There is only one psychiatry

“There is Only one Psychiatry Treating Children in Ethiopia.”

Born in Gojam, northern part of Ethiopia, Atalay Alem (Prof.), married and a father of two, is among few Ethiopians specialized in the field of psychiatry. Graduating from Addis Ababa University in 1983 in medicine, Atalay first worked as a junior medical officer and later as a medical director at Adigrat District Hospital. A year later, he joined Amanuel Hospital, the only psychiatric hospital in the country where he gained three years of experience in mental healthcare. Soon after, he received training in clinical psychiatry at Victoria University of Manchester, UK.

Nine years later, he attained his Ph D. at Umeå University in Sweden. After returning to Ethiopia, Atalay worked for tof Amanuel Mental Hospital as a psychiatrist for many years and then as a medical director of the Hospital for six years before joining Addis Ababa University as an Assistant Professor in 2000. He also led the establishment of the College of Health Science as a separate and autonomous entity under the auspices of Addis Ababa University a decade ago.

Beyond that, he is among leading researchers in Ethiopia in the field of mental health, focusing on the epidemiology of mental disorders in rural, urban, semi-nomadic and isolated islander communities, childhood disorders, and child labor. Many credit him for his relentless efforts over the past three decades in raising the accessibility of mental health services and research in Ethiopia.
Being a principal and co-investigator of the Butajira Mental Health Project gave him an opportunity to lead one of the largest community surveys in the world for major mental disorders. In doing so, his project identified the course and outcome of over 68,000 cases of schizophrenia and bipolar disorder to improve treatment.

Just a month and half ago, Alem was honored with the annual Harvard Award in Psychiatric Epidemiology and Biostatistics for his lifelong contributions in the field of mental health in Ethiopia and worldwide. EBR’s Samson Berhane sat down with the experienced scholar to learn about the existing state of mental healthcare services in Ethiopia.

EBR: The level of attention given to mental health is very low. People with mental illness are usually segregated in society. Budget allocated to the prevention and treatment of mental illness by both federal and regional governments is insignificant. How do you evaluate this?
Atalay: Compared to other health related complications, mental illness is overlooked. The health system adopted from down to top did not give much attention to mental illness and its consequences. However, the Ministry of Health, in its latest annual conference to evaluate health services across the country, seems to have given more attention to the matter, compared to what has been in the past. During the conference, there were panel discussions related to mental illness. We have also discussed what should be done in the future to tackle the problem. Yet, considering the extent of mental illness in the country, this is not enough.

Do you think there are enough health facilities that provide services to people with mental illness at a lower level?
If citizens encountered any health complications, they are first advised to go to health centers. If the health center is not in a position to cure them, they will be referred to hospitals. However, in the case of mental illness, this does not seem to be possible. First of all, people with mental illness are usually discriminated against by the society. With the lack of awareness about the illness, even people with such complications who go or are taken to health centers cannot get proper service as there are no professionals specialized in this field. Even at the hospital level, the service given to people with mental illness is not satisfactory.

In the case of referral hospitals found in regions, for instance, although there are few professionals specialized in this field, they don’t have the capacity to treat mental illness. This forces people with mental illness living in rural areas to come to Addis Ababa to be treated at Amanuel Hospital. This shows that the regional health bureaus give low attention to the illness. Even when the MoH assigns graduates who have the ability to treat such illness to regions, the health bureaus usually decline such offers as they think it is less important. As graduates specialized in such fields become unemployed, regional health bureaus which do not allocate enough budget for such matters seem to misunderstand the growth of mental illness amongst the society. Meanwhile, mental illness patients suffer from lack of services in the areas where they live.
Be that as it may, the existing state-owned hospitals that provide services to people with mental illness in Addis Ababa lack important materials and equipment.
As a result, they are not preferred and many believe their success rate is low. On the other hand, similar services provided by private hospitals is very unaffordable for many. Is it not possible to commercialize such services so that it would be available for patients at an affordable price?
It is not an easy task to commercialize such health services in Ethiopia. First, the number of professionals specialized in mental illness and working in hospitals is very low. As a result, the existing physicians can only treat a very small number of patients. This affects the supply of pharmaceuticals and there are medicine shortages. As there is low demand for such medicines compared to others, private suppliers are not interested in importing from abroad. So, it is largely imported by the Pharmaceutical Supply Agency. This, coupled with the high amount of capital needed to pay rent and salaries, investors are not interested in engaging in such medical services. And those private entities, which have joined the sector, cannot provide the service at a low price as their expenses is very high.

