Trip Reports

Australia (Amy Bauer, MD)

In May 2006, I spent a month working with the Rural and Remote Mental Health Service (RRMHS) based at Glenside Hospital, a psychiatric campus affiliated with the Royal Adelaide Hospital in Adelaide, South Australia. Because there are no psychiatrists in South Australia living outside Adelaide, RRMHS provides psychiatric care to the state’s population by utilizing a primary care consultation-liaison model.

Upon arrival, I obtained a temporary medical registration (similar to a limited medical license), allowing me to participate in direct clinical care. Over the course of a month, I had frequent visits to country towns by road and by plane, practicing in five different country health centers and visiting primary providers in two other regions, including two on restricted Aboriginal lands. Approximately three days per week were spent in Adelaide, during which time I observed and conducted psychiatric assessments via video teleconferencing of inpatients in regional general hospitals and outpatients. I also spent several days on the inpatient unit, seeing patients transferred from towns we visited.

The elective was an excellent opportunity to work as part of a service with a well-developed model for providing psychiatric care in a rural setting. In addition, Australia is a terrific place to learn about community psychiatry. The national health system provides a backdrop to clinical care that allows individual providers to approach health from a population-based perspective.

Ken Fielke, MD, clinical director of RRMHS, provided supervision along with other psychiatrists on the service. Accommodation consisted of a private cottage approximately 10 minutes walk from the hospital. Costs for accommodation and the medical license were paid for by the South Australia Department of Health.

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Belize (Paolo Cassano, MD)

Belize, an independent state since 1981, is part of the British Commonwealth and is located in Central America, south of Mexico, east of Guatemala, north of Honduras. Belize is the land of many peoples: Mayas, Mestizos, Garifuna, Creoles, Chinese-Americans, and isolated minorities such as the Mennonite community. While Belizeans can proudly admire their ancient Mayan towns, the Garifuna joyful music, the jungle and one of the most beautiful coral reefs, the nation counts only two psychiatrists for more than 280,000 people. Moreover, despite the fact that more than half of the population is less than 18 years old, there are no child psychiatrists in Belize. The psychiatric nurses carry the burden of the psychiatric care in the six geographic districts, supervised by psychiatrist Claudina Cayetano, head of the Mental Health Program in Belize.

The collaboration of the MGH Division in International Psychiatry with Dr. Cayetano and her psychiatric nurses started in 2003 after Alex Cohen (Harvard Department of Social Medicine) visited the Mental Health Program of Belize. In December 2005, Paolo Cassano (currently PGY-II MGH - McLean resident) visited Belize and shadowed the psychiatric nurses and Dr. Cayetano in their daily activities for one week. In June 2006, psychiatrist Sarah Acland from Louisville, KY and Paolo Cassano jointly visited the Mental Health Program in Belize to pilot a first "hands-on" clinical training for the psychiatric nurses, which was conducted by Dr Acland.

The present collaboration with the Mental Health Program in Belize is aimed at providing the nurses of Belize with practical "hands-on" clinical teaching, mainly through fourth year MGH/McLean psychiatric residents. The residents interested in the initiative are expected to conduct two to four week electives in no more than two Belizean districts (each time), teamed with a medical student from HMS. Residents will be supervised via email by Dr. Cayetano as well as by a member of the MGH Division in International Psychiatry. The clinical activity will mimic the MGH standards for in-house supervised outpatient care by fourth year residents, with at least biweekly contacts with the mentor and his/her availability throughout the week.

The nurses will learn from the supervised residents about clinical management, while working in their own clinics. The elective will provide the resident and the medical student with an opportunity to learn from the nurses of Belize how to approach diversity in terms of ethnicity and culture when caring for psychiatric patients. We expect that the two Belizean and the MGH psychiatrists will benefit as well of this initiative; their challenge will be to strive to adapt the evidence-based knowledge to the local resources, when guiding the residents. Ultimately, the entire process has the potential to improve the local algorithms for patients care.

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Brazil (Marketa Wills, MD)


The Black Psychiatrists of America, Inc. was founded approximately 30 years ago by MGH Professor Emeritus, Chester Pierce. For more than 25 years, the organization has held an annual Transcultural Conference. These conferences are hosted by psychiatrists in countries that have a large population of members from the African diaspora. This tradition facilitates a bi-directional exchange of ideas and represents an opportunity for American Black psychiatrists to establish connections with other black psychiatric communities from around the world.

