ooperation In Mental Health: an Intallan Project In Nicaragua , Saraceno

Cooperation in Mental Health: An Intalian Project in NicaraguaAuthor(s): Benedetto Saraceno, Fabrizio Asioli, Alessandro Liberati and Gianni TognoniSource: Caribbean Studies, Vol. 21, No. 3/4 (Jul. - Dec., 1988), pp. 91-100Published by: Institute of Caribbean Studies, UPR, Rio Piedras CampusStable URL: http://www.jstor.org/stable/25612949 .

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Benedetto Saraceno, Fabrizio Asioli, Aiessandro Liberati, Gianni Tognoni

Cooperation In Mental Health: an Intallan

Project In Nicaragua

ABSTRACT We report on the experience acquired over the last four years

developing a program of cooperation in Mental Health in Nicaragua. The philosophy of "transfer" which inspired the program and the

general framework of Nicaragua's Mental health system is discussed

together with the results of the cooperation activities including a

training for mental health workers in six teaching and supervision modules, a mental health manual for primacy health care workers, an

epidemiological survey of the practice of the 15 existing psychiatric services. Besides discussing the key aspects of the general reform of the psychiatric system after the revolution the paper focusses on the differences between organization and patterns of care seen in urban and rural areas. The traditional psychiatric concept of post traumatic stress is criticized.

Introduction

Over the last few years health has increasingly become one of the main focused of the attention of the international community for two main reasons

- it has proven a dramatic indicator of the quality of the North-South

relationship - it is one of the areas where the medical and lay public opinion of the North appears to feel more explicitely a kind of moral obligation to do

something for the deprived population of the South

Although help and assistance are the most common attitudes, they may often underlie a precise ideology which sees the North-South relationship in terms of a North bending over the South with compassion, and trying to

adopt and simplify its sophisticated knowledge and technology to fit the limited capacity of reception of the underdeveloped partner. Such an

attitude is evident in most cooperation programs, even if the adoption of the classical "small is beautiful" approach often gives positive sound and appearance to the intervention. The restrictive interpretation given in most

(1):



92 CARIBBEAN STUDIES, 21:3-4, 1988

instances to the WHO policy of essential drugs is possibly the clearest

example: what is stressed most often is the fact that a limited number of

drugs must be chosen to cope with the very limited resources, while the accent of the original definition was, and still is, on the affirmation that a few drugs provide an adequate scientific answer to the majority of the needs of the population (2).

The thesis we want to maintain in this paper can therefore be formulated as follows:

1) the process of knowledge and technology transfer must be regarded as an intensive research project: the organizational and cultural

constraints of less-developed countries impose a rigorous conside

ration of what is transferred. The models, and the instruments of

psychiatry, become therefore an object of research through, (not before or after), the cooperation process.

2) in the specific case of psychiatry the North-South relationship may best be seen as a very productive and revealing contribution of the

South to the understanding and the practice of psychiatry in the North:

the encounter with a psychiatry which is framed in proverty reveals the

poverty of psychiatry. The transfer process corresponds to the disco

very that the package that is "naturally" available for exportation (the one which is routinely used to think and to practice psychiatry) is a sum of a series of "assumptions" far from being scientifically validated. The result of this research attitude is the rediscovery that

psychiatry is a cross-roads of doubts, which extend to theory, tools,

practice (3-5);

3) the logical process which led to the "essential drug concept" proves to be perfectly applicable to psychiatry. An essential approach declares the reality as a permanent object of experimentation. It also

implies the verification of whether, how, and with what results the

variables related to the health structures, patients needs, and

intervention tools interact in the concrete field conditions. The poverty of the situation imposes a monitoring and surveillance, attitudes where

the adoption of epidemiology as framework of any routine activity (6

7) becomes mandatory;

4) along the same line, Primary Health Care' (PHC's) link to psychiatry does not appear and option but the obvious "conditio sine qua non" for a psychiatric strategy assuming the continuity and not the

fragmentation of care as its most appropriate reference framework (8 10).