Are you saying there is no possibility at all to make the service cheap?
There is. The requirement asked by the regulatory body is outdated and is in contrary to what mental healthcare centers should comply to. The standards set by the regulatory body is even higher than what is asked in very developed countries like the USA. A very small room is enough to open a mental healthcare center.

Maybe apart from that, a receptionist who registers patients is required to open such a facility. But for anyone wanting to open a small mental health care center in Ethiopia, a facility with seven rooms is required. The requirement also lists the number of professionals needed. All these requirements are unnecessary in the case of our profession and it is making the mental health care services provided by private entities very expensive and unaffordable.

Have you tried to lobby lawmakers or push the government to change the requirements?
Yes. In association with other professionals, we have tried to push the government to amend the regulation, but to no avail. Our repeated efforts bore no fruit. In Ethiopia, when a certain law is approved, it is drafted by officials who don’t understand the profession and the comments of experts are sidelined. We have asked the government to revise the requirement needed to open a mental healthcare center or facility, but that did not go beyond false promises. This has adversely affected the accessibility of the services to patients.

Meanwhile, efforts are being exerted to make state-owned mental health care centers accessible to as many people as possible. Besides Amanuel Hospital, another one with better facilities is already constructed and has recently become operational in the capital. Of course, hospitals only dedicated to people with mental illness are not recommended in today’s world. It is because, firstly, there is a tendency to discriminate against people going to such hospitals or see them differently. Secondly, if the hospital gives only mental healthcare services, patients won’t get other medical services, if in case they encounter other health complications. Keeping this in mind, I advise mental healthcare services to be provided at any general hospital like any other medical service. For instance, all private hospitals in Addis provide mental health services along with other services. This is a huge improvement from the past. But with the degree of the problem, a lot more must be done to make the services accessible to everyone.

Another problem in the healthcare sector is staff turnover. Medical doctors usually complain that they are underpaid and they are being exploited despite working long hours. Please reflect on this.
Staff turnover is not a problem distinct to the healthcare sector. It is a challenge felt across many industries. It is also linked with the macroeconomic situation of the country.

But since you are very close to the doctors, I believe you will understand their problems more than others who talk about the matter based on hearsay.
It is hard to find a professional who is being fairly compensated based on his/ her efforts. As I explained earlier, this is linked with the economy of the country. It is not only doctors who are being underpaid. This is a feeling shared by many, largely because of the economic situation of the country. I know that there are many doctors who are not even able to cover their monthly expenses. But it should be noted that an adjustment cannot be made only for doctors. Other professionals also deserve the same treatment. But all this depends on the budget priorities of the government and the economy.

Doctors and health practitioners are increasingly becoming users of abusive drugs, like Ketamine and Pethidine—medicines that have emerged as popular choice among young drug users. Does this worry you?
I need data on whether the health professionals who use such drugs are increasing or not. But like anyone, I hear conversations being passed around about the matter. It would have been great if my colleagues specialized in drug abuse were asked about this. Nonetheless, if you ask me why this is happening, it is something linked with the change in characteristics of the community. Doctors or health professionals are no different from the society. They are a part of the society. They have feelings like anyone in the community. It is not surprising to see them being inclined to such behaviors, like abusing drugs.

In fact, they can more easily access medicines and drugs and can even write their own prescriptions. So, it is not surprising to find health professionals consuming such drugs. Some might try and link this with the frustration of health professionals as well as the amount of salary and benefits they get. But that is an erroneous conclusion. Like any person, the doctors may use it to comfort themselves and concentrate, although that will bring unintended consequences. Having said that, whether someone is a health professional or not, drug abuse depends on the personal behavior of the individual.

Mental healthcare services in Ethiopia tend to focus on adults, while the challenges of children with mental illness are overlooked.
This is so true. There is a lack of trained professionals who can treat children with mental illness and related health complications. It requires a different kind of training to give such treatment. We are aware of that. We tried to send some professionals abroad so that they could specialize in the field. For instance, at Tikur Anbessa, we used to have two specialized psychiatrists who received sub-specialty training in providing treatment for children with mental illness. One of them passed away and we now only have one specialist in child psychiatry.

