Patient progress in Sri Lanka

Mental Health Nursing,  Mar 2004  by Eliatamby, Niresh

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Sri Lanka is transforming its mental healthcare system with the help of VSO volunteers. It is also experimenting with health groups crossing traditional bboundaries Mental health workforce planners in the UK could usefully study this process. Niresh Eliatamby reports

Ibrahim Latif has been shunned by those around him for most of his 56 years. 'I was at Angoda in the early 1970s, you see,' he says simply. His wife divorced him, and his family moved to another town. For decades, 'Angoda,' a suburb of the capital Colombo, where the country's main mental hospital was located, has symbolised the ostracisation of mental health patients in Sri Lanka. People sent to Angoda were regarded as violent and dangerous to society.

But with few other institutions or doctors treating mental health patients, it wasn't just the serious cases that were sent to Angoda. Those with mild forms of common mental illnesses dreaded being sent there, fearing they would be locked up with the 'incurables.' Patients were dragged, kicking and screaming to Angoda by families who did not want them anymore. Worse, patients who improved and were discharged from the hospital received little or no follow-up treatment in their villages. Often they relapsed and ended back in Angoda. 'I often tried to get a job. But it was difficult because people knew I had been at Angoda. I even travelled to Saudi Arabia and worked as a room-boy in a hotel for four years,' said Latif ruefully.

'It had been the concept in Sri Lanka's mental health service to dump patients in Angoda and lock them up,' says Dr Hiranthi De Suva, the country's director of mental health services. Hardly a solution to mental health problems in a nation that regularly tops the world's suicide rates, where wife beating and child abuse are common, and alcoholism is common. It is impossible to say how far these disorders are related to the brutal 20 year civil war between the majority ethnic Sinhalese and minority Tamils, which has left 65,000 dead and displaced more than a million from their homes. Statistics on the extent of mental illness are unreliable, but state hospitals treat 50,000 patients annually and the number is rising.

'This is the tip of the iceberg. We don't know how many are treated at private clinics and by traditional village healers. Many patients don't seek treatment at all due to the stigma,' says Dr De Silva.

Social beliefs have added to the stigma of having a mental patient in the family, in a culture where many marriages are still arranged by parents. 'My parents wouldn't let visitors see me, because they were afraid that they wouldn't be able to arrange marriages for my two sisters,' said Mohamed Nawaz, 32, a patient whose family lives among the tea plantations of the Central Province. 'They didn't want it known that I had been at Angoda.'

But over the last few years, Sri Lanka's mental healthcare system has been undergoing a steady transformation. Today, Latif and Nawaz arrive by themselves for treatment. But not at Angoda. Instead, they are regular visitors to Sisila, a mental health rehabilitation centre at Delthota, a small town in central Sri Lanka, which is at the forefront of a drive to revolutionise care of mental health patients. Sisila is one of several institutions that have benefited from the Community Mental Health Project, a long term effort by the Nivahana Society, the University of Peradeniya and the Central Province Health Ministry, aided by VSO.

The success of the Community Mental Health Project, which is introducing community-based treatment into Central Province, means it is regarded as a pilot project for the country. 'I believe there should be similar projects in every part of the country and it would be excellent if we could have many more VSO volunteers working with them,' says consultant psychiatrist Dr E K Rodrigo, president of the Nivahana Society. This organisation, which was founded in 1988 by a group of psychiatrists and others, specialises in helping develop services for mental health, disabled people and abused women.

Dr De Suva agrees: 'We have a National Mental Health Advisory Council and a National Plan for Mental Health which recognises that mental health needs to be community based. But the government can't do it alone. We need more expertise and resources, and it would be useful if we could have more VSO volunteers in different regions, since the Ministry of Health intends setting up community mental health centres in each of Sri Lanka's 26 districts.

'VSO volunteers have brought new concepts and ideas to Sri Lanka in the field of mental health,' says Susil Kalyanatissa, assistant medical officer in charge of Sisila, which caters to 35 in-house patients and has fortnightly clinics for hundreds of others. 'It has really made a difference here and my staff of 16 have learned a lot from them, especially the way they handle patients. Thanks to VSO, we now have a three-year development plan, a proper set of rules and regulations for the centre, structured training programmes for new staff, and modern methods of administration.'