This year, the conference was held in Salvador de Bahia, a city in the northeast province of Brazil. The focus of the conference was the psychology of race in Brazil. Brazil has an exceedingly complex racial classification system. Unlike in the United States where a dichotomous distinction between whites and blacks exists, in Brazil, there are over 138 terms to describe skin color. According to the lectures that we received by leading national experts on racial studies, the differences between these two systems of nomenclature have their roots in the distinct ideologies of the British and the Portuguese who originally colonized these lands and later imported slaves. The British, who arrived as full families escaping religious persecution, looked upon their slaves as completely distinct from themselves. In contrast, the Portuguese settlers were largely made up of exiled men who intermarried with indigenous women and later African slaves in order to create a "buffer class" that would serve to support the Brazilian economy.

Currently, Brazil grapples with many inconsistencies with regard to racial politics. African culture and tradition has, in large part, been appropriated by the entire Brazilian culture. All Brazilians are proud of the African, Portuguese, indigenous, and Spanish heritages that combine to create a vibrant culture. Food, music, religion, and dance have been greatly influenced by African societies. These African traditions are colloquially looked upon as the foundation of Brazilian culture and are regarded by many with pride. The "corner pub" understanding of race is that race is a nonentity. Brazil has long been held out to be a racial democracy--indeed, a racial utopia-and most Brazilians do not think in racial terms at all.

However, when indices of educational achievement, race, health, income, and status are studied from a racial perspective, it is clear that "black" & "brown" Brazilians fall far beyond their white counterparts. The poverty-stricken favelas (slums) are populated almost exclusively by Brazilians of color. The national census recently developed five racial categories and Brazilians are required to self-report race. This system, however, has many confounders. For example, members of the same family often report themselves as being of different races.

Recently, a "Black Movement" that has gained momentum, emerging from small pockets of educated Afro-Brazilian communities. We had the opportunity to visit community development programs who have spear-headed this movement. National political leaders have taken notice; the issue of affirmative action was a key consideration in the last presidential election. Three years ago, the government voted to roll-out an affirmative action program in the public universities. The details of the undertaking are still being worked out. Psychiatrists and other social scientists are contributing to the national discussion on race.

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Brazil (John Palmieri, MD)

Cultural Contributions
While Brazil is a vast land of contrasts and tremendous diversity, there are some general comments regarding cultural norms which impressed me during my stay. One of the most striking aspects of service provision in Brazil is the emphasis on family involvement. The importance and value of the family is indeed one of the most important aspects of Brazilian culture. This value system permeates all aspects of care—family members are an integral part of CAPS visits, hospital rounds and home visits.

The Brazilian people also share a general optimism about life. Even in difficult circumstances, there is a sense that a solution can be obtained, that adversity can be overcome. Brazilians use the word jeitinho (dar um jeito) to characterize that ability to find solutions and hope in the most problematic of situations.

Additional cultural value is placed on the concepts of empathy and solidarity. Though the country has clear divides among racial, social and economic lines, there is unquestionably a sense of universality which infuses relationships. In that regard, doctor-patient relationships often assume a more informal quality than what is routinely practiced in the United States. Brazilians tend to be more responsive to a friendly and casual manner in treatment relationships; the psychiatrists in Sobral were effective not only because of their training and experience, but importantly because they were invested in the lives of their patients.

The cultural approach to illness also bears some brief comments. While the prevalence of Schizophrenia and Bipolar Disorder is likely not tremendously divergent from that published in American literature, the manifestations of illness bear a certain cultural stamp. There is a clear physical manifestation to illness, not only to anxiety disorders but also to mood and psychotic symptoms. Patients frequently describe symptoms in terms of heart, respiratory or GI symptoms (e.g., air hunger). In terms of substance use, there is a clear cultural significance to alcohol use. The notion of the farmer drinking in an arid climate conjures up a sense of nostalgia which lends implicit approval to alcohol abuse.

The Setting: Sobral
The city of Sobral is located in the Northeast of Brazil, in the state of Ceará. It is located in the dry interior of the country (referred to as the sertão), about 224 kilometers from the capital city of Fortaleza. The most recent population estimates place Sobral with about 155,000 habitants, though that number is likely underrepresentative. The population is generally young, with 85% of the population between 0 and 49 years of age. The unemployment rate in 2000 was 9.64 %. Ceará is widely considered one of the poorest states in Brazil. Despite this poverty, Sobral is regarded as the cultural, political, economic and health center of this interior region. It is sometimes disdainfully referred to as the “United States of Sobral” due to its perceived intellectual superiority, and odd sightings such as the traditional yellow American school buses (complete with English lettering) can be seen coursing down the busy city streets.

Given significant resources which belie its small size, Sobral represents one of the more successful ventures in Brazil with respect to transformation of the health care system. But before highlighting the many wonderful aspects of the system there, it is worth reviewing briefly the mental health reform process in the area.

