Gesine Heetderks and Michael Huppertz
Mindful Change Foundation
From April 1 to 11, 2019, we travelled to Côte d’Ivoire to gain an insight into how the SAMENTACOM project, funded by our foundation, has progressed and how it can be developed. SAMENTACOM aims to implement a social-psychiatric-oriented care for people with mental illnesses and epilepsy. The project was initiated during our stay in Côte d’Ivoire in January 2018 — triggered by the disturbing reports of mentally ill people living without medical help under the most degrading conditions in the poor countries of Africa and Asia — and has started work since then.
Our current visit was carefully prepared and organized by the project leader, the Ivorian psychiatrist Prof. Koua from the University of Bouaké, and his staff. In addition to Prof. Koua, the team in charge includes another psychiatrist, two psychiatrists still in training, a sociologist, an Agent de Santé (staff member in one of the health centers), a pharmacologist, a lawyer, two geographers and an assistant. We were involved in the work on all the construction sites relevant to the project. We participated in several discussions with staff, but also with patients and relatives, and suggestions from our side regarding the ongoing work and further development of the project were welcomed. Critical questions were also welcome.
The main topics of our trip were:
1. The development of psychiatric and neurological work in the existing health centers;
2. Further training on psychosocial aspects of the treatment and further development of supervision;
3. Cooperation with the Camps de Prière –Prayer camps (CdP);
4. Cooperation with the national pharmaceutical authority to ensure the supply of medicine
1. The development of psychiatric and neurological work in existing health centers.
In Côte d’Ivoire, there is nationwide care with small, simple health centers that are responsible for all health issues, but generally do not treat psychiatric or epileptic patients. Therefore, the aim is to enable these health centers to take care of these patients. SAMENTACOM has therefore initiated a pilot project in 10 health centers, mostly in the rural area of Bouaké. So far, it has been investigated what psychiatric help is already available there, psychiatric consultation hours have been set up and regular supervision by Prof. Koua’s staff in form of joint local treatments has begun. One of the main problems of the project was to find the patients in the villages and prayer camps, to make them visible and to enable them to receive treatment. In the future, this must be one of the tasks of the Agents de Santé, who will be trained as part of the project.
The drug treatment of psychoses and epilepsies represents an indispensable progress. The need for additional psychosocial training for those who work with the mentally ill has become clear, not only so that they can better respond to their mental situation and social environment, but also so that they themselves can cope better with difficulties in dealing with the mentally ill. We were impressed by a meeting with about 50 Catholic sisters, some of whom are in charge of a health post and some of whom have received psychiatric training from Prof. Koua. They seemed highly motivated, and at the same time they talked about many situations with mentally ill people, in which they felt helpless and sometimes scared. The desire for monthly supervision was expressed and it became clear that they needed a lot of support.
2. Training on psychosocial aspects of treatment and further development of supervision
We experienced supervision in one of the ten health posts of the project. One of the nurses of this post had taken part in the basic psychiatric training with Prof. Koua. The consultation was conducted by this nurse together with a psychiatrist from the team. This will take place once a month in the future. During the consultation most patients had epilepsy, some had relapses because they had stopped taking their medication, and others were treated for the first time. One patient had been chained up three times, treated once with antipsychotic medication and then taken to a prayer camp during another psychotic episode.
It was noticeable that the nurse turned more to the relatives with their questions than to the patients themselves. The tone was short and concise, there was little recognizable sympathy. There were frequent interruptions due to mobile phone calls. The patients behaved rather submissively. — Other employees take a lot of time talking to patients and their relatives, show a lot of patience, but of course it takes less time when you talk to the relatives instead of the patients. Our impression is that decisions are not made or even negotiated with the patient.
Parallel to the consultation, Prof. Koua, together with an employee, conducted an initial training course for the Agents de Santé there on how to recognize and deal with mentally and epileptically ill people. Their task will be to go to the villages and encourage the sick to come to the clinic, talk to the families and stay in contact with the sick during the treatment. This training is an important part of our project. There were 8 Agents de Santé present, including a woman. The Agents were very involved, they described problem cases. The message from Prof. Koua was very clear: in the future they should also be given the task to report suspicious cases to their center, but they do not have to make a diagnosis and of course they should not carry out any treatment. Rather, it is a matter of establishing contact between the patients and their villages and the health centers and accompanying them. They know all the patients in the villages and in the prayer camps.
With regard to the psychological training and further education of the SAMENTACOM team in dealing with mentally ill people, we have succeeded in recruiting a clinical psychologist from Abidjan. The idea is that together with Prof. Koua he will produce a brochure in which the important elements of the psychological treatment will be explained. The team of Prof. Koua can then take over the training in the health posts.
3. Cooperation with the Camps de Prière (CdP) prayer camps
The prayer camps are villages with spiritual offerings, which usually accept mentally and epileptically ill people against payment, mostly for long periods of time, even against the will of the people concerned, at the request of their relatives. Mental illnesses and epilepsy are religiously interpreted in Africa often as possession by evil spirits, and so the treatment consists of prayers and sometimes also torture to which the sick are subjected in order to drive the evil spirits out of them. They are often chained to trees in the open air, sometimes for years, so that they cannot run away and cause any damage. The path of the patients usually leads via healers who practice traditional medicine to the prayer camps, which are mostly evangelically oriented, with traditional religious elements playing a more or less important role. In view of the helplessness of many relatives in dealing with mental illnesses, the accommodation of the sick in prayer camps often seems to them to be the only possible solution. The Camps de Prière are therefore of central importance, and the development of constructive cooperation with them, if successful, is an opportunity for the development of psychiatric care in West Africa.
