Report on our trip to Côte d’I­voi­re in April 2019 and the sta­tus of the SAMENTACOM project

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