Mental health reform in Brazil lagged behind the general health reform movement. In terms of general health services, the hospital had traditionally been the center of health care delivery. For many years, ambulatory services were considered inadequate and poorly organized. Even municipal health councils formed in the early to mid-1990s did not have a clearly defined mission, did not meet with any regularity and did not document well its achievements. In 1997 the Office of Strategic Planning was developed with the goals of improving quality of care, providing integrated services which are equal, accessible and universal. Efforts were made to decentralize the existing hegemonic system and infuse the new plan with principles of solidarity, humanity and respect. There was a notable shift from thinking of health as the absence of illness to viewing health from a quality of life perspective which is attained by more than merely biological factors. In the above vein, the Program of Family Health (Programa de Saúde de Familia—PSF) was created by the Ministry of Health in 1994, with a designated focus on promoting the health of communities in the broadest possible sense.

As noted above, the mental health changes were realized on the tails of this general health reform. In the 1970s, the mental health system in Sobral was a largely private one. Even as recently as the late 1990s, the hospital remained the centerpiece of mental health service delivery. From 1995-1999, there was an average of 957 hospitalizations per year in Sobral, with an average length of stay of over 30 days. Some private offices persisted, but public ambulatory and emergency care was limited. There remained no comprehensive public system to treat mentally ill patients.

By 1997, though, initial planning was undertaken to transform the system. In 1998, a proposal was developed to create a comprehensive program in mental health. This ultimately led to the development of the community mental health center (Centro de Atenção Psicossocial—CAPS). A team of professionals—psychiatrists, medical doctors, nurses, social workers and psychologists—formed the core element of this new model.

While community initiatives were being aggressively pursued, attention was also directed to the existing hospital system. This included evaluations of facilities, confronting both poor physical conditions and prior reports of patient abuse. Through the installation of better community services, including diagnosis, prevention and treatment, the goal was to reduce to number of inpatient beds and integrate patients into the community. Additionally, efforts were made to better streamline the pre-hospital evaluation process so that patients are hospitalized for clear clinical indications.

Finally, an important aspect of mental health reform involved re-establishing the dignity of the mentally ill, challenging discrimination against patients and providing public education. Efforts were made to confront the notion of the mentally ill as totally incapacitated and, at worst, dangerous. One nice initiative involved opening the hospital doors to the community to paint a mural. All of the above elements coalesced by the year 2000 to form an integrated network of mental health.

Current Network
The PSF represents a cornerstone in the new integrated system. The health post is designated as the basic unit for health care delivery. The municipality has been divided into 23 geographic areas, with 39 designated PSF teams. An important component of health care promotion is attention to psychosocial factors. Psychiatric medications are dispensed directly out of these facilities. Part of the job responsibility for the network psychiatrists involves traveling to these facilities to provide on-site consultation to patients for their medical colleagues. Psychiatrists participate in triage and treatment decisions, referring more complex cases for outside psychiatric follow-up and assisting the medical professionals in managing more mild and moderate cases in the primary care setting.

CAPS provides an opportunity to provide public sector psychiatric care in a community setting. The range of services is varied and includes triage and urgent evaluations, individual therapy and pharmacology, group and family treatment and sociotherapeutic activities. Psychiatrists also rotate to make home visits to those patients for whom access to the central site is not possible. More than its role in treating individuals and families, CAPS serves a vital role in the community.

The specialized services of CAPS-AD (alcohol and drugs) are an equally important aspect of care. Individual and group substance abuse services are offered throughout the day. The facility also has day observation beds for patients requiring more constant medical supervision. Integration with the community is also noticeable here. A current proposal involves education, diagnosis and treatment around substance abuse in the prison population.

Sobral also has a therapeutic residential program which is staffed 24 hours per day. The focus here on is development of daily living skills and gradual integration into the community.

The psychiatric wing of the general hospital, though downsized, retains an integral role in the network of care. There are presently 16 beds on the unit, which is managed by a team of professionals including psychiatrists, nurses, nursing assistants, psychologists, and occupational therapists. Significant efforts have been made to improve the inpatient quality of care, to ensure a basic standard of medical attention. Discharge planning has also become facilitated through the improved communication and coordination of the varied levels of care. From July through December of 2000, there were 204 hospitalizations (an average of 34 per month), with an average length of stay of 11 days. Both the number of admissions and the duration of stay have decreased significantly since the late 1990s.

One aspect of the network which permeates all venues is the focus on education. Psychiatrists are called upon often to use their knowledge and expertise to fight the stigma of mental illness and to help promote awareness. I was privileged to observe numerous examples of this commitment to education throughout my stay, on individual, family and community levels. The struggles faced by the team in attempting to educate a mother who kept her mentally ill son chained up continue to resonate with me. Additionally, I saw more formalized efforts, including radio broadcasts on depression, brochures on various aspects of mental health and participation in area-wide conferences and trainings at the local school for health professionals.

