My informal orientation meeting with Brother Jimi Hyata, the director of the Comisión de Salud Mental de Ayacucho (COSMA), was interrupted by a clinic nurse requesting that a visiting American psychiatrist attend to a young girl in distress. I joined the doctor and soon saw the first patient of my six–week psychiatry elective in Peru—a short, well–groomed 12–year–old indigenous girl with shiny black hair and deep brown eyes that appeared distant. Her father reported that she had been in isolation for weeks, crying and “hearing voices” that frightened her. Strikingly, the girl told us that she didn’t feel like herself anymore. The doctor and I suspected an early psychotic break and started her on antipsychotic medication with a plan to visit the patient in her home the following morning to monitor her response to this treatment.
Prior to my arrival in Ayacucho, I had encountered numerous novel and challenging situations while completing a rural medicine elective in southern Ecuador sponsored by the Yale Office of International Medical Student Education (OIMSE). This introduction to my OIMSE elective in Peru, however, felt unexpected and unsettling. I wondered how many young people with psychotic disorders there are in Ayacucho, and whether the benefits of treating a young girl with powerful antipsychotic medications would outweigh the adverse effects of sedation, metabolic disturbances, and movement disorders. Moreover, I was intrigued to discover what other mental disturbances I would encounter in this city that simultaneously epitomizes the beauty of the Andes and embodies the region’s darker history of political violence and economic oppression. Having had only six weeks of clinical psychiatry experience under my belt, I had the sense that the two weeks in Ayacucho and the four weeks that were to follow in Lima working in psychiatric clinics and hospitals would truly alter my vision of “global mental health” and address some of my ethical concerns about cross–cultural psychiatry. I wondered whether mental illness manifests differently in foreign settings and how the Western system of psychiatric diagnosis, based on the Diagnostic and Statistical Manualof Mental Disorders, fourth edition, is appropriately or inappropriately utilized in settings that differ socially, culturally, politically, and economically.
The region’s only functioning mental health clinic, COSMA is situated discreetly on a seemingly random street at the bottom of a hill in southern Ayacucho among residential complexes and local eateries. Passing through the clinic’s unmarked wooden door, the visitor sees a bright, open–air complex with clean tiled floors and walls painted with mountain scenery and the complex designs of traditional Andean tapestries. The multi–level clinic contains treatment areas, offices, a pharmacy, an occupational therapy room with looms for producing tapestries and other handicrafts, and an apartment where I was living with Brother Jimi Hyata, a Peruvian psychologist who has been running the mental health clinic since its directorship was transferred to the Brothers of Charity in January 2011.
During the five days that followed, I worked primarily with Alfredo Massa, M.D., FW ’09, a psychiatrist from Lima who completed his residency in New York City and a fellowship in addiction psychiatry at Yale. Together, we saw follow–up patients at the clinic and also spent a half day at the asilo de ancianos (nursing home) in Ayacucho. Working at the nursing home was a unique opportunity that presented a number of challenges related to providing mental health care in a low–resource setting. In a short amount of time Massa and I saw a large number of elderly patients, many of whom were dressed in traditional attire, and we had a limited ability to gather information—many were Quechua speakers, hard of hearing, and/or mentally impaired. Moreover, little background information was known about a number of patients who had either been dropped off by their families or had come in off the street. And, in what is a common practice in many psychiatric facilities both in Peru and in other countries, psychiatric and medical records were kept separately—I often found myself wishing I could see what medical diagnoses and treatments patients had received. Given those limitations, we adjusted patients’ medications based on what we could observe and what the sisters, who cared for the patients every day, reported about their recent behavior and function. Other challenges we encountered resulted from the reality that the nursing home relies on the donated services of various psychiatrists who come from Lima each month. It was often not entirely clear why certain medications had been started or why dosages had been adjusted. Massa explained that psychiatrists often do not want to discontinue or decrease a medication they did not start and it is difficult for any one psychiatrist to follow the effects of their prescriptions. (I later learned that this problem is also common in nursing homes in the United States, where patients may be treated by different health professionals at different times.) Although I found myself wishing we could perform more in–depth evaluations and learn more about these patients’ lives and medical histories, I left feeling reassured that the asilo residents were living lives of dignity and that we were doing the best we could under very difficult circumstances to help maximize their quality of life.
