions. The WHO indicates that 14% of the global burden of disease is attributed to Mental Illness? A Study in Nigeria showed that people’s main response to mental illness was fear, followed by avoidance and anger. This suggests a lack of education about the reality of mental illness. More seriously than this, sufferers of mental illness are vulnerable to human rights violations, to physical and emotional abuse and from discrimination both from health workers and the wider community. Without a mental health service these injustices cannot be tackled.

Developing a Mental Health service
The imposition of an external model of mental health services does not engage the resources and talents of South Sudan and is not likely to meet the specific needs of a country emerging from 25 years of civil war. Consideration has to be given to the cultural appropriateness of imposing western ideas about mental illness on South Sudan .The Juba link has encountered many health professionals and health students in who are interested in developing a career in mental health including medical assistants recently qualified doctors and nurses and students from these groups. Without the structure of a mental health service the skills and abilities of those individuals cannot contribute to improving mental health in the Country.

Development of a mental health training programme
Currently those wishing to train come from the medical assistants, nurses and doctors
Consideration also needs to be given to school leavers with appropriate educational achievements. It is important to study other programmes of a generic mental health practitioner training such as is being developed in Ghana.In the short term it may be necessary to train key professionals overseas to set up services and training programmes. Retention problems will be much less with local training
All associated links will need to work in clear partnership with memoranda of understanding. There is a need for ongoing mental health input to existing undergraduate training s of the various disciplines. Overseas mentorship could be established with appropriate IT facilities such as the WHO is already establishing for mental health. Primary care physicians also need to have their mental health training needs recognised as do health care assistants.

Proposal for developing a mental health Policy for South Sudan
A three week visit to be organised by the mental health members of the St Marys Hospital- Juba Teaching Hospital Link and mapping exercise to engage with a wide range of people, groups and resources. The visit will include professionals from mental health disciplines ideally including a psychiatrist, psychologist, mental health nurse, mental health service manager. It will be helpful to include a forensic psychiatrist and or senior forensic mental health professional. The visit will work alongside the two medical assistants based in Juba Teaching Hospital who have responsibility for Ward 11 and patients in Juba prison and Outpatients. Their co-operation and expertise will be essential for a worthwhile study outcome. These dedicated professionals with specialist hospital training work in extremely difficult circumstances and very poor resources and unrealistic work loads.
The visit will also engage the Prison Service, Community services, Charities and Non Governmental Organisations, Ministers and the private health sector.
[ The visit may also be able to undertake some teaching in mental health to the School of Nursing, nursing and medical staff. ]At the end of the visit a suitable model of service to match the urgent needs of South Sudan will be proposed which will initially be centred in Juba but can extend across the country as a model for all areas. Within the plan will be the following key services which are vital for a functioning modern mental health service.

Key Services

• The appointment of at least 2 psychiatrists to lead the service and mental health manager
• The development of a modern mental health unit within the grounds of Juba Teaching Hospital , Availability of psychotropic drugs will be essential and a therapeutic environment
• Consideration also needs to be given to the development of a separate forensic psychiatric unit to look after the most ill and potentially most high risk
patients. A range of options would need to be considered for the most appropriate location. Identification of numbers of these patients should include studies in hospital, prison and community
• The development of mental health legislation which allows for the detention of mentally ill people for treatment subject to criteria and with safeguards to ensure their rights are protected.
• Training of mental health professionals. His is fundamental and a range of options needs to be carefully studied leaning on experience of other developing countries
• The development of a community based psychiatric service

This plan would then be presented to the appropriate Ministers.
Preparation of visit
In order to be as effective as possible during the visit it would be useful to have key information on the numbers of people receiving treatment in Juba prison, numbers prescribed psychotropic medication and in receipt of medication etc. If contact could be established through letter /e mail with the Medical assistants working in mental health prior to the visit that would be helpful.

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