Despite the significant progress and success outlines above, challenges remain. The Brazilian government has left the program administrators with insufficient funding to implement the changes needed. Psychiatrists are severely limited in their treatment options (pharmacologic and otherwise) due to budgetary constraints. In addition, there is tremendous variation in the availability and quality of the service within the state and country. The local hospital, for example, is often encumbered by patients from outside municipalities due to inadequate resources.

Thoughts on My Experience
My time in Sobral was carefully organized. My weekly schedule was divided into 10 blocks, with morning and afternoon sessions on each workday. I rotated with various psychiatrists in all of the setting noted above, with a particular emphasis on community sites such as the PSF, CAPS and home visits. I was fortunate enough to stay in the homes of some of the professional staff, thereby gaining a more deeply personal experience of the work there. I also was allowed to participate in some of the educational experiences noted above. The Brazilians I met were without exception warm, gracious and hospitable. I am forever indebted to them for this rich experience.

Contacts: LF Tofoli
(88) 36147299 or (88) 88127299

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Chile (Trina Chang, MD)

The Instituto Psiquiatrico is a specialty psychiatric hospital in the public health system, meaning that it serves predominantly a poorer population. It contains inpatient units [mostly acute psychiatric inpatients, though there is also a unit of "chronic" patients (probably a cross between a state hospital and a dementia unit) and two forensic units], a psychiatric emergency room, and an outpatient clinic; psychiatry residents also rotate through two rural clinics.

My role was primarily observational, rotating among a wide variety of sites. I spent one morning a week in the team meeting of the adolescent/young adult inpatient unit (mostly first-break psychosis), where new admissions were interviewed by the team as a whole. I spent another morning with the affective disorders program in the outpatient clinic; in this five-hour meeting, we generally heard an academic presentation (for example, journal club presentations by residents) and interviewed new intakes and consults. One afternoon was devoted to the psychiatric emergency room, where I shadowed one particular attending one-on-one (and had the opportunity to speak with patients on my own for more time). I worked with that same attending for another day each week, seeing patients with her in the two rural clinics. Through other residents there, I was able to have some other clinical experiences -- for example, visiting the forensic units and seeing some of the residents' interesting patients. I could have spent an afternoon on the chronic patient unit, but the scheduling didn't work out.

I also participated in didactic/semi-clinical experiences with the residents: for example, the department-wide weekly case conference, where an interesting patient was presented each week and usually interviewed in front of an auditorium of listeners; interviewing seminars by one of the senior department members; family therapy didactics, in which the residents had a one-hour class on family therapy and then got to watch a family therapy session live through a one-way mirror; and other small-group didactics (covering topics ranging from narcissistic personality disorder to postictal psychosis). In addition, a psychopharmacology conference (with speakers from the U.S., England, Spain and Germany) was held when I was there, so I and all the other residents spent a day at that symposium.

Because of my interest in public health and systems, I was also allowed to attend the weekly meeting of the outpatient clinic department heads, where various programs talked about what they were doing and what they wanted to do. I also went to a meeting of representatives of various public sector hospitals where they discussed what was going on in their hospitals.

Through other contacts, it would probably be possible to arrange visits to some of the richer private hospitals and to a C/L service at a general hospital, but unfortunately, it didn't work out with my schedule either.

Language requirements: While the experience can probably be designed and adapted to your Spanish level, the more Spanish you speak, the more you're likely to get out of the experience. All of the psychiatrists there understand English (in fact, they have to read journal articles in English on a regular basis), but some are less comfortable than others speaking it. However, all patient interaction will be in Spanish. If you don't at least understand some Spanish, you'll need to work one on one with an attending or resident who's willing to explain afterwards in English.

Lodging: Harvard's David Rockefeller Center for Latin American Studies can suggest a variety of options, from homestays (costing about $550 a month) to apartments to houses where students are renting rooms.

Funding sources: Unknown.

Contact: Dr. Hector Parada (a child psychiatrist from Chile, now at MGH Chelsea; contact him through the Partners system)

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China (Karen Ron-Li Liaw, MD)

In May of 2006, I returned to Shanghai, the largest city and commercial center for this country of 1.3 billion. I spent the month rotating through various inpatient units and outpatient facilities at the Shanghai Mental Health Center. SMHC was founded in 1958 and is considered one of the premier teaching hospitals in China. The main hospital has 1800 inpatient psychiatric beds divided into women and men’s units grouped by disorder (psychotic, mood, substance abuse, psychosomatic, child & adolescent, and geriatrics). I also saw patients through the psychological counseling center which opened its doors in 1992 to improve access to care for people with depression and anxiety and to help reduce stigmatization of mental illness within society at large. The rotation was an incredible opportunity to learn about the Chinese mental health care system, work with overseas colleagues in a consultative and collaborative manner, see a variety of patients and illness presentations, and brush up on my Mandarin Chinese. Here’s an excerpt from my informal blog home...

