In the 3rd week of my placement, we attended a field trip which provided the opportunity to shadow a psychiatrist in his day-to-day role. We travelled the 9-hour journey to the region of Kilinochchi, twice the size of Colombo and only 5% of its population. It is an area made up of rural farming land, jungle and small villages and Doctor Jagen, our mentor for the day, is the only qualified psychiatrist in the district.
Health care in Sri Lanka is free but an estimated only 10% of those who need, use it. For areas like Killinochchi, access is difficult due to location (many areas are only serviced by 2 buses a day and can be as much as 60 miles away from specialised services). The prevalent income for people in this area is farming and fishing so for many, visiting the hospital would cost them a day’s work. There is tremendous stigma here and the belief in the supernatural power of God as a healer supersedes the willingness to engage with doctors. Everything is ‘out of their hands’ and most who seek help do so in the form of rituals from temples and local healers. Dr. Jagen, the psychiatrist we shadowed, explains these struggles noting that the free services are available but not used. He gives us an example case study:
Let’s say a man in a family has schizophrenia, he receives psychiatric help and returns home with medication seemingly ‘cured.’ The family are grateful to God for him getting better and he will never return to the clinic for follow up. The attitude is that he is cured – ‘why should he sit between two mad people?’ ‘Why should he take pills for mad people? He is fine now.’ Typically, there is a relapse 6/9 months down the line and they approach the doctor again and this cycle repeats.
The challenge is to keep them in this context which is very difficult due to poverty, lack of education and stigma. The attitudes toward mental health here are firmly rooted in Karma with the belief that ‘crime is crime,’ and any circumstance is ‘almighty’s verdict.’ The person should live with the disability as his punishment and hope for better in the next life. Dr. Jagen explains that this belief makes providing health services very difficult. He says that education is necessary to improve things but that modern modes of communication e.g. newspaper articles, TV interviews are not appropriate or effective within these rural populations.
To tackle this problem he has worked hard to recruit like-minded volunteers from these small communities to go door-to-door and talk to people and help improve their understanding. He trains them as Community Support Officers to find people who have psychiatric admission history and those who are in need.
In the last 2 years he has been working with local leaders, medical facilities and schools in communities to find accessible places to set up clinics to help educate and provide mental health support. Currently, he is running an incredible 22 drop in clinics with up to 700 people visiting a month all with extremely limited resources. Here, he provides quick one-to-one appointments to diagnose and prescribe medication as well as carrying out general health checks e.g. taking blood pressure.
We shadowed Dr. Jagen on his outreach visit to a small jungle-village hospital where he expected some 40 patients. Here we observed his appointments as he carried them out and he would turn to us and translate and explain his reasoning for his decisions. He tells us that psychiatry here follows the British medical system, “it is because of Queen Victoria that I wear a shirt.” Everything is recorded in English – meaning that most clients don’t understand their medical records, diagnosis and medication – on paper. There aren’t the resources to digitally record and the areas are very prone to power cuts, “this is what works.”
I was struck by the high prevalence of Schizophrenia diagnosis and the high involvement and reliance on family. Family members and friends are present during the individual’s appointment, often talking on their behalf or listening in, showing the enormous sense of community here and perhaps a sign of growth in understanding. In many instances, a family member is sent in place of the patient to advocate and collect prescriptions if they can’t make it – typically due to farming or religious commitments.
By 11.30 he finishes up here and we follow him to an extremely remote men’s elderly home situated on a farm set up and run by the local community. Here, Dr. Jagen describes himself as a Geriatric Doctor, again demonstrating the vastness of his skills. There are no nurses, doctors, social workers or OT and Dr. Jagen describes feeling as though there is much more that they need that he cannot provide. Most patients were found homeless after leaving or being rejected by their families, he notes here that Kilinochchi subsequently has a low presence of beggars on the street. Despite conditions and lack of resources, I was humbled again by the strong sense of community. Most of the men were born and bred farmers so they felt at home and those who were able could continue work on the land surrounding. Dr. Jagen explains that being a Hindu community, they are vegetarian and can eat from the land and anything they require can be asked of the local community by donation, sometimes even approaching his own wealthier patients.
The Kilinochchi field trip was hugely informative and quite emotional, it allowed the opportunity to meet people and hear their stories, suggest input and ask questions throughout, an experience unlike anything we’d be able to be a part of at home. It is an inspiration to see the work and impact Dr. Jagen is continuing to make. The approach here is heavily rooted in the medical model and without the education and resources for therapeutic intervention, medication is usually the first port-of-call. I found this difficult to see but understand that Sri Lanka is developing and feel humbled that by being part of SLV not only are we contributing to improving the well-being of the people we work with, but also helping to impact attitudes surrounding stigma by using alternative methods that can facilitate recovery.