MENTAL HEALTH IN NICARAGUA 93

The transferrability of these Statements into practical actions will be better seen through a review of the experience acquired over the last four years in

Nicaragua, where the circumstances of the development of the health care

system and the country as a whole have created an unique situation of interest for psychiatry. We anticipate that at least some of the lessons we learned there could be of broader interest for other countries and could

ease interactions between developed and less developed countries in this field (11). 2. General framework

The Somoza dictatorship had left to the victorious Sandinists-led popular revolution of 1979 a dramatically simplified heritage (12). Apart from a rudimentary circuit of private care for the very few who could afford it, psychiatry was concentrated in one structure, the national

psychiatric hospital of Managua where three psychiatrists were in charge of 400 in-patients of whom 132 were chronic (more than five years of

institutionalisation). The custodial model in its full expression was the rule, with patients definitely cut off from their environment and extensive use of all the traditional concentration tools (physical restraints, electroconvulsive treatments, intensive use of pharmacological sedation), with no rehabilitation programs. Psychiatry was distinct from the health care system (13). In the early months of 1980, drastic modifications were already on the

agenda of the Ministry of Health, where an ad hoc department was set up, and priority was given to the observation of psychiatric care models of other countries as a basis for a reasoned planning of the new system. The model of care which is progressively emerging pivots on decentralization of care into 15 community mental health centers, activation of the resour ces of general hospital as referral centers for emergency, avoidance of

long term psychiatric hospital stays, a substantial proportion of chroni

cally institutionalized patients having been discharged over the last four years and relocated at home (14-15).

3. Background, objectives, methods The basic difficulty in the development of psychiatric care as outlined

above lays clearly in the limitation of specific skills available in the country. Of the few psychiatrists in practice, even fewer were willing to

accept a profound revision of their established role and methods. There was no tradition of decentralized work, in an interaction closer with the community than with the hospitals.

According to the overall philosophy of the Nicaragua health care system, a team approach, with no strong hierachical relationship, had to be favou red. As can be seen we tried to pivot our intervention within the general




framework of the health policy. The characteristics of the poverty and war were largely ignored in favour of the other characteristics, the

atmosphere of social mobilization and creative enthusiasm in the fields of health and education.

We chose in other words to work in a framework where the stress problem and risk conditions were, together with the poverty and war, the general condition around which the country was implementing its project.

This choice characterizes other projects in Nicaragua and the conceptual framework of many analysis: the Essential Drugs Program developed by

WHO and the Nicaragua Ministry of Health has been developed taking into account and stressing the "context wich certainly reflects exceptional external political, economic and military pressures'^ 6) but at the same time the fact that Nicaragua is "an example of what should be done towards Health for All by the Year 2000": the unfavourable conditions created by the aggression must not hide the favourable context offered by the Nicaraguan Unified Health Service (SNUS) (16-18).

In the words of Halperin and Garf ield: "in just three years, more has been done in most areas of social welfare than in 50 years of dictatorship under the Somoza family... these changes in housing, nutrition, sanitation, and education and the developments in health care that we have reported point to a broad and profound change in the nature of Nicaraguan society" (19).

A two year field training plan was accepted by the Ministry of Health, after a feasibility evaluation. The initial minimal funds were obtained through the cooperation of a few Italian solidarity groups, before the project could enter the WHO supported areas of interest (the total cost of the 4 years project was 44.000$; WHO Office participating with 7.000$). The goal was to expose all the psychiatric teams in the fledgling care network to intensive 2-3 weeks courses run by members of the research group in close collaboration with national representatives of the mental health sector.

A small number (five) of mental health workers had also the opportunity of spending 1 -2 months in selected Italian psychiatric institutions to gain direct experience which the organization of the services and to obtain

documentary material for pre and post graduate teaching. The search for and verification of the "essential" are based on supervision of the team's

practices and comparison of the principles with the data collected in a pilot epidemiological survey of the practice of the 15 services involved.

4. Results and products 4.1 Training

Training was successful and has so far involved 60 mental health workers in six teaching and supervision modules. Because the project was mainly




care-oriented, and to strenghten the basic non-hierarchical organization of the psychiatric work, a team approach was in fact adopted. The mem

bers of each team (generally one doctor, one psychologist, two social

workers, two-three nurses) attended and worked jointly in seminars

addresing six main areas:

1) theoretical and practical understanding of the relationships among diagnosis, prognosis, treatment, outcome;

2) emergency and crisis;

3) rehabilitation strategies; 4) psychopharmacology;

5) team work methodology and its implications for structural

organization;

6) need and feasibility of the adoption of epidemiological instruments in routine practice.