5.9.06 cui mian, chi gong, & human bridges
yesterday to my surprise, i was escorted to the old psych wards (a new multi-million dollar facility was slated to open its doors this month which is why my trip was delayed in the first place) which are housed in a dilapidated building circa 1950. imagine 100+ floridly psychotic women in one open ward...it is quite a sight. i quickly slipped on a white coat and followed the inpatient team on morning rounds through a special section of the ward designated for the sickest patients. it was like walking onto the set of one flew over the cuckoos nest except in chinese. one patient who has been on the unit over 4 years followed the team screaming threats in shanghainese and singing folk songs while another restrained to a chair across the room echoed her threats and songs over rows of catatonic patients. new medical students were being oriented on the job by house staff, "always watch your back" as the attending swept me aside to avoid projectile phelgm. a young college student recently hospitalized for first break psychosis made a break for the iron gate as we left the unit and 'security' (aka 'the tallest doctor') carried her back in kicking and screaming. and that was just the morning.

i think this is the best part yet...staying put and getting to know the unit and small group of people. it's a colorful crew, 4 house staff about my age, the unit director, and rotating faculty each morning. at first the questions about psychiatry and life in the states came slowly, but by lunchtime the flood gates had opened.. both ways. they often refer to the 1980s (the second revolution) as when the country began to open its doors...allowing a tightly controlled influx of foreign ideas, books, television programs (i can't tell you how many people have asked me about Dr. Jason Seaver and Kirk Cameron from Growing Pains). i, of course, ask about all the things i'm not supposed to ask about..falun gong, tiananmen, SARS, google, the cultural revolution, AIDS, brokeback mtn. our time together is short and i think we're all keenly aware of it..like kids who stay up all night whispering at slumber parties while their parents are asleep.

this morning's new faculty instructor was shocked (and quite displeased) to find a visiting psychiatrist from america on the unit. he immediately called up the hospital director, my host, (the one i didn't throw-up on) and let her have it for not notifying him in advance. apparently, the last visitor they had was from france and he kicked her off the unit. now i understand why the director wanted a junior person from mgh to be the first to come over .. i'm as non-threatening as it comes but the message is clear .. 'we're opening our doors.'

i didn't even get to tell you about the cui mian (hypnosis) workshop i attended tonight. maybe for another time..

goodnight (goodmorning) from shanghai, ronli

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Ethiopia (Eric Achtyes, MD)

We went with Dr. Gregory Fricchione to Addis-Ababa, the capital city of Ethiopia. There are four million people in Addis and it is a city of contrasts. The very rich and the very poor are in close proximity to one another. It boasts the largest open air Market in Africa and, at 8300 ft above sea level, it is the highest capital city in Africa. The population is split, roughly 40% Muslim and 40% Ethiopian Orthodox Christian, with the remaining 10% following various religions. We went to work at the Amanuel Mental Specialized Hospital, the country's only inpatient psychiatric hospital. Amanuel has room for 360 inpatients and also supports the country's only psychiatric residency training program. While there, we were asked to teach the first year residents an introductory series of lectures on the basics of psychiatry for three hours every morning during the two weeks of our stay. We lectured on the introduction to the psychiatric interview, the mental status exam, the neurologic exam, diagnosis, formulation, and interviewing the substance abusing patient. We performed role plays with the residents, saw patients on the wards, and had them interview and present patients to us. The population of patients at Amanuel is enriched in bipolar disorder, schizophrenia, depression and comorbid substance use. The families bring the patients to the hospital only as a last resort when they can no longer manage them at home. Medications available included the typical antipsychotics, the 'big three' mood stabilizers, tricyclic antidepressants, fluoxetine, three benzodiazepines and an anticholinergic medication. Ninety percent of the patients can't afford to pay for their treatment and the government covers the cost. Fifteen years ago, there were only two psychiatrists for the whole country. Now there are more than twenty, with new graduates starting every year. With a total population of 65 million people, that's a caseload of 3.1 million per psychiatrist! The new graduates are taking posts on the faculty of medical schools around the country, which previously had no psychiatrists on staff to teach the medical students. The leadership of the psychiatric hospital and residency program are bright and motivated clinicians. While there is much work to be done, the future looks bright for psychiatry in Ethiopia.

