St Mary’s Hospital, Isle of Wight (UK) – Juba Teaching Hospital Link
REPORT OF TRAINERS’ VISIT TO JUBA TEACHING HOSPITAL, SOUTHERN SUDAN
8 MARCH 2010 – 26 MARCH 2010
A visit to Juba Teaching Hospital and related health facilities was undertaken by four members of the St Marys, Isle of Wight (UK) – Juba Link from 8 March 2010 to 26 March 2010 by Kim Hayter (Registered Mental Nurse), Bob Marks (Mental Health Manager/Registered Mental Nurse/Registered Learning Disability Nurse), Jane Salih/Newson-Smith (Psychiatrist) and Frances Read (Registered Midwife/ Registered General Nurse). This was the fourth visit of trainers’ from St Mary’s.
MENTAL HEALTH TEAM
Mental disorder is a hugely neglected problem in developing countries and this is particularly true in post-conflict nations. The World Health Organisation has stated there can be no help without mental health. The multiple interrelationships between mental disorders and other health conditions and the practical implications of the co-morbidities cannot be overemphasised. Mental disorders increase the risks of communicable and non-communicable diseases and vice versa. Mental health is an integral and essential component of good health. The problems of adversity of resources for mental health, inequity and inefficiency are most marked in low income countries. This so much applies to Southern Sudan which has a huge mental health/disorder problem and this is in the context of a post-conflict situation.
The mental health brief was to provide a psychiatric module to Medical Assistants in general Medical Assistant training. A previous visit by a team member identified that the mental health unit at Juba Teaching Hospital is led by two specialist Medical Assistants. and the very rudimentary mental health service for Southern Sudan has a few additional Medical Assistants in post. On the previous visit Medical Assistant students showed a great interest in learning more about mental health and disorder:-
OUR MAIN OBJECTIVES
To gain further understanding of the practices on the psychiatric ward. There has been no previous visit by mental health nurses. It was hoped to develop with the ward staff their training needs.
To work alongside the Medical Assistants and staff in the psychiatric out-patient department at Juba Teaching Hospital.
To update on mental health facilities at Juba Prison and to gain further understanding of the role of prisons in managing severe mental illness and training needs of the health and custody staff.
To look at the scope for development of community mental health and learning disability community projects.
Teaching of Medical Assistants at the Institute of Health, Juba.
The Institute is situated opposite Juba Teaching Hospital next to the doctors’ accommodation. It is the largest Institute for training Medical Assistants in Southern Sudan, others exist in several states.
It provides a three year training in health studies and therapeutics, including prescribing. The students have school certificates, including science subjects. Many students have a nursing background and also many come from the military. .
They are taught in English, both written and spoken. There are no IT facilities and textbooks are minimal. They are taught in large classrooms for thirty to forty students with desks in neat rows and blackboards with chalk.
There is no air conditioning nor any leisure facilities. Many students travel long distances and funding can be problematic. Some are sponsored by their states, some by their hospitals, others take night jobs to self-sponsor their studies.
After final examinations they complete a hospital based housemanship, rotating between specialities, working alongside medically qualified doctors. After the hospital based fourth year, students have a graduation ceremony. They then return to their states or remain hospital based. They are a very valuable part of the workforce and, for example, provide the anaesthetic services.
On our first morning we met with Stephen Friday (the Acting Principal Tutor) while the Principal is away on other duties. He has a nurse background, a Medical Assistant training and a year’s tutor training in Uganda. We discussed with him how we could be most helpful in the limited time available. He explained that normally the psychiatric module has been taught by the Senior Medical Assistant who is their psychiatric tutor. He asked us to teach a mental health module to third year students and gave us eight timeslots. He told us the students were keen for this module and they can back-up their theoretical experience by attending clinical services at Juba Teaching Hospital where they are made welcome.
Our preparation involved attending in whole or in part the St Mary’s Hospital Principles of Adult Learning Course. This helped us in setting out course plans, lesson plans and assessing students needs. Bob Marks managed the newly acquired Link data projector and we all took PCs. Bob developed course evaluation forms, which were used at the beginning and end of the course. The following course plan was developed:-
• LECTURE 1 – an introduction to the course and the importance of mental health and, stigma.
• LECTURE 2 – mental illness and disorder, mental state examination and history taking.
• LECTURE 3 – mood disorders, suicide and attempted suicide.
• LECTURE 4 – schizophrenia and other psychoses.
• LECTURE 5 … neuroses, post traumatic stress disorder.
• LECTURE 6 – psychopharmacology and epilepsy.
• LECTURE 7 – organic psychiatry, disabilities, including learning disability.
• LECTURE 8 – summary of course, student presentation, presentation of certificates of attendance.
We used PowerPoint presentations. Unfortunately the temperature was so high that initially the data projector kept cutting out.