Through many revisions and comments the teaching material used in seminars has progressively grown into a formal text (20) which was revised and approved by the Ministry of Health and distributed not only to mental health services workers and to those in the Psychiatric Hospital but also to emergency departments of general hospitals and, after a short seminar, to primary health care centers (it is interesting to note that these seminars were led by local mental health workers). The manual is one of the few texts available as an essential training tool in psychiatry in Less Developed Countries that has not been translated from another language and - even more important

- is not an "import" from an established world of

thought into a fledgling system of care and values (21). 4.2 The study on services and patterns of care

The survey was conducted in the first half of 1986 and results presented and discussed at a national 3 days seminar attended by all the project participants who where thus given the opportunity of comparing their training and practical experiences. While detailed presentation of metho

dology and results can be found in another paper (22), we report here of the essential of the survey.

A census of all existing services conducted; Managua's pshychiatric hospital was excluded. Information on structural and organizational aspects, care actitivies and professionals' characteristics (age, sex, spe cialty and weekly working hours) was collected. Participation was exce llent as it is shown by the fact that in only one out of 15 existing services

data could not be collected because of mental workers refusal to cooperate.




Patterns of care were studied by reviewing diagnostic and therapeutic care given to a sample of "new cases", (i.e. patients first seen by each

participating services independently on whether they had or not a

psychiatric history). Information on personal characteristics (age, sex, financial resources), referral mechanism, psychiatric history, reason for

attendance, symptoms at first visit, diagnosis, type of treatment prescri bed, drug type, dosages and schedules, data of follow up visit was sought by one mental health worker in charge of the study in each service. Standardized questionnaires and a simplified version of ICD 9 (field tested

during the pilot phase to integrate standard terminology and jargon used in the country) were used.

From the point of view of general policy the survey confirmed that an

important shift in care provision from the Mental Hospital in Managua to the 15 community-based centers had occurred. This was also confirmed by the finding that no patient was admitted to the mental hospital during the index month in which the survey was carried out.

From the point of view of the services geographic distribution however important inter-regional differences emerged. Most services (n=8) were in

fact located in the Capital's area where only one third of the population lives. Somehow related (though any causal hint can only be hyhothesized) to this uneven distribution of facilities is their different pattern of contacts with patients. Where more services were in operation in fact we found a

greater proportion of "old" cases (i.e. patients with repeated contacts with

them) while in rural areas, where services were quantitatively and qualita tively understaffed, the proportion of contacts with "new" (i.e. patients not

yet known as psychiatric cases) was far higher. Quantitatively the old

cases/new cases ratio ranged from the median value of 11 (range 4.9-2.0) in urban areas to that of 6.7 (range 3-12) in rural areas.

As for patterns of patients care, only a short comment on the few

findings seems worthwile (Table 1) refering to differences in patterns of care between urban and rural areas.

While patients seen at rural services were, in the aggregate, youger than

those cared for in urban facilities other differences emerged in terms of

reasons for visit and related diagnoses indicating that a picture consistout

with "minor psychiatric disorders" was more frequent in urban services.

Finally, drugs prescription pattern showed same inconsistencies still in

urban services where antidepressants were prescribed with a frequency

largely in excess to that one would have expected looking at diagnosis distribution.




TABLE 1 Essential findings of the pattern of care study with particular reference

to the urban/rural differences

Age % -30 yrs

Income sources

% Self supporting % Family supported

Reasons for visit1

% Family confict

% War related problems

Symptoms % With anxiety and/or depression

Diagnoses % With neurotic depression2 % With schizophrenia

Prescription % Of antidepressant

Urban areas

43%

69% 27%

19% 9%

57%

28% 4%

34%

Rural areas

57%

45% 49%

12% 18%

44%

13% 11%

14%

1 The probability of family conflicts was doubled (Relative rish (PR)=2.0,95% Confidence Intervals (Cl) 1.09-3.8) and of war-related problems halved (RR=0.4, 95% CI-0.23-0.92) in urban services.

2 This difference corresponded to a 70% increased probability (RR=1.7,95% CI-1.1 -2.7) of this diagnosis in urban services.

5. Discussion The experience which we described for Nicaragua represents a situation

many aspects of which may be classified as original, interesting, if not

unique for the discussion of the relationship between a stress, a society, and psychiatry.

The country represents and summarizes what can be expected from the interaction of different types of Stressors: a two generations long and most

repressive dictatorship, a state of war which has gone on for years, the structural condition of a very poor developing country.