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Ethiopia (Karen Ron-Li Liaw, MD)

en route from addis to alexandria. seem to have caught the cold that's been circulating from the tikkur anbassa (black lion hospital) pediatrics ward to the awash minibus to amanuel hospital to greg & ann to me. in the row in front of me, there is a beautiful ethiopian newborn girl who has just been adopted by an american couple (not angelina and brad). her lake langano eyes open wide looking around the cabin, gurgling and kicking with delight. people can't help but smile as they walk by.

yesterday, dr. atalay alem, the founder of the psychiatry training program and now vice chair of the university, took us out for our last ethiopian fasting menu lunch. he's one of those people whose vision and dedication are awe inspiring – the kind of guy you'd follow into battle no matter how bad the odds were stacked against you. i asked him how he managed to grow the department from a two-man affair to a thriving community of scholars and clinicians. he said that he would have never been able to do it without the help of his overseas colleagues and their ongoing teaching, research, and moral support.

that afternoon, we drove out of the city into the entoto mountains passing poor rural communities and dozens of women carrying heavy bundles of fuelwood on their backs. my skin seems to have grown thinner and more porous over the course of these few weeks because seeing this much poverty and need feels increasingly heartbreaking and unbearable. one of the reasons that i wanted to come on this trip was so that i could stop reading the news about aids, hunger, poverty, & unrest in africa as something that was happening "over there." and i leave now holding both a sense of helplessness in the face of staggering need and empowerment that the work that we've done will have meaningful and long-lasting effects.

she's asleep now. i wonder about the life that she will lead in the states and how different it will be from life in ethiopia. still a very small world..
see you on the other side,
r



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Ghana (Carol Wool, MD)

Site for Psychiatric work in the Volta Region, Ghana
The Volta Region of Ghana is in the Eastern part of the country. The capital of the region is Ho. In Ho there is a tertiary care regional hospital. The facility is six years old. It is well conceived and beautiful. The whole hospital has 240 beds, but not all can be used because of lack of staff doctors and nurses. Ghana suffers from a severe brain drain. Qualified doctors and nurses often leave to get better pay in the States and England.

In this hospital there is an in-patient psychiatric ward with 10 beds and an out patient clinic, which has 2,500 visits a year. Two psychiatric nurses who are Registered Mental Health Nurses provide most of the care. There is also an attending psychiatrist for the unit. The nurses provide care for the in-patients, out patients who come to the hospital clinic and people who are ill in the community. There are also community clinics called Zonal Health Centre Polyclinics and a smaller District Hospital in the area.

In Ho there is an NGO site, which is part of a larger organization called Cross Cultural Solutions (CCS). This organization can act as a bridge to the community. Volunteers come here for instruction in language and the culture of the region. The director and the staff then place volunteers in appropriate venues for the volunteer's skills. They have a close working relationship with the man who serves as the CEO, the main surgeon and internist for the regional hospital.

In addition to the regional hospital there are other modes of traditional healing in the area. The director of CCS would be available to connect an interested physician with these settings as well. Volunteers have visited these sites in the past and have been able to learn about traditional healing practices there.

With some forethought there are many projects that could be done which would be helpful to the community. In addition the venue would certainly provide a wonderful learning experience for any psychiatrist interested in international health.

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Jordan (Bill Pirl, MD)

I was invited to give two lectures at King Hussein Cancer Center in Amman, Jordan. The Center was having an International Neuro-oncology Workshop focusing on high-grade gliomas. I was asked to speak on the psychiatric complications of CNS tumors and caring for families of patients with CNS tumors.

King Hussein Cancer Center was formed about one year ago under the direction of Sumir Khleif, an oncology researcher from the NCI who returned to his homeland of Jordan. Dr. Khleif has been trying to bring the Center up to western standards of cancer care and has recruited many US-trained physicians originally from Jordan to work at the Center. The Center takes care of both adults and children. The Center is divided into disease management teams, the most organized of which is the neuro-oncology service.

Although medical care is not socialized in Jordan, cancer care is free at the Center. The royal family has contributed to the development of the Center in memory of King Hussein,who died of lymphoma.

The Center has a psycho-oncology service that consists of a psychiatrist, a psychologist, and a social worker. The service provides both inpatient consults and outpatient care. Dr. Jamal Khatib is the psychiatrist. Unfortunately, he was at Memorial Sloan-Kettering Cancer Center when I was at his center, but I met with him in NYC a few weeks after I returned to the US. He is open to collaboration and we are planning on extending two of our survey studies at MGH to include King Hussein Cancer Center.

Although the staff of the Cancer Center were inspiring in their dedication to providing the best possible care to their patients, there were still some striking differences in care--most notably the lack of informed consent for procedures. Jordan, however, is still one of the most medically sophisticated countries in the area.

The King Hussein Cancer Center would like to strengthen its ties with well-known academic medical centers in the West and would be happy to collaborate and/or have physicians visit their programs. The Cancer Center does not seem very well-endowed and funding for visits may need to be grant-based. (They received a NCI training grant that allowed them to put together the workshop I attended.) Almost all of the medical staff speaks English, but I do not think that English is as common in the patient population.

Anyone who is interested in King Hussein Cancer Center is more than welcome to talk with me. Dr. Khatib would be the best contact about psychiatric opportunities, but I could also give contact information for Dr. Khleif the CEO and Director of the Center.

