Educators Without Borders Teaching psychiatry in Ethiopia

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Educators Without BordersTeaching psychiatry in
Ethiopia

• John Teshima
• Staff Psychiatrist
• Division of Youth Psychiatry

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Learning Objectives

• At the end of this presentation, participants
  will be able to
• describe some of the distinctive features of
  mental health care in Ethiopia
• debate the role that educational institutions in
  developed countries can play in the training of
  health professionals in developing countries
• reflect on the challenges and rewards of teaching
  psychiatry in Ethiopia

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Ethiopia

• population 81 million
• half of the population is under 18 years old
• one of the worlds poorest countries
• gross national income per capita is 1190
  international dollars
• (WHO, 2008)

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Prevalence of mental health problems

• 12-18.7 for all disorders
• 0.9 for schizophrenia
• 1.8 for bipolar disorder
• 10.8 somatoform disorders
• 2.7-3.7 problem drinking
• suicide rate 7.8 per 100,000
• (Alem, 2001)

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Mental health beliefs

• most Ethiopians believe that psychiatric symptoms
  are due to spiritual causes
• they first seek out traditional healers
• typical treatments herbal remedies, holy water,
  exorcisms
• only when such methods fail, do families seek
  modern psychiatric treatment
• (Alem et al., 1999), (Alem, 2001)

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Mental health services

• 54 outpatient clinics
• staffed by psychiatric nurses
• 6 inpatient wards in general hospitals
• only in 4 out of 9 federal regions
• one psychiatric hospital
• Amanuel Hospital in Addis Ababa
• (Desta, 2008)

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Mental health services

• in 2002, there were 9 psychiatrists
• all practicing in Addis Ababa
• all foreign-trained

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How to increase Ethiopias psychiatrists?

• continue to send medical graduates abroad for
  training
• establish a training program locally with
  Ethiopian faculty
• import a curriculum and faculty from an existing
  training program

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Problems with sendinggraduates abroad

• they dont come back
• there were more Malawian doctors practicing in
  Manchester than in the whole of Malawi.
• (Broadhead Muula, 2002)
• roughly 80 of Ethiopian medical school graduates
  leave to work in other countries
• (Araya, personal communication, 2008)
• they come back with knowledge and skills that are
  not specific/relevant to the local context

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Problems with establishing alocal training
program

• not enough faculty to teach and supervise
• challenging for a small number of faculty to
  create a curriculum

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Problems with importing acurriculum and faculty

• curriculum is usually the same as for the
  original institution
• (Harden, 2006)
• thus can be insensitive or irrelevant to the
  local context
• focus tends to be revenue generating
• e.g., Cornell University in Qatar, Duke
  University in Singapore
• (Harden, 2006)
• not feasible in a poor country such as Ethiopia

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TAAPPs solution

• in 2002, the Toronto Addis Ababa Psychiatry
  Project was created
• a collaboration between the Departments of
  Psychiatry at U of T and Addis Ababa U
• combines the numbers and strengths of U of T
  faculty with the local experience of Addis Ababa
  U faculty
• U of T faculty providing their services pro bono

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Format of TAAPP

• teams of two psychiatrists and one resident from
  U of T spend 1 month each in Ethiopia
• each team collaborates with the Addis Ababa
  faculty to develop a curriculum
• 3 trips per year initially
• trips focus on a specific theme, e.g., Psychotic
  Disorders, Child Psychiatry

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Teaching duties of TAAPP

• formal seminars and workshops 3 afternoons per
  week
• clinical supervision
• inpatient wards
• outpatient clinics
• emergency department

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My TAAPP experience

• in the summer of 2007, my wife and I agreed to go
  on a TAAPP trip in 2008
• after months of meetings and many hours of
  preparation, we left for Addis Ababa on March 8th

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Formal teaching challengesthe content
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Formal teaching challengesthe content

• some mental health problems have very different
  prevalence rates in Ethiopia
• e.g., 1.5 for ADHD
• (Ashenafi et al., 2001)
• only 14 psychiatric medications are available in
  Ethiopia
• a few typical antipsychotics, a few TCAs,
  lithium, valproic acid, a few benzodiazepines,
  fluoxetine

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Formal teaching challengesthe process
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Formal teaching challengesthe process

• engaging the residents in interactive teaching
  methods was initially slow going
• teaching in Ethiopia is almost exclusively
  didactic
• limitations to the classroom environment

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Clinical supervision challenges
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Clinical supervision challenges

• high volume of patients to see
• patients were very ill
• treatment and disposition options were very
  limited

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Teaching rewards

• after a warm-up period, the residents did engage
  well in interactive teaching
• the residents were very quick to implement new
  knowledge or feedback on their performance

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Conclusions

• Ethiopia desperately needs more mental health
  professionals
• international collaboration is a feasible
  approach to developing training programs
• teaching can cross borders, languages, and
  cultures

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