Rehabilitation psychiatry: description of a provincial setting in Zimbabwe

Psychiatric services in Zimbabwe are, by African standards, relatively sophisticated and are modelled on the British system. A new patient is assessed using the Maudsley history-taking format modified to suit local situations, and a mental state examination. A physical examination and routine investigations follow. X-ray facilities and basic laboratory work-up such as haematology and microscopy are available at ProvincialleveI. EEG, ultrasonography, echoencephalography, CT scanning and serum anticonvulsant levels are available in Harare and Bulawayo. An account of the mental services in Zimbabwe from 1980 to 1986appeared in the Lancet (Hollander, 1986). The development of psychiatric services in Zimbabwe followed the recommendations ofthe first Pan African conference on mental health in 1961. The application of these guidelines led to a considerable measure of success in Zimbabwe (Buchan, 1989). This account of the rehabilitation of the mentally ill in Masvingo Province further illustrates how a comprehensive and multifaceted service has been implemented in a rural part of the country. Patients are initially assessed at the psychiatric clinic of the general hospital and then placed in an appropriate facility offering care depending on the degree of their disturbance or dependency. Masvingo lies in the south eastern part of the country bordering Mozambique and South Africa. It covers an area of 55,309 square kilometres with a population of 1.2 million. The psychiatric service is run by one consultant, one medical officer (senior registrar), a social worker and several psychiatric nurses. There is a mental hospital with a bed capacity of 300 and a staff complement of about 200. Complicated cases are referred to Ingutsheni Hospital Bulawayo or the Harare Psychiatric Unit. Two other Provinces have psychiatric units (Mutare and Gweru) whereas those without admit to the general wards. As in other African countries, an alternative health care system operates in parallel to the modem sector. Patients use both systems for solution of their problems, thus representing the adherence to cultural beliefs and an explanation ofdisorders incorporating dual causality (Reeler, 1987).'Patients initially visit the traditional healer ("n'anga") before contact with the hospital not only for amelioration of symptoms but also to discover the aetiology of their illness. Mental problems are caused by angry spirits ("mudzimu") of departed family members. Another belief exists that illnesses are caused by witches ("varoyi") who bring misfortune upon people. A similar picture has been reported in Botswana (Ben-Tovim, 1987). Therapy involves use of herbs ("muti"), prayers conducted by "prophets" of various religious sects and other traditional psychotherapeutic techniques. The healers are so successful that they are able to handle mild to moderately ill patients, particularly those with anxiety states and other neurotic problems including relationship difficulties. They are officially represented by a body known as Zimbabwe National Traditional Healers Association (ZINATHA). The role of the traditional healer is acknowledged but little formal contact exists. This is confined to the referral of patients by healers to the hospitals and a few medical practitioners who offer both traditional and modem care. Rehabilitation activities are carried out in the hospitals as well as in the community (Community Based Rehabilitation).