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Mali (Ilana Braun, MD)

I’m back safe and sound after an exciting honeymoon in Mali, a country rich in cultural diversity, warmth of its citizens, and arts, if not in its Western psychiatric acumen. Thank you for offering me the very interesting reconnaissance assignment. I wanted to put down my thoughts while they were still fresh, and look forward to discussing with you further in person.

First a little background: Mali is quite a large country geographically (about the size of CA and TX combined), home to 10.5 million people. Due in part to an extremely high birth rate (the second highest in the world) and in part to a lack of Western medical resources, nearly half of the population is under the age of 15-years and life expectancy hovers around 47-years. The world’s third poorest country, it has a GDP of only 4.79 billion and an average annual skilled worker’s salary of $1560.

The country boasts a total of 50 inpatient psychiatric beds, all in Point G Hospital, a sprawling general hospital and teaching institution situated on a bluff on the outskirts of Bamako, the nation’s capital. The cost for a two to four week stay is ~ $30 and is normally absorbed by the patient’s family. Psychoactive medications in frequent use there include typical neuroleptics, tricyclic antidepressants, as well as occasional risperdone and sertraline. Other medications are deemed too expensive and talk therapy is nonexistent. The facility also accommodates up to 15 new outpatients per day (it is not clear whether other such outpatient facilities exist elsewhere but the doctor with whom I spoke didn’t think so).

My husband and I were fortunate to visit the psychiatric ward, although only the high acuity portion. The small shed-like building was dilapidated and filthy. Upon entering (there were no locks on the front door), we were both given starts by what appeared to be a fast-talking head mounted on an interior wall. Closer inspection revealed several heavily barricaded cell doors, each with tiny apertures, through which one manic patient had managed to wedge his head. An empty chamber similar to the one he occupied evidenced hard surfaces, shards of broken tile, and the dried remains of smeared feces. The single staff psychiatrist was unfortunately at a funeral during our visit, but the contact information for his coverage, a general internist is Dr. Joseph Traore, Tel: 00223 637-26-88.

The State Department website reports that, outside Bamako, psychiatry is “nonexistent.” According to the Western-educated owner of our tour company, the majority of Malians - whose religious affiliations range from Muslim (90%) to Anamist (6%) - believe that both mental illness and developmental disability are manifestations of past transgressions or evil. Many afflicted individuals are ostracized from their communities. While in Mali, I learned from a fellow traveler of an anthropologist, Katherine Dettwyler, whose fieldwork in Mali dates the 80’s. In her expose, Dancing Skeletons, she apparently reports that deformed newborns are left outside their villages after dark. They usually disappear by morning and the villagers believe that they have been transformed into snakes.

For the psychiatrically ill outside Bamako who do receive treatment, management is limited to traditional medicine. My husband and I visited the stall of a traditional healer in Djenne, a mud-brick market town (and UNESCO site) dating back to 300 CE. The shaman, whose wares include ostrich knees, baobab leaves, and alligator skins, offers manic, depressed, and psychotic patients a leaf and animal hide mixture to burn. The inhaled fumes he believes to be curative. If the Department of Agriculture might have let me in the country, I would have purchased some of the concoction to show you. Instead, we will develop the pictures we took.

In Dogon Country, a beautiful region populated largely by cliff-dwelling Animists, my husband and I visited the Centre Regional de Medicine Traditionelle (CRMT), a Western-style red brick building with an herb garden in its central courtyard. Begun in the late 80’s as a cooperative between the Italian government and several Malian physicians, the institution aims to research traditional medication for “the benefit of the Malian people.” The Italians pulled out of the venture in the late 90’s and only two Malian physicians remain (they are now funded by the Malian government). I was disappointed to learn that the research is purely descriptive (i.e. if patients and traditional healers believe certain remedies to work, that is proof enough), a far cry from double-blind placebo-controlled trials. The facility sells prepackaged, purified traditional medications and I bought a packet for sexual dysfunction (the closest to a psychiatric indication that they offered) to pass on to you. A chief ingredient is sea salt. The contact information for one of the researchers is Moussa Tembely, MD.

Who receives treatment and who doesn’t? My anecdotal observation is that in the few wealthy villages (i.e. those with a steady influx of tourist dollars), physical deformity, developmental delay, and mental illness appear to be readily tolerated. Along well-trodden tourist routes, children with physical deformities, developmental delays, and apparent behavioral disturbances frequently greeted my husband and me requesting, like the healthy children, a gift or money. In poorer villages (i.e. the ones we happened upon when a former Peace Corp volunteer requested we deliver a package or when our driver came down mid-route with malaria), such afflictions were notably absent. Our guide may have had it right when he commented euphemistically that, “in Africa, only the hardiest survive.”

