Acceptable and Unacceptable Norms

Today I had the opportunity to speak to one of the psychiatrists on the mental health unit.  After briefly welcoming me to the team, he candidly elaborated on the ward’s operational deficiencies; overmedication of patients, under qualified mental health workers prescribing and administering medication (including injectables), absence of standardized professional ethics and protocols, and ultimately insurmountable budget constraints.  It does not require a Master’s degree in public health to confirm some of the points he listed.  I had noticed within a few hours of reporting for duty that the clinic was in bad shape.  There were several large holes in the ceiling, the inpatient quarters were filthy and poorly equipped and the proverbial rubber rooms or safe rooms looked like old jail cells.  The psychiatrist further relayed that visiting NGO’s from overseas had exasperatedly asked him, “What are acceptable norms and what are unacceptable norms to you?”  As an outsider, it is easy to castigate the clinic for providing substandard care.  However, knowing the realities of Uganda’s fiscal landscape, it is surprising that the clinic is operational at all.  Psychiatric clinical officers, psychologists, nurses and mental health attendants collaborate to offer a much needed therapeutic outlet to the community.    On an ordinary day, our unwelcoming waiting room is crowded with patients waiting to see clinicians or waiting to have their prescriptions refilled.  In addition to the overwhelming client load, the mental health workers are presented with cases that are clearly medical in nature.  Medical teams who are frequently beyond capacity refer their overflow to us without prior medical screening.  This is how a patient with a lesion on his brain can end up being diagnosed with a conversion or mood disorder.  Despite these limitations, valuable services are being provided everyday; a former LRA abductee receives psychosocial rehabilitation and counseling, an 18-year-old sexual abuse victim is admitted to the ward and can temporarily escape her tormentor, a 21-year-old student who feels alienated from her family can openly admit that she has been harboring suicidal ideations.  Weighing the positives and negatives, it is difficult to arrive at what are acceptable or unacceptable norms.  Would it be more ethical to deprive people of all care to avoid improper care?  As a PhD candidate in International Psychology, I am keenly aware of the role of ethnocentrism in our evaluations of non-western scenarios.  The psychiatrist confirmed this when he went on to ridicule NGOs who come to Uganda to train working mental health professionals on how to detect and identify trauma.   Circumstances beyond a Ugandan professional’s control tend to negatively influence our perception of their competence.

At the end of our discussion, the doctor asked me, “Now be honest, would you feel comfortable having a family member or friend admitted to this ward?” Diplomacy aside, the honest answer is no.  Not because I feel that they could not benefit from the unit’s counseling services, but because I feel that nobody deserves to be housed in squalor.

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