You mean in Tikur Anbessa or all over Ethiopia?
There is only one psychiatry specialist who can treat children in Ethiopia. But for the future, we have already planned to widen our scope and teach such fields. We have already developed curricula. To this end, we are planning to send psychiatrists abroad for training. The trained professionals would then be able to teach others in Ethiopia. In doing so, we are going to have more specialists in the near future.

Many complain that the quality of mental illness healthcare at state-owned hospitals is low. As a result, the recovery rate of patients is low, critics say. There is also uneven quality of service amongst the state-owned hospitals. For instance, some say St. Paul Hospital is better than others. Do you agree?
This is inaccurate information and a misguided conclusion. There is no scientific research proving that some hospitals have a better quality of healthcare service than others. Without this, it is hard to reach to such a conclusion. It is possible to compare healthcare centers or hospitals in regards to number of staff, professionals or facilities as there is available data in this regard. It is hard to compare patients’ recovery rate without scientific research.

How about patients’ experiences? Does that not count?
It is hard to generalize using comments of two or three patients. Such conclusions should be made after research conducted using scientific methods.

But services provided by state-owned hospitals have poor quality.
This is a problem seen across the board. Not only hospitals that provide mental healthcare services have issues with quality; but also others that offer other medical services. It is true that there is quality of service issues at state-owned hospitals but this is not surprising considering the number of patients they serve and the size of their staff. For instance, Tikur Anbessa gives medical services that is not given by other private hospitals in Addis Ababa.

In fact, Tikur Anbessa does much more than many other hospitals combined. Whenever private hospitals encounter medical cases beyond their capacity, we know that they refer it to Tikur Anbessa. Some private hospitals refer very complicated medical cases, which may not even be cured in modern foreign hospitals, to Tikur Anbessa, fearing their image would be jeopardized if the patient dies. Having said that, it is undoubtable that there is a long way to go in improving the services provided by state-owned hospitals. But that depends on the budget of the government and the economy. If it is difficult to retain employees because of low salaries and benefits and if it is hard to buy necessary equipment essential for efficient services, then it is obvious that there will be quality issues.

On the other hand, the government claims that health coverage has almost reached 100Pct across the country. But there are still issues with quality and services provided at lower levels (health centers in Woredas and Kebeles) are very few. In this case, can we say provision of health services have improved or reached a point where we can say “100Pct” is achieved?
With regards to accessibility of health services, it is undoubtable that Ethiopia has made huge strides. But there is a lot left to do in improving quality of healthcare services across the country. Staff retention is also another challenging obstacle in the medical sector.

Considering the existing capacity of federal and regional governments, is that possible to do?
That is linked to the economy of the country. The government must focus on productive sectors and attempt to ensure sustainable and holistic economic growth. Without doing so, it is hard to raise the budget of the government to improve hospitals and retain professionals. There must be trainings to improve the skills of health professionals. Additional benefits are also required to encourage health professionals working in different hospitals and health centers.

Hygiene is an important factor in treating mental illness. But that seems to be neglected in state-owned hospitals that provide mental healthcare services.
Hygiene is important for any healthcare sector. Hygiene related problems are not only being witnessed in mental healthcare hospitals. It is a problem observed in all hospitals. First, there is a lack of awareness about its importance. Secondly, the way buildings are being designed and constructed is making it hard to ensure the hygiene of hospitals is kept. Additionally, there is also a shortage of budget to improve hygiene in hospitals.

Talking about designs of hospitals, it seems like buildings of hospitals and other healthcare centers are being constructed without considering the interests of people with disabilities.
True. This is a design problem that must have been solved at an earlier stage before the construction of the health facility. Architects tend to overlook the interests of people with disabilities though it is improving compared to what has been in the past. Compared to the old buildings constructed without considering the needs of disabled people, recent ones are improving and have the necessary infrastructure for people with disabilities.

Some professionals complain that the medicines prescribed by psychiatrists in Ethiopia are not prepared per the behavior of patients. For instance, khat addicts are being given drugs prepared for users of cannabis or heroine, according to health professionals I spoke to. Do you agree?
What you said might be right, but I don’t believe that should be concerning at the moment. In fact, the most worrying issue is the fact that we don’t even have those medicines in hand. There is no problem with the variety of medicines. The big problem is the shortage of medicines, most of which disappear after being imported.