The students had difficulty understanding our accents and it took us a few sessions to appreciate that their understanding of written English and English spoken by their colleagues and tutors was much greater than their understanding of our spoken English. We observed that the tutors tend to walk round the room speaking very clearly and using the blackboard. Thus we had a steep learning curve in our teaching presentation. Gradually the classes became much more interactive,
We were able to leave them copies of our PowerPoint presentations as Bob had brought a printer out which proved invaluable.
The final class, led by Kim Hayter, was particularly successful. She assigned student leaders the tasks of presentations for groups in advance of the lesson. Two fourth year Medical Assistants working at Juba Teaching Hospital who wanted a career in mental health came to help facilitate.
The students did extremely well in their presentations. Certificates of attendance were distributed amidst much clapping, and Stephen Friday joined this mini ceremony.
Analysis of evaluation forms distributed for early lectures and later ones were generally very positive and reflected our increasing awareness of their teaching needs. They requested a more intensive course and they also wanted mental health to come earlier in their three years.
They all emphasised the extreme need for mental health skills and the dire state of compatriots with severe mental illness. They wanted more written material and they wanted more mental health textbooks.
We left an index file of our PowerPoint presentations plus fact sheets on the major conditions from the Royal College of Psychiatrists, the National Institute of Mental Health (USA) and other reputable sources. The lack of IT facilities both at the Institute and at Juba Teaching Hospital is very problematic, the students are entitled to use the library at Juba Teaching Hospital. They found particularly helpful the book on “Where There Is No Psychiatrist, by Vickram Patel, but commented they need more copies. The psychiatric section of the Oxford Textbook of Tropical Medicine also proved invaluable (same author).
TEACHING OF YEAR FOUR MEDICAL ASSISTANT STUDENTS AT JUBA TEACHING HOSPITAL
These students have passed their final exams and are doing their clinical placements prior to their graduation ceremony. Firstly, they were extremely helpful in making arrangements for our visit with the Institute and the psychiatric ward. They had attended talks the previous year and a group of eight to ten of them requested a further series of lectures.
So they attended a parallel series to that given at the Institute and four of these remained very keen on a career in specialist mental health.
The talks were given in the Link room in the resource centre. The smaller group facilitated more group discussion. They were hungry for knowledge and keen to know how to get a mental health training.
At the end of the one and a half hour session they would often ask for more and say it had been too short. It was good to see that several in this group had maintained their interest over the previous eighteen months since the preliminary visit.
Ward 11 is the psychiatric unit combined with the sleeping sickness unit at the far end of Juba Teaching Hospital, opposite a primary school. Colleagues from a nursing background had little idea of what to expect or how further training could be facilitated before arrival.
The unit from the outside is ,like other wards and has approximate accommodation for ten in-patients. It was immediately apparent a large pool with raw sewage was just outside the unit, creating a foul stench and a breeding ground for malaria. This provided a most unpleasant and unsuitable environment for patients and their families. There were no working toilets on the unit. Furniture is minimal with some basic beds, but little else.
The nursing team was led by a newly qualified certificated nurse who expressed a wish to learn more about mental illness. Communication was difficult as very little English was spoken. The relatives carry out all the basic care and are often able to act as interpreters.
There are no therapeutic activities whatsoever. As with the rest of the hospital, there is no food programme, in-patients are totally dependent on their relatives. We saw amazing care from the relatives, which extended even to other patients.
The unit is led by the Senior Medical Assistant (George Nazuro) and his deputy (Kiramisu). The Medical Assistants are highly respected by the nurses and carry out the tasks that would be assigned to a medically qualified Psychiatrist. They have received a specialist psychiatric Medical Assistant training in Khartoum. They are addressed as doctor by colleagues in the hospital. Dr George Nazuro was on leave for the whole of our visit, Dr Kiramisu welcomed us warmly and we spent a considerable amount of time with him. The Medical Assistants do regular ward rounds, accompanied by the nurses.
Patient records as minimal, as are any observations and physical examination. Some of the patients had severe psychotic illnesses, schizophrenia and bipolar disorder. Alcohol abuse is also a big issue. We also noted a high level of physical co-morbidity and the difficulty in obtaining medical investigation and treatment for potentially treatable infectious diseases. Tests could be done for sleeping sickness, cholera and typhoid, but little else.
There was some availability of psychotropic medication and relatives did have the option of buying more modern alternatives from pharmacies. Disturbed patients received an intravenous mixture of Chlorpromazine, Promethazine and Diazepam. This meant they were drowsy or asleep in the daytime and there could be wakefulness at night.
The nursing staff were observed to be kind and fearless with the patients, but with very limited therapeutic options. It is a most impoverished environment which does not facilitate recovery. Kim Hayter led on occupational activities and brought out some games such as jigsaws and small balls to engage the staff with the patients. This was very successful, the nurses showed great keenness.