Both the doctor at the Point G Hospital and the traditional medicine researcher would be interested in further dialogue with the international medicine division at MGH. I am fascinated by the region, suspect that other countries in West Africa (i.e. Ivory Coast, Liberia, and Sierra Leone) claim even fewer psychiatric resources, and am very much invested in helping in any way I can.

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Navajo Reservation (John Roseman, MD)

I spent the month of February 2006 in the small town of Crown Point, NM, which on the vast Navajo reservation in the Four Corners area. Crown Point has a small general hospital with an emergency room, but no psychiatric unit. During my month there, I would attend the daily morning sit-down rounds of the entire MD staff and a few nurses. I would then participate in outpatient intakes with the one staff psychiatrist at the hospital. Typically, he would have two intakes scheduled per day, but the no-show rate was very high. I would then sit in on therapy sessions with him and his outpatients when the patients were comfortable with me being present. I would occasionally be asked to do psychiatric consults on the inpatient medicine unit or in the emergency room. Every other week the staff psychiatrist and I would spend an afternoon at one of two high schools in the area, where he would run a clinic for the students. Weekends would be free for exploring that beautiful part of the country. The hospital offers free housing (in a furnished 1970s-era trailer) for visiting medical students and residents. One highlight of my stay was attending the monthly Navajo rug auction that takes place in the town, at which fantastic rugs can be purchased directly from the weavers co-op.

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Pakistan (Batool Tauseef Kazim, MD)

So I am back after a truly life changing experience !! The magnitude of the disaster is in-describable! I can have a presentation ready which I can assure you will be moving and not leave any eye dry ! This was such a humbling experience and I realized that there is a huge role for me to play for multitude of folks. I had to improvise on my lectures, basically translating into Urdu and holding interactive sessions, which were most useful with doctors, medical students and survivors.

Please check out my friend Annie's web site for her blogs and photos of the trip. She is a Psychiatric Nurse and musician who came with me along with her husband Larry: www.anniewenz.com.

We did group therapy, including her live flute playing, aroma therapy, using pure essential oils and guided imagery, where I helped the survivors create a peaceful/happy place. The responses from teachers, survivors, children, doctors, volunteers etc. were simply overwhelming. We were being called angels of hope and peace. Most folks had not smiled or seen hope until then, or at least that was the feedback they gave us.

We were treated like VIP's on our return back to the capital Islamabad, and then I also had the privilege to meet with President Musharaf at the President's house.

Dr. Chaudhry was very gracious and understanding that I could only accommodate Lahore for one day, having spent most of my time in the Northern earthquake zone. We did do teaching and sessions with staff and patients there.

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St. Lucia (David J. Borrelli, MD)

Thank you for your interest in hearing more of my trip to St. Lucia and the volunteer work available.

St. Lucia has a population of 150,000 people, and with health care provided at one private hospital, one public hospital (St. Judes in Vieux Fort) and an equivalent of a state mental hospital, Golden Hope in the capitol, Castries (approximately 120 beds).

St. Judes Hospital is a small community hospital, operating on a shoestring budget, but well thought of on the island. The Medical Director, Sylvester Francois, M.D., is from St. Lucia, medically trained in Cuba and is a terrific person. The Coordinator of Volunteer Services, Mr. George L. St. Jour, is a 55 year-old retired school principal, also St. Lucian, who directs a significant volunteer program. I came to know him through two colleagues, both ophthalmologists, who volunteer their time and that of their residents to the program. The psychiatrist at St. Judes, in the southern part of the island, is R. G. Swamy, M.D. is a very likeable, knowledgeable young man who trained in Bangalor, India. His colleague in the north, Dr.Srikumaron Sambisam (aka, Dr.Kumar ) at Golden Hope, trained with him in India, and works with a Cuban psychiatrist who staffs the Golden Hope hospital.

St. Judes has a history of medical students in their last year who participate for periods of four to six weeks, as an elective in Medicine. Two students from St. George Medical School, London and one from Wales were present. There is also a physician and his nurse/wife who are volunteering for one year, and a number of specialists who consult for periods of 1one to two weeks per year.

There is opportunity for volunteerism and training at St. Jude's Hospital. There is work to be done in the way in which psychiatric crises are managed in the community (the police are not trained well in dealing with psychiatric emergencies), and the newer antipsychotic and antidepressant medications have only been recently introduced. Both Drs. Kumar and Swamy are very involved in the community healthcare outpatient clinics in more rural areas. Dr. Kumar at Golden Hope has an interest in medical informatics, and his efforts approach heroic as he deals with a very ill population with few resources.

Should anyone wish to speak to me regarding opportunities with St. Jude, I would be happy to speak to them. I anticipate returning there sometime in the next year.

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Thailand (Ravi Hariprasad, MD)

Please click here for Ravi's Thai trip report.

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