Visiting the Only Mental Health Facility in Burundi

November 26, 2009

I am visiting a fellow trainer of Nonviolent Communication this week in Burundi, another country in East Africa. Burundi, a small country surrounded by Rwanda, Tanzania and Democratic Republic of Congo, is about the size of Massachussetts and has a similar population of 8 million, about a million more than Massachussetts.. Like Rwanda, there is a long painful history of conflict between the Hutu and Tutsi populations of Burundi during the 20th century a result, in part, of differences between the groups fostered by the Belgians and Germans starting in the late 1900s as a way to encourage submission to their authority. Over half a million have died in various genocides during the past five decades, including over 50 members of the extended family of my host, Jean-Baptiste Ndirukiyo. He says there is essentially no family in Burundi untouched by genocide. It is one of the 10 poorest countries in the world with a Gross Domestic Product of $400 a year. This compares with a GDP of about $47,000 for the United States which, I was surprised to discover, puts us at about sixth highest in the world (depending on which ranking you use), behind Qatar ($86,000), Luxembourg($82,000), Norway ($54,000). Singapore ($51,000), and Brunei ($50,000).

In today's Burundi paper I read that 63% of the population is “sous-alimentation”, or underfed. I also read articles about domestic violence and about a man whose home was bombed and who may lose a leg because he had changed political parties. It seems that the long history of political and ethnic violence may be associated with violence in other ways in the culture. My first day in Burundi I went to the local phone store of the major carrier to get a Sim card for my phone. The number of people waiting to get served was larger than I have encountered in other African countries and it was also the first time that I observed people pushing their way in front of others, not respecting a queuing system. They did this so aggressively that I was extremely uncomfortable and had some feelings of hopelessness about ever getting served. Both my host and I became a bit more aggressive ourselves in order to maintain our place in the queue and I noticed that I was very unhappy about doing this, much preferring a greater sense of mutuality and order in handling such a situation.

Knowing of my interest in Psychology, this morning Jean-Baptiste took me to visit the only psychiatric facility in the country. We spoke with the Administrative Director who was very kind, taking his time to show us the facility and to answer our questions. It was also helpful that his English is quite good. Kirundi is the local language and, like Rwanda, French is the language of instruction in the schools. Given my own limited French and the less limited but still somewhat weak English of my host, communication has not been as comfortable as I would like. This reminds me of how much the ease of my trip has been supported by the greater prevalence of English in the countries I have visited. A dear friend of mine (Carolyn Keys) from Pendle Hill, the Quaker retreat center where I lived in 2008-9, spent two years living in Burundi promoting trauma healing from the genocides through the Alternatives to Violence Project . The language challenges I have encountered would stimulate such a strong feeling of isolation in me that there is no way I would want to do that.

The facility has 100 beds to serve the population of 8 million. Last year the facility also served 5,000 out-patients at the main facility in the capitol, Bujumbura and an additional 8,000 in 5 outlying provinces at satellite clinics. There are only two psychiatrists in the country, one of whom is not doing psychiatric work; one is associated with this facility which includes 2 psychologists, 3 psychological assistants and 5 doctors. The facility also serves people with physical ailments only which, the Director told me, has the desirable effect of not leading to social stigmatization for people receiving treatment at the facility because they are known as having a mental illness.

People stay for brief periods only at the facility, being re-integrated into their home communities typically within a matter of weeks. There are only two very long-term patients at the facility. The major diagnostic categories that are recorded in a recent report are schizophrenia, bipolar disorder and psychotic disorder.

I asked one of the psychologists about tools used to assess the patients and he referred to the Rorshach (ink blot test) and showed me 3 sets of puzzle pieces which appeared to be the only parts of the Wechsler Adult Intelligence Scale that the facility owns.(The Scale has quite a few sub-tests for meaningful interpretation.) He said that he works with documents about the patient and especially values being able to observe interactions among the patients as a way to get information about the abilities and challenges of each person. When I asked about the types of therapies used, I was told that many receive medication while on the ward, but that they are less able to get medicine when they are discharged, for reasons of cost, especially getting to and from a clinic from a distance away. The psychologist referred to their use of individual, group and family therapy. I was not able to get a clear picture of the theoretical approach that they use in their work. He said that the patients raise different topics in discussions and try to support each other by sharing their experiences and talking about their fears. Something called work therapy is frequently used and the Director hopes to add a facility for music therapy. As we walked in the wards the patients frequently approached us and started talking to me, the only white person around. I couldn't understand what they were saying to me in Kirundi (one guy did say he loved me in English) and no one seemed to be eager to give me any detailed translations. I was told that sometimes they were asking me for things or to help them.

I thought it was very interesting that even patients categorized with severe mental illnesses are essentially cared for in their home communities, just having a brief intervention in a residential facility. When I looked at the Massachusetts mental health web-site for purposes of comparison it talked about the efforts to de-institutionalize mental health treatment and have people live in their home communities. Is Burundi ahead of the United States in this regard?

One more note – even though the national university is turning out graduates with degrees in clinical psychology (I am not sure at what level) the Director was unaware of any psychologists providing private services or any other mental health care in the country.