Male inpatients in pajamas wander aimlessly across a football field-sized courtyard where patches of green grass grow despite the dusty red soil and merciless sun. Other patients sit and stare all day, some wearing chains around their ankles to prevent them from escaping. Many women pass their days braiding one another’s hair under a dark overhang that protects them from the scorching equatorial sun.
Only a handful of overwhelmed doctors staff this 360-bed hospital — not surprising given that the entire country of 75 million people has just 17 psychiatrists and 190 psychiatric nurses.
Earlier this year, two psychiatric residents from Massachusetts General Hospital traveled to the Addis Ababa hospital as the first participants in a program set up by the hospitals to ease the burden on Ethiopia’s doctors and to help teach the country’s newest psychiatry residents — all three of them.
Dr. Karen Ron-Li Liaw and Dr. Eric Achtyes, both fourth-year psychiatry residents at Mass. General, spent two weeks in Ethiopia in January while it was under threat from neighboring Somalia, which it had just bombed with US help.
Ethiopia remains one of Africa’s poorest countries. Almost two-thirds of its population is illiterate. Like much of Africa, the country is beset by AIDS; international health agencies estimate that as many as 1.3 million Ethiopians are infected with HIV and that up to 130,000 die annually from the disease.
“When you’re faced with starvation, when you’re faced with war, when you’re faced with HIV/AIDS not being addressed, you’re going to have some very tragic manifestations of mental illness,” said Achtyes, 32. “That’s part of why we’re here and why we want to be here.”
As the Mass. General doctors walked around Amanuel Hospital, groups of patients followed them, touching them, asking for money. The doctors toured the dormitory-style rooms, observing patients sleeping in seemingly endless rows of neatly made beds spaced just 12 inches apart.
In one bed lay Janie, a refugee from Burundi who suffers post-traumatic stress disorder: Her entire family had been killed during that country’s civil war, including her mother and sister, who were murdered in front of her. She had not left her bed since her arrival two weeks earlier.
The next morning, class began with the Boston doctors practicing a few phrases in the native Amharic language and discussing social customs, such as whether divorce is acceptable in Ethiopia (it is becoming more common).
The Boston doctors’ main task for the next two weeks was to teach the critical first step of psychiatric diagnosis — the patient interview and the mental status exam. Liaw and Achtyes taught the students how to elicit important and often intimate details from patients who in this conservative and deeply religious society — predominantly Orthodox Christian and Muslim — avoid talking about taboo subjects such as sexual history or drug use with anyone, never mind an unfamiliar doctor.
“It’s like you’re trying to fill an endless bucket,” said Liaw, 29. “There is a gaping hole in terms of resources, but it’s a valiant effort to be establishing this program. “
Last year, Addis Ababa University graduated its first class of psychiatric residents, nearly doubling the number of Ethiopian psychiatrists.
Dr. Atalay Alem, who helped to start the postgraduate program at Addis Ababa University, said: “This is the beginning. It’s small, but it is a major step for mental healthcare service in Ethiopia.”
One of the biggest challenges is showing Ethiopians that mental illness can be treated with proper medication and therapy and that they should seek care from medical professionals.
This was not obvious even to one of the new Ethiopian psychiatric residents, who attends “holy water” sessions with her family. “Holy water” or “spiritual healing” sessions are a common form of medical treatment for thousands if not millions of Ethiopians. People wade in or drink special water that they believe helps remove evil spirits possessing their bodies and causing their illnesses.
“It makes you calm, it gives you a kind of spiritual cleansing,” Dr. Miheret Tamirat said of the water treatments. “It does work. There are different kinds of possessions — the priests know the kind of possessions that can be treated with medicine versus holy water and will send people to the medical doctor sometimes.”
Liaw and Achtyes traveled to an AIDS support clinic for women where they spoke with many patients who had been ostracized by their families for fear of catching the disease. The two wanted to meet for themselves the women who had been doubly stigmatized because of AIDS and mental illness.
One woman, who was eight months pregnant and did not want to give her name for fear of people learning of her illnesses, sat nervously in a classroom full of young mothers holding their babies. She was secretly attending her twice-weekly “Mother to Mother” class, a new program where women with AIDS learn parenting skills. The classes are held in a health clinic that is so protective of its participants’ privacy that there are no signs on the doors, no class pamphlets, no sign-up sheet — nothing to indicate that such a meeting even exists.
For the 31-year-old, living with HIV means battling the extreme depression that accompanies the disease. “When they told me that I’ve got HIV, the first time I heard it, I was thinking to commit suicide. I was really nervous and I was so depressed, so that was my plan,” she said.
Because of her religious devotion, she would not have considered seeking help at Amanuel or another psychiatric clinic for her suicidal thoughts.
She has not told her husband about her illness, even though she said he infected her with the virus. “If he hears it, he might throw me out of the house and I will be left on the street,” she said. “I wanted to wait until I’ve had the baby.”
A recent study by an Ethiopian psychiatrist found that at least 30 percent of all HIV/AIDS patients suffer from mental illness . These AIDS patients suffering from mental illness often have a lack of regard for themselves, then behave recklessly and spread the disease. So treating their mental illness can have a significant ripple effect.
Back in Boston and at work at McLean Hospital recently, Achtyes reflected on his trip and the contribution he tried to make in Ethiopia.
“The hardest parts for me were seeing so many critically mentally ill patients all in the same place,” he said. “And only the sickest are ever brought in by their families for treatment. It’s overwhelming to think about the countless others who suffer without ever receiving treatment of any kind.”
