Psychiatry in Jamaica

For 200 years, white slave masters forced black African slaves to labour on the plantations in Jamaica. Slavery was officiallyabolished in 1838, although slave masters became the new employ ers, and harsh work regimes and low salaries tended to continue a pattern of established cruelty. The period of slavery has influenced life in Jamaica into the twentieth century, including the care of the mentally ill. Hickling (1993) suggested that mental illness was tolerated by the African community, but was intolerable to the British, and that mentally ill slaves were fre quently incarcerated in cellars by their owners. In 1962, Jamaica became independent. It has a population of 2.5 million and is still a developing country. A national survey indicated that only 39% of dwellings had piped water indoors, 52% had a flush toilet and 66% had electricity (STATIN,1990). Among the wealthy minority, a family may spend 2500 Jamaican dollars (Â£50) a week in the supermarket. By contrast, the majority of the population are lower class, and an income of 600 Jamaican dollars a week (Â£10) is not uncommon. During a five-month visit to Jamaica in 1994 collecting data on psychiatric complications of sickle cell disease, I made contact with many of the psychiatrists and psychiatric services in the island.

For 200 years, white slave masters forced black African slaves to labour on the plantations in Jamaica.Slavery was officiallyabolished in 1838, although slave masters became the new employ ers, and harsh work regimes and low salaries tended to continue a pattern of established cruelty.The period of slavery has influenced life in Jamaica into the twentieth century, including the care of the mentally ill.Hickling (1993) suggested that mental illness was tolerated by the African community, but was intolerable to the British, and that mentally ill slaves were fre quently incarcerated in cellars by their owners.
In 1962, Jamaica became independent.It has a population of 2.5 million and is still a developing country.A national survey indicated that only 39% of dwellings had piped water indoors, 52% had a flush toilet and 66% had electricity (STATIN,1990).Among the wealthy minority, a family may spend 2500 Jamaican dollars (Â£50) a week in the supermarket.By contrast, the majority of the population are lower class, and an income of 600 Jamaican dollars a week (Â£10) is not uncommon.
During a five-month visit to Jamaica in 1994 collecting data on psychiatric complications of sickle cell disease, I made contact with many of the psychiatrists and psychiatric services in the island.

Bellevue Hospital
The Bellevue Hospital is the only large mental Hospital in Jamaica.It was opened in 1862 and still houses 1300 patients in huge wards, dilapidated and dingy, linked by a network of open-sided corridors.Here, goats graze, patients sit and wander, and washing is hung out to dry.Almost 10% of the buildings are deemed unfit for occupancy (STATIN, 1992).It is not uncommon to see an out-patient sitting on the grass waiting to be seen, hand-cuffed or with hands and feet bound with rope.Allin-patients pass through the admissions room, where doctor, nurse and administrator sit side by side, each interviewing a different patient or his relatives.The admissions ward is kept locked, but marijuana ("ganja") can be smuggled in through the ever open but barred windows.Against the odds, with limited funding and with fewer than half a dozen junior doctors, the senior medical officer coordinates the provi sion of psychiatric care.Ward staff are enthu siastic and organise activities, and an occupational therapy and rehabilitation unit function within the grounds.However, care is mainly custodial since the closure of a rehabilita tion programme by the government which came into power in 1980 (Hickling, 1993).
There are no acute psychiatric in-patient units outside Kingston and psychotic patients are frequently admitted to general medical wards without specialist psychiatric care (Hickling, 1991).The only psychiatric rehabilitation unit outside Kingston has extremely limited re sources.For example, it is unable to rehabilitate patients in the use of money since there are neither social security payments nor any token financial incentives available.
Admissions to Bellevue Hospital fell consider ably from 136 per 100 000 population in 1971 to 69 per 100 000 in 1988.This has been attributed to the development of community mental health services (Hickling, 1991).Most people with ser ious mental Illnesses live in the community with very caring families.Mothers, daughters and sisters of patients frequently attend clinics, offer support and supervise medication.Jamaicans are strongly kin-oriented.Most women 'father' in addition to mothering their children, because economic and traditional constraints keep 'babyfathers' from fulfilling the provider role, and participating in the upbringing of their children (Sobo, 1993).Traditional constraints on the father date back to the era of slavery when the residential unit on the plantations was mother and children only, with responsibility for their maintenance resting on the slave owner.The father's place in the family was never secure, he had no sanctions over it and at any time could be removed from it.Families headed by a single mother, with father absent, remain a common pattern in Jamaica today.
If a patient becomes estranged from his family, he may find himself on the streets, and from there in a surgical ward following a road traffic accident or gunshot wound.Eventually he may be dis charged to a back ward at Bellevue.For the destitute there is little support.Food stamps are issued under the Poor Law.but periodically new referrals are refused for months on end.

Mental health officers -the backbone of community care
Most adult users of the psychiatric services have psychotic illnesses.A recent island-wide survey using the Present State Examination, a standar dised psychiatric research interview, showed a low incidence of schizophrenia, far lower than that found in Jamaican families in Britain (Hickling & Rogers-Johnson, 1994).Many pa tients with schizophrenia receive psychiatric care and depot neuroleptics at 'Modecate Clinics' run by the mental health officers -general nurses with experience in psychiatry who have com pleted a nine-month course in psychiatric nur sing.They deal with the routine care of patients with psychotic illness, and are the mainstay of mental health care in Jamaica.Some work almost independently of psychiatrists, and in rural areas may Initiate treatment, including medication.They are involved with many aspects of psychiatry, from child mental illness to HIV counselling.They have a huge responsibility, often with inadequate financial resources, and insufficient in-service training to keep up to date with current psychiatric practice.Psychiatrists are few and far between, with less than ten consultants for the entire population.