Psychiatric services in Zimbabwe are, by African standards, relatively sophisticated and are modelled on the British system. A new patient is assessed using the Maudsley history-taking format modified to suit local situations, and a mental state examination. A physical examination and routine investigations follow. X-ray facilities and basic laboratory work-up such as haematology and microscopy are available at ProvincialleveI. EEG, ultrasonography, echoencephalography, CT scanning and serum anticonvulsant levels are available in Harare and Bulawayo.
An account of the mental services in Zimbabwe from 1980 to 1986 appeared in the Lancet (Hollander, 1986).
The development of psychiatric services in Zimbabwe followed the recommendations ofthe first Pan African conference on mental health in 1961. The application of these guidelines led to a considerable measure of success in Zimbabwe (Buchan, 1989).
This account of the rehabilitation of the mentally ill in Masvingo Province further illustrates how a comprehensive and multifaceted service has been implemented in a rural part of the country. Patients are initially assessed at the psychiatric clinic of the general hospital and then placed in an appropriate facility offering care depending on the degree of their disturbance or dependency.
Masvingo lies in the south eastern part of the country bordering Mozambique and South Africa. It covers an area of 55,309 square kilometres with a population of 1.2 million. The psychiatric service is run by one consultant, one medical officer (senior registrar), a social worker and several psychiatric nurses. There is a mental hospital with a bed capacity of 300 and a staff complement of about 200. Complicated cases are referred to Ingutsheni Hospital Bulawayo or the Harare Psychiatric Unit. Two other Provinces have psychiatric units (Mutare and Gweru) whereas those without admit to the general wards.
As in other African countries, an alternative health care system operates in parallel to the modem sector.
Patients use both systems for solution of their problems, thus representing the adherence to cultural beliefs and an explanation ofdisorders incorporating dual causality (Reeler, 1987).' Patients initially visit the traditional healer ("n'anga") before contact with the hospital not only for amelioration of symptoms but also to discover the aetiology of their illness. Mental problems are caused by angry spirits ("mudzimu") of departed family members. Another belief exists that illnesses are caused by witches ("varoyi") who bring misfortune upon people.
A similar picture has been reported in Botswana (Ben-Tovim, 1987). Therapy involves use of herbs ("muti"), prayers conducted by "prophets" of various religious sects and other traditional psychotherapeutic techniques. The healers are so successful that they are able to handle mild to moderately ill patients, particularly those with anxiety states and other neurotic problems including relationship difficulties. They are officially represented by a body known as Zimbabwe National Traditional Healers Association (ZINATHA). The role of the traditional healer is acknowledged but little formal contact exists. This is confined to the referral of patients by healers to the hospitals and a few medical practitioners who offer both traditional and modem care.
Rehabilitation activities are carried out in the hospitals as well as in the community (Community Based Rehabilitation).

The district level
Each of the seven districts in the province has a community psychiatric nurse who is the resource person tasked with the treatJIlent of mental illness, prevention and promotion of mental health. The CPN is hospital based and is allocated five beds for admissions. Discharged patients are followed up by the CPN assisted by Rural Health Centre staff. Mental health promotion consists of lectures to school children, fellow members ofstaff, Government and NGO officials. Popular topics include introduction to psychiatry, management of various mental disorders, dangers of alcohol and drugs and stress reduction. A quarterly statistical form is used for data collection giving a breakdown of ICD-I0 diagnostic categories and demographic characteristics. There is a reference manual compiled by a university lecturer to enable rural health centre staffreliably to diagnose and manage common conditions, using an essential drug list/formulary (Chikara, 1988).

The Provincial General Hospital
The Department of Psychiatry based here is run by four nurses and serves Masvingo Town (population 60,(00). The team visit patients at two old people's homes, two prisons, two halfway houses and a school for the mentally handicapped on a fortnightly basis. Once a week, they run a busy out-patients clinic of about 30 attendants per session. Thirty beds have been set aside in the general wards for the assessment and treatment of less disturbed patients who do not warrant transfer to the mental hospital 50 kilometres away.

The Psychiatric Hospital
Known as Ngomahuru, it started as a leprosarium in 1927 run by the Reformed Church. It was converted into a TB sanatorium in 1945. The first batch of chronic mentally ill patients were received from Bulawayo and Harare in 1969 for long-term care.
The modem era in terms of the care of newly diagnosed cases started in 1983 with the appointment of Dr Kazmy, a Pakistani psychiatrist who, with the backing of the then Deputy Secretary -Mental Health, Dr Hollander, established the Acute Unit.
The chronic patients were then divided into a long-stay unit (for functional illnesses) and an adult mental handicap unit (incorporating organic brain syndromes). Since then two Urban Halfway Houses and a Rural Half-Way Home have been set up. It is thus now possible to provide a wide variety ofcare in different settings depending on the patients' needs using any of the facilities in the province.