Some of your students say that you prefer speech therapy rather than medication. Is that true?
I don’t advise all my patients to get speech therapy instead of medications. Although speech therapy is the best method, Ethiopia does not have a lot of professionals specialized in this field. It’s true that I prefer to communicate with my patients before giving medications, but I don’t think I am a specialist or an expert in speech therapy treatment. Most people conclude that speech therapy is better than medications without diagnosing the case of the patient. As a professional, I believe the same prescription cannot be applied for all medical cases. It depends on the type of the mental illness or psychological disorder.

Khat has been commercialized for long and is consumed among Ethiopians. Now it is being publicized as a good norm. Considering the growing consumption of the drug, do you think that is a correct move?
I don’t think this is right. I’m aware that many sociologists and historians have different arguments about the benefits of the crop. Some argue it is a base for our social interactions, mentioning that it has been consumed for ages. However, they fail to consider its side effects. Studies that we have conducted show it has negative consequences on health. Although it is a source of income for farmers and it is one of the top export commodities, it has an adverse impact on the productivity of the consumers. It makes consumers make wrong decisions, while affecting their mental state and leading to severe mental illness. Khat can also cause infection on teeth gums, teeth and throat. Lately, however, every issue is deemed to be politicized in Ethiopia. The same is true in case of khat. Some claim that it is the main cash crop around the area where they are born and raised, so they argue that it should not be banned or discouraged. Some even use it to mobilize youths for political purposes. Meanwhile, it is becoming the main factor for various types of mental illness.

The side effects range from depression to not being able to recognize oneself. It causes damage to our heart, teeth, teeth gums, and throat. Khat also increases the risk of high blood pressure. Additionally, it has damaging effects on sperm cells, according to different studies. Khat consumers are likely to develop behaviors such as the tendency to make swift decisions, exposing them to sexually transmitted diseases, like HIV. Although all these consequences of khat are known, further studies still need to be made on the crop and its side effects.

The government should also diversify export items and help farmers find other cash crops as a substitute for khat. I know that khat can grow in a short period of time and bring better revenues compared to other agricultural items. However, the government should work hard in explaining the irreversible negative effects of khat and how it undermines the productivity of the coming generation. Another solution could be decreasing the demand using different measures, such as increasing taxation. Movements launched for the prevention of HIV should be also directed towards minimizing the usage of khat. This shouldn’t be the concern of only the MoH and other institutions must give equal attention to the matter.

Some studies conducted by western scholars indicate that racism is caused by antisocial personality disorder. Do you think the resurgence of ethnic extremism in Ethiopia is caused by a similar disorder?
I don’t believe that antisocial personality disorder is in any way associated with ethnic extremism in the case of Ethiopia. However, in a country where racism and radicalism prevail, people with antisocial personality disorder tend to be more in number. This is because they are less aware of their actions and are not thinking rationally. Likewise, some people’s actions in Ethiopia are manifested by group behavior and mobs. This is irrational and most follow such causes without knowing the consequences and the rationale of their actions.

In Ethiopia, every issue is now being ethnicized. Is there any remedy for this in your profession?                                                        As a professor of psychiatry, I believe the trust among our society has been eroded for a while now. Although this has existed for long among our society, trust is at its lowest at the moment. Lack in trust coupled with ethnicization of politics is endangering the existence of Ethiopia as a country. This is like fire and grass. If there is no trust among us, a community cannot exist. Most Ethiopians believe that they will win if they only use force, kill and take the property of someone they differ with.

Forcing others to be beneath us has been considered as being the characteristic of heroes. Even the traditional ways of expressing ones strength by performing “Fukera” and “Kererto” can be mentioned as examples of forceful ways of resolving problems among Ethiopians. Even historians give an exaggerated image of Ethiopians. They mention Ethiopians as if they are different from other human beings, while intentionally overlooking our shortcomings and bad values. That false image paves the way for harmful deeds and values being passed from generation to generation. I am not saying that we don’t have good values like kindness, hospitality, and caring for one another.

Ethiopianism has been wrongly perceived as a sign of superiority for generations. I have travelled to almost all African countries and I never witnessed other Africans who like Ethiopians, consider superiority and revenge as signs of heroism. We are still arguing over what happened 100 or 200 years ago. We are attempting to accuse today’s generation for something done by their forefathers. That is wrong. Unless we stop considering revenge as the only mechanism to resolve our differences, we won’t find a solution to our problem. All in all, Ethiopianism must be reconstructed and we must work on enhancing our positive values, while denouncing the bad ones.

8th Year • Nov.16 – Dec.15 2019 • No. 80

Samson Berhane


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