Substance abuse
Substance abuse, especially alcohol, is a major health problem In Jamaica, and in the rest of the Caribbean (Hickling.1993).Marijuana is cheap and widely used.Cocaine is used far less, but is a recognised problem.Narcotic use is rare.The University Hospital has an eight-bed alcohol and drug detoxification unit.Staff are enthusiastic and well trained by experts from the USA.They work alongside Alcoholics Anonymous, but badly need more dry hostels and half-way houses.Sadly, the unit is too small, and many patients cannot afford the charges of other, private clinics.

Suicide
Headlines in The Gleaner, Jamaica's main na tional daily newspaper, recently reported a four fold increase in rates of suicide (Williams, 1995).These had been estimated to be very low, 1.4 per 10O 000 population, in a carefully devised study of all Jamaicans who had died suddenly in 1975-76 (Burke, 1985).The study also identified particularly low rates in women (0.6 per 100 000), and suggested that the stable environ ment of a traditional society, and in particular a clearly defined female role, act as a defence against suicide.It is not possible to pinpoint the reasons for the recent increase, although there are major changes taking place in Jamaican society, particularly for women.For example, the number of children born per woman has fallen from 6 to 3 in the last 20 years, two-thirds of graduates from the University of the West Indies are women, and women are becoming high achievers in medicine, business, law and politics.Among extended families, it is not a new phenomenon for young children to be sent to grandmothers or aunts when the mother mi grates from the country to Kingston, or abroad, to seek education or employment.However, it was observed in a child psychiatry clinic that children separated from their parents or parent figures tended to have more mood swings, showed anti social behaviour and had lower IQs than those without a history of separation (Wray & McLarren, 1976).

The Mental Hospital Act 1873
Current mental health legislation dates from 1873, with a few amendments made In the last couple of decades.Until 1974, a mentally ill person could be arrested by the police on a charge of lunacy and sent to Bellevue.At the time of my visit, a new Bill had been drafted, but it urgently needed revising.For example, it did not specify a maximum duration of detention, and it stated that a voluntary patient may only be discharged on receipt of a written request and "shall not be kept in a psychiatric facility for more than seven days" from the date the request is received.However, plans for community super vision and a system of review for involuntary patients were included.

Attitudes to mental illness, and the future
I asked several psychiatrists why many acres of unused land at Bellevue Hospital, in the heart of Kingston, are not sold and the proceeds used to fund a community psychiatric programme.They frequently referred to the intense stigma attached to mental illness in Jamaica, and its likely adverse effects on community care.The Statistical Year Book of Jamaica (STATIN, 1992) states explicitly that "Negative public perceptions of the mentally 111 and their potential for productive lives limit interest and support for psychiatric services and a truly comprehensive, integrated psychiatric delivery system".However, stigma appeared far less evident than I had been led to suppose.For example, there was clearly a demand for treatment of minor psychiatric Ill nesses, as demonstrated by the success of the Bethel Baptist Medical and Counselling Centre in Kingston which has a flourishing counselling service.Hickling (1991) suggested that decentra lisation of psychiatric care to the community has already led to a reduction in the stigma attached to mental illness, although it was unclear how this was measured.It is unknown how much traditional beliefs and healing by obeah, bush healers and Church healers have influenced popular attitudes to psychiatry.This aspect of mental health was not explored during my visit to the island.Although no major studies of health beliefs and folk aetiology have been carried out in Jamaica, it appears that bizarre behaviour is considered the main component of mental illness, and withdrawal and depression are excluded.

Financial constraints
Finances for health care are limited.One Jamai can psychiatrist suggested that in a situation of budgetary constraints there is "the sometimes unconscious notion that money spent on mental health programmes could have been better utilised" Grenade.1991).Michael Beaubrun, Professor of Psychiatry in Jamaica, stated in 1984, "There is no dearth of mental health plans in the Commonwealth Caribbean.Indeed the problem is rather a lack of implementation and a tendency to reinvent the wheel" (La Grenade, 1991).Individual psychiatrists practise with enthusiasm, in spite of the lack of facilities.Even at the University Hospital, psychiatric clinics are often cramped with only a curtain separating the patient being interviewed from those in the waiting room.At a health centre outside King ston, the noise from the waiting area through the thin wooden partition and the hum of the old electric fan made it difficult to even hear the patients talk.In spite of the drawbacks, the University Hospital trains psychiatrists for all parts of the Caribbean.The four year postgrad uate training programme includes clinical experi ence in substance abuse and child psychiatry, and a year of research.

Jamaican patients in Britain
This article has concentrated on the public psychiatric services available to the majority of the Jamaican population.Private psychiatric care is also available for those who can afford it.Jamaican patients in Britain may wish to return to their country of origin either for a holiday or permanently.A knowledge of psychiatric care available may be important in making these decisions.
Ethnic minority groups in Britain may also have cultural beliefs both about mental illness and psychiatric services in their countries of origin.These may influence their perceptions of psychiatrists and psychiatric services in Britain and may be among the factors contributing to the sometimes volatile encounters between patients and mental health workers.An understanding of cultural issues, some of which have been outlined here, may be of benefit in managing patients from the Jamaican community in Britain.