Rehabilitation activities
The Rehabilitation Department takes patients for woodwork, arts and crafts, pottery and activities of daily living. Those unable to leave the ward take part in ward activities. A patient is given the object made during therapy to take home on discharge. Those who require further r~habilitationare referred to one of the halfway homes. At present a Community Based Rehabilitation Programme exists in one district only. 553

Halfway homes
There are two urban halfway houses in Masvingo Town catering for male and female patients. They live like a family and are supervised by a resident nursing assistant. They stay for four to eight weeks and are encouraged to look after themselves and administer their own treatment. They keep a vegetable garden and poultry. Patients are allowed to venture into the town centre as they regain their confidence.
A Rural Halfway Home has now been opened adjacent to the psychiatric hospital using funds donated by the First Lady, Mrs Sally Mugabe. The emphasis here is on agricultural activities, such as farming, rabbitry, piggery and poultry. On discharge, a patient is given a pair of rabbits to start breeding at home. A hospital board chaired by a local general practitioner provides money for equipment and stock feeds.

The resettlement scheme
There are two resettlement areas about 3 kilometres from the psychiatric hospital. The scheme was established for chronic patients who have lost contact with their relatives but no longer require continuous in-patient care. So far 37 males and females have been resettled in two villages. The Social Welfare Department assists each resident with ZS50 (£12.50) monthly. They maintain their own herd of cattle, goats and chicken. The women are put on injectable contraceptives with their informed consent ifthey are still in the child-bearing age.

Comment
The rehabilitation efforts carried out in Masvingo Province over the last ten years are beginning to show positive\ results in destigmatising mental illness. Already the community'S attitude towards the mentally ill is changing for the better. Resettled patients are now regularly included in joint village activities. More recently the villagers voted for a primary health care and maternity clinic to be built in the grounds of the mental hospital.

Psychiatric aspects of the exchange visit between Bexley Hospital and Centre Hospitalier Specialise de
Ville~Evrard ADRIAN JAMES, UMDS, Division of Psychiatry, Guy's Hospital, London SEI The Centre Hospitalier Specialise de Ville-Evrard is situated 17 kms from the centre ofParis and serves an area of approximately a quarter of the north-eastern outskirts of the city. I visited as one of a multidisciplinary party of 20. The visit took place over five days and returned their visit to Bexley Hospital, Kent in South East England, which took place in November 1989. English lessons take place in the hospital as part of the hospital's responsibility for continued education for its employees and they had initiated the visit to England to improve the standard of their English. The hospital dates from 1868 and at its peak in the 1960s had over 2000 patients, but this number subsequently diminished to approximately 800.

Training ofpsychiatrists
Medical practitioners train for seven years in France and after this they may specialise in psychiatry. This involves working for a further four years as an 'intern' during which time experience is gained in a variety of settings. They do not have large training rotations as seen in the UK. They must then pass state examinations in order to be fully qualified. There is no further training, and research is discouraged outside of specific research posts within the big cities in France. There are psychiatric colleges but they do not set the examination and it seems they compete for prestige and formulation of ideas on psychiatric issues. Practitioners will then work as assistants for a chefde service who is roughly equivalent to our consultant but with more wide-ranging administrative responsibility and powers. Each chef de service covers a population of 60,000 people and will have 13 assistants working for him, along with one intern. Some of the assistants will be part-time, working for the rest oftheir time in private medicine. Overall it works out at eight whole-time equivalent assistants for each consultant. Each consultant provides both medical and psychotherapeutic input along eclectic lines. Many consultants are analytically trained.
The chefs de service are responsible for all adults over the age of 18, including the elderly mentally ill. He or she has wide powers to provide a service as he or she sees fit but is responsible to a unit general manager at the hospital who.is in overall control of many chefs. Once appointed as an assistant is it not usual to change jobs, which are on long-term contracts. Individuals will then decide whether to stay as assistants working full or part-time or to take further examinations to become a chefde service.

Provision ofservice
The large mental hospitals in France are running down their serviCes as community care becomes more developed. The asylums provide both in-patient and day patient care on large wards known as pavilions.