PSYCHIATRIC OUT-PATIENT DEPARTMENT
This is a small building opposite the main out-patient department where the Medical Assistants have their office and see out-patients. They wait with their families on the veranda outside. There is a small nursing team and a counsellor. There is no obvious appointment system, the patients and their families come along during the morning.
We were made very welcome here and sat with Dr Kiramisu on many assessments and had useful clinical discussions. One of the nurses here told us she would love further training in psychiatry, but it is just not available for nurses.
Very disturbed patients are not always admitted to Juba Teaching Hospital and if the relatives agree, a form is signed by a magistrate so the patient can be taken to the mental health facility at Juba Prison.
We had contact with Dr Waahab Kaole prior to our visit, he is a Senior Forensic Prison Psychiatrist in Nigeria and is employed by United Nations Mission in Sudan (UNMIS) on a twelve to eighteen month secondment at Juba prison
He came over to Juba Teaching Hospital and had an illuminating talk with us. He drew our attention to the fact that there are now no psychotropic drugs available in the prison, which makes his job very difficult.
He kindly arranged for us to meet Robert Leggat (Corrections Co-ordinator, Corrections Advisory Unit, Southern Sudan) at UNMIS headquarters who gave us a very helpful overview of all the problems of the mentally ill people in prison in Southern Sudan.
A visit to the prison was facilitated for us and we visited the male side, mainly the wing for the mentally ill. Here, despite a lot of work by international agencies working with the government of Southern Sudan, the situation is dire and the scene for the mentally ill is devastating human misery. This situation needs urgent attention, in particular basic psychotropic medication is essential. Previously the supply used to come from Khartoum, but this has now stopped.
Dr Sarah Petrie (NGO Co-ordinator, Southern Sudan and Public Health Consultant) met with us in Juba and arranged a round table meeting of those involved in prison mental health. We were able to attend this and there was extensive discussion about how this vital medication could be obtained urgently. A regular sub-group has now been set up.
Bob Marks led on a visit to The Usratuna Project (this is a children’s disability service. It is funded and co-ordinated under the joint Auspices by the Ministry of Health (GOSS,) Ministry Of Health Central Equatoria, Juba Catholic Arch Diocese and The Christian Blind Mission). This was arranged by Andrew Mogga Lubago (Fourth Year Medical Assistant Student). It is in delightful surroundings for children with physical and mental disabilities. The local workers go out into the community all day to identify children with disabilities so that services can be arranged for them.
Bob Marks and Kim Hayter subsequently had an intriguing day out in the Juba community with Christopher Jada (an outreach worker for the charity) who is training at the new Catholic University of Juba to be a Physiotherapist. They witnessed a brilliant community outreach service for children with disabilities in a localised area, but with potential to cover much more of the city. Counselling, support and advice, along with some practical help in the form of anti-epileptic medication is being dispensed and mosquito nets were allowing families and the community to cope. It was evident there are problems with alcohol in community and with drug addiction. It showed the potential for mental health services to work on a similar model to develop community services with trained workers.
SUMMARY OF MENTAL HEALTH VISIT
The main objective of teaching a psychiatric module to Medical Assistants was successful, despite the need for a steep learning curve in our teaching methods. There is now much opportunity to build on this and, in particular, introduce the subject earlier in the course. IT facilities are urgently needed.
The overwhelming problem in the ward was the sewage swamp. By the end of our visit we saw evidence of drainage work starting. We saw a need and a wish for general nurses to have a specific mental health training and opportunities may open with the development of the new school of nursing and midwifery.
We were disappointed to find the recent lack of psychotropic medication in the prison and this presents the most urgent need. Many international agencies are involved in the development of the prison service to reach international standards after the years of conflict. The current situation for the mentally ill is unacceptable.
We would agree that there is an urgent need for a specialist wing in the prison for those with major mental illness where treatment can be initiated. In the longer term a new unit with modern facilities is needed.
There is an absence of community mental health work in Southern Sudan, but the model observed for disabled children could be adapted for mental health as an outreach approach. There is a training need for community workers, this could be delivered on a small scale to such a project on a subsequent visit.
Our mental health visit was to Juba and we understand mental health services are even less developed in other states. On the positive side, there are many very able Medical Assistant students who wish to specialise in mental health. There is an urgent need to set up a training for mental health professionals for the whole of South Sudan even if taught in different sites and various international groups are helping South Sudan in this to make is sustainable. As well as the Medical Assistants already in training and trained, there are nurses who wish to specialise in mental health and there are school leavers who wish to go into it direct. A lot could be learnt from other countries in Africa which have set up or are setting up specialist mental health training.
Report of visit to Juba teaching Hospital March 2010.
Midwife France Reed
The return to JTH 18months after first visit was very positive.
The staff were very welcoming and at once reminded me of my previous attempts at Arabic.
Some of the staff had left and there were new members.