So far, there is no overview of how many Camps de Prière there are and where they are located. They are not registered anywhere, and anyone can set up such a camp. The aim must therefore be a national survey in this matter. To this end, SAMENTACOM conducted a pilot survey in the Bouaké area and presented it in a very successful brochure. 71 prayer camps were recorded and mapped, 40 of which were visited. If this is extrapolated for Côte d’Ivoire, there should be around 2000 prayer camps in this country.
According to the pilot survey, the vast majority of the prayer camps are willing to cooperate. We have visited several prayer camps, including one we visited last year. However, after a very friendly reception it turned out that the religious leaders had decided to pray only with the patients and not to allow any more medical treatment by the SAMENTACOM team. In a conversation with the village elders, Prof. Koua urged everyone to allow the treatment; otherwise they would come into conflict with the law. We saw three patients chained to the camp — one of whom we had seen chained there a year ago — living there without psychiatric help. One can only speculate about the director’s motives for refusing to cooperate. In any case, perhaps a more regular contact and regular talks could have prevented such a break — also with the clear message that detaining patients and refusing to help them at the same time is a violation of the law and a violation of human rights that will not be tolerated. However, the legal situation and, in particular, the human rights dimension of such action appears to be generally rather unknown. For future conflicts of this kind with prayer camps, it is therefore important to find out about the legal basis and also to sensitize the relevant police authorities to this problem.
However, it has also become clear how important it is to support patients and their relatives in learning to articulate and represent their own interests. In a village we showed the impressive film: “La Maladie du demon” by Judith Kugler. A suggestion made by Prof. Koua at this meeting with patients and their relatives to found a self-help group and to invite the local authorities and the police to participate, met with a broad response. The founding meeting was scheduled for the end of May.
4. Cooperation with the national pharmacy authority to ensure the supply of medicines
Together with Prof. Koua we had a meeting with representatives of the National Pharmacy Authority for the Public Sector (NPSP). The aim was to reach an agreement with the NPSP that would lead them to order, pay for and deliver the medicines to the centers involved in our project (and possibly for more centers in the future) at a lower cost than in the pharmacies. So far, we have sent medicines to Côte d’Ivoire in collaboration with Medeor. Medeor is a German NGO that delivers medication to poor countries at low cost.
At the meeting it became clear that the NPSP only wanted to get involved if the quantity of drugs needed was so large that it was worth the effort. To this end, the NPSP wants to collect data on the drugs used and those needed in the future. In the meantime, it has been decided that this data collection by the NPSP will soon be carried out in all known centers that treat patients with epilepsy and severe mental illnesses in relevant numbers, and that on this basis the drugs will then be procured by the NPSP itself in the future.
Results and tasks:
1. We have seen the balance sheet for 2018/19 (until 31.3.2019), it is ok. The planning for 2019/20 is outlined, a detailed planning will follow.
2. The payments of the patients for medicines supplied by us or Medeor will be registered and returned to the project. They are to be used to finance any further medication that may be necessary and also for the work of the centers, e.g. to finance motorcycles or agents’ salaries.
3. 20 Agents de Santé will be specially trained for mentally and epileptically ill people. Of these, 10 will be financed by us in the future (2 each for 5 centers). We are also willing to pay the material costs for the agents. The main problem of the project will still be to find the patients in the villages and prayer camps and to enable them to receive treatment. This function can and must mainly be fulfilled by the agents.
4. A monthly supervision by the psychiatrists of the project is planned
5. For the time being no further central training courses will be carried out because sufficient nurses have already been trained for this phase of the project. Instead, there will be decentralized training courses on site in the health centers and training courses for CdP staff. The idea is to continue using the prayer camps, at least in part, by upgrading them as real sanatoriums with controls and conditions. However, it remains to be seen how many CdPs are prepared to do so and understand the therapeutic concepts. Where possible, police training could and should also be offered.
6. In addition, a guide for psychological training should be drawn up by the psychologist and Prof. Koua, which should first be binding for the SAMENTACOM team and then for the staff in the health centers.
7. We will support a National Enquête on the Camps de Prière. It will be carried out by the end of the year. The University of Bouaké is the supporting body. Prof. Koua submits the application and makes the calculation. We take care of the financing, be it through us and/or through cooperating foundations.
8. Medical therapy will be continued in a more differentiated form. More attention should be paid to side effects, and more attention should also be paid to compliance, including that of relatives and the prayer camps.
9. Data on drug demand in the centers will be collected by the NPSP. It is planned that the NPSP will then, as with all other diseases, take over the supply of medicines for mentally and epileptically ill patients.
10. The legal situation regarding human rights violations must become clearer. In this respect, we must become more aware of national law.
11. We have been recommended to negotiate a convention between our Foundation and the Ivorian State; our recognition as an NGO in Côte d’Ivoire can facilitate our work in this country with the authorities. This is in preparation.
12. The number of centers in the project is not yet to be increased, but rather the quality and quantity of work in the centers is to be improved. We may then gradually add individual centers, if possible those that are already at work and possibly also religiously oriented, even if we agree that this is a model for the whole country and that sooner or later it should and can be extended nationwide.
April 2019