Because of its smallness, the country may be the object of a comprehen sive observation to allow the epidemiological evaluation of the interplay between the needs of the whole population (not only of subgroups) and the overall project of a public health policy (23).

With the obvious exclusion of the "standard" and most of the times hidden acute pathology which is expected to occur within the army, what has




been observed in the pattern of care study can be legitimately considered the full psychiatric expression of a "stressed" society, and the overall

response given to it. Confronted with these facts, the model of psychatric attitude and intervention which has been offered to, and even more which has been developed within the above framework, is the result of a research

hypothesis generated not to respond to the "specific" request of a "spe cial" condition but to the intrinsic exigencies of the rationale presented in the introductory section: psychiatry as a scientific discipline has proven to be "poor"

- in so far as it sticks to an approach based on the separation between the technical understanding and management of psychiatric

problems and thorough revision of the significance and role of psychiatry as a theory and as a way of looking at the interaction between health care and society.

The "experimental" results of the exposure of the Nicaragua society to the comulative challenges listed have been observed and read therefore from two angles: - as indicators or descriptors of the profile of a particularly stressed

society, to be compared with what could be expected and described in other less or similarly stressed populations;

- as windows into the understanding of the more basic interactions between psychiatry as a science and society as the object of such

science, between psychiatric problems as sentinel events of disease and societal processes and the general project of a society where the events take place.

The sketchy epidemiological profile which has been obtained in the survey is easily readable with the criteria which can be used to describe and

interpret standard epidemiological descriptive studies: urban psychiatry is different from the rural one, a gradient of problems and interventions is found between the more developed and complex urban setting and the

simplified, less developed non-urban environment: similar to what some

studies have documented to happen between more and less developed countries.

The same data however can be consistent with a different interpretation a

definite and dramatic overall stressing situation expresses itself more

intensively and traditionally in terms which closely mimic "our"

psychiatry, where the overall project of the society is absent or diluted or

perceived with a high degree of ambiguity. Where the cumulative exposure to stress would be expected to produce its more dramatic results, psychia tric pathology is at its lowest point of expression. The expected "stress losers" appear to be "psychiatric winners".




That is, the observed differences between town and country in the peculiar

Nicaraguan setting suggest that an emotional surrounding positively charged with personal and ideal meanings is crucial to coping with stress. A strong, positive personal emotional-drive may be the coherent response to and consequence of a strong collective ideal drive.

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307: 388-392, 1982. 20 Saraceno, B., Asioli, F., and Tognoni, G. Manual de Salud Mental. Ministerio de Salud,

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BIOGRAFIAS *

Benedetto Saraceno, is a psychiatrist, head of the psychiatric unit at "Mario Negri" Institute for

Pharmacological Research in Milan (Italy). He has done extensive fieldwork in training men

tal health personnel in Nicaragua and Costa Rica and has been advisor of Nicaraguan Mental Health Authorities. He is author of a Manual of Mental Health, in Spanish, for primary health, care workers. He serves as consultant to many governmental and international agencies in matters of health care for the mentally ill. He is the Mario Negri Institute representative on

the Board of the Italian WHO Collaborative Centre. * Fabrizio Asioii is a psychiatrist, head of the Outpatient Psychiatric Services of Reggio Emilia (Italy).

Consultant of Italian health agencies for mentally ill, he has been involved as senior scientist in

the Nicaragua project. His main areas of interests are psychiatric services, organization and

management of psychiatric emergency. *

Alessandro Liberati, had his M.D. degree in 1978. He spent a two-year training period inn the US

at the Department of Epidemiology of the Harvard School of Public Health. His main areas of

interest are health services research and health program evaluation, and in these areas he is

presently involved in several studies in Italy relative to the evaluation of quality of care in on

cology, in treatment programs for people with drug-addiction problems and in psychiatry. In this framework he has been involved in the training program in collaboration with the Nicara

guan government reported in the paper with the specific task of designing and conducting the epidemiologic survey.

* Gianni Tognoni, is the Head of the Laboratory of Clinical Pharmacology of the "Mario Negri"

Institute in Milan, Italy. His interests in the field of drug investigation are documented in more than one hundred scientific articles and cover pharmacokinetics, drug epidemiology, and

controlled clinical trials. He has been a member of the WHO working group on essential drug

(from 1977 to 1981), and WHO consultant in various field missions in Latina America, African,

and Arabian countries.



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