An early meeting with Janet Michael was arranged and I visited her at the ministry. We discussed how the plans for the school of nursing and midwifery were coming along and the opening of the school is to be on May 10th. There are a few financial issues. There are currently 10 student midwives in waiting, as opposed to the wished for 20, however the training is still going to proceed.
We also discussed what Janet wanted me to focus on during my stay. Again as last time, documentation, by the midwives, infection control and sepsis. We also discussed delivering breech presentation babies vaginally, and it is the same In Juba as in UK, Midwives have lost these skills as in hospital, the obstetricians prefer to perform a caesarean.
During my first visit, I had not visited the antenatal clinics and therefore I made this one of my first maternity visits/shifts. Everybody who works here is so motivated. Screening for HIV is now happening. UNICEF running PMTCT (prevention of mother to child transfusion.) councillor working voluntarily at present! Women come from a wide area some needing to stay over night somewhere. They may have 1 or 2 antenatal visits or more if they lived nearer. Due to staff shortage, and large number of women coming to the clinic, I volunteered my services. I was going to palpate, . I was told the sphyg was out of action due to the battery, so I produced my manual one.
The women all attend the clinic at the same time. Margaret a midwife, speaks to the women collectively n the waiting room, health promotion, diet, exercise screening bloods. Then they all come through. Approximately 25 women were seen in 2 hrs.
3 babies died on the same night whilst I was there. At one point 2 babies were in the same incubator. There was just one nasal cannula to deliver oxygen to the babies, so it was rinsed under the tap between applications. There appears to be no neonatal nursing expertise, and the paediatricians did not appear to attend.
Workshops were planned for the following week; I had the old pathology lab as before. This is now a conference room, with a very large oval table, many chairs, air conditioning, ceiling fans and water coming out of the taps. A contrast to 18 months ago where the room had to be thoroughly cleaned, chairs and table borrowed from waiting rooms and clinics.
8 attended the workshops. 2 newly qualified nurses and 6 midwives. JTH is short staffed therefore this is a good number. The level of English spoken was varied, from none at all to fluent. Jemelia Sake, senior Midwife once again translated admirably. By all of us sitting round the table, made for good debate and discussions during the sessions.
The 3 days of workshops were divided as follows.
Day 1. Documentation, writing in women’s notes.
The discussion revealed that some doctors not happy with midwives and nurses writing in notes. All encouragement given here. Midwives as important as doctors, but the most important people are the women.
Importance of documentation was explained as midwives and doctors working in a team, and that it is the midwives who are the first present when the women are in trouble and they inform the doctors.
Documentation important to keep statistics, for what works well as well as what is not so effective.
The second part of the workshop concentrated on good asceptic practise. Preventing cross infection, effective handwashing, and signs and symptoms of sepsis. And treatment.
The morning was a refresher on intrapartum care, and the documentation of.
The afternoon was breastfeeding and helping women to breastfeed.
Visual aids very effective in this session.
This was chiefly obstetric emergencies. Practised giving inflation breaths to baby, on teaching model I brought out.
Estimated blood loss with bottles of red coloured water. Ante and post partum haemorrhages.
Pre-eclampsia and eclampsia.
The importance of documentation again stressed.
All teaching aids very well received. Teaching packs were made up, plastic folders, with pens pencils, exercise books, highlighter pens, paperclips and handouts to go in as each topic was broached. Also gestation wheels, and tourniquets were given, and a few midwifery dictionaries.
The remaining stationary was left for the school of nursing and midwifery.
The feedback regarding the workshops was very positive.
Clinical Work with Midwives
The operating theatre in maternity is now in full use for caesarean sections, and occasional gynaecological operations, e.g. ectopic pregnancy.
I had been asked to take maternity protocols by one of the obstectric consultants. Whilst are written for St.Mary’s Hospital IOW, they can be adapted for Juba teaching Hospital. Dr. Mergani the consultant who requested the protocols was unfortunately away, however, I left them with Sister Jemelia Sake together with a copy for the midwives. Hopefully the Doctors and Midwives can work together in the adaptation of protocols and guidelines.
This visit, it was possible to be given some statistics that were not available previously.
There are approximately 7000 births a year at JTH.
In 2008, there were 28 maternal mortalities. In 2009, there were 19.
There is one photocopier, in the hospital, which during this visit was not working, but was being fixed.
The visit was positive. Other agencies are helping, e.g. UNFPA and UNICEF. But still much more needs to done to continue to improve the maternity department, and to reduce the maternal and neonatal mortality rate.
We would like to thank the government of South Sudan (France’s acknowledgements to be added) for their invitation to this visit and for providing accommodation. We are grateful to Dr Louis Danga, Dr Sarah Petrie, Dr Waahab Kaole, Dr Kiramisu and to Andrew Mogga Lubago and to the staff of the Usratuna Project.