At COSMA, Massa and I saw patients suffering from psychotic disorders, mood disorders, and substance abuse problems. Patients had given good medical histories and we were able to conduct interviews to fill in gaps in their information. For me, these visits were primarily an exercise in trying to understand what was happening linguistically, psychologically, and socially, as I was simultaneously a student of Spanish, psychiatry, and Andean culture. Moreover, working with Massa, whose native language is Spanish, often left me feeling like an inexperienced water skier trailing behind a high–speed motorboat. I was generally able to follow the gist of the interview and usually had the opportunity to ask some questions of my own, both of the patient and of Massa for clarification. It was a positive learning experience as well as a preview of what I would encounter in the Lima hospitals after departing Ayacucho. By the end of each day, however, my mind was certainly stretched to the limit.
In Ayacucho, I was most affected by the younger patients diagnosed with such psychotic disorders as schizophrenia. It seemed like these young patients, like the 12–year–old girl with psychosis, were being robbed of their very personhood by their illness; my interactions with them left me feeling that they perceived a real self hiding behind a mask of mental illness. As a result, they were trapped in a bizarre and troubling world in which functional existence is a perpetual struggle. That said, these patients were engaged in treatment with participation and cooperation from their families. They were not locked up in a cellar or confined in chains like some patients with severe mental illnesses in other parts of the world.
Another striking feature of the patient population at COSMA is the large number of patients treated for alcohol and substance abuse disorders. Ayacucho province, I was told, has a higher prevalence of substance abuse than other parts of the country—a statistic that reflects the political violence and civil war that had plagued the region during the 1980s and 1990s. The destruction of families, an atmosphere of mistrust, and socioeconomic hardship had created an ideal breeding ground for mental illness and existential suffering. Now, 10 years after the end of the violence, the trauma continues to reverberate through the population, manifesting itself in a tendency to self–medicate with drugs and alcohol—anesthetics available to the masses. Unfortunately, these problems have arisen within a context lacking in awareness of mental illness and access to mental health services—problems that affect most parts of the developing world.
At the end of my first week in Ayacucho, Massa returned to his practice in Lima while I stayed five more days working with the clinic nurses, psychologists, and rehabilitation team as well as seeing more of the city and its surroundings. Working in the clinic had been a memorable learning experience, but I found the home visits more compelling. Not only are home visits convenient and free of cost for patients, they are also enlightening from the perspective of a health care provider, anthropologist, and traveler interested in seeing how people from a different cultural and socioeconomic background live. These visits offered me a glimpse into people’s homes, how and where they spend time, and how a family dynamic operates, which is critical in a culture in which extended families often live together in close quarters. Some visits were particularly useful from a clinical standpoint, as we were able to observe how our patients functioned in real life. One patient was too paranoid to work in the family bakery and was reluctant to speak with us in his garden, outside the safer confines of his house. Another patient with schizophrenia was working in construction but experiencing increased auditory hallucinations. On further questioning, we discovered that he was taking far less antipsychotic medication than his prescribed dosage due to confusion arising from having two different formulations of the same medication.
After participating in these home visits for a couple of days, I was convinced of the therapeutic potential of providing health care within the community setting with a team that knows each patient intimately. This strategy not only builds a strong rapport with the patient and their family, but also allows the attenuation of any cultural differences that exist between the psychiatrists from Lima and their rural campesino patients. The holistic understanding of patients and their life circumstances that results enables health care providers to craft treatment plans tailored to each patient’s situation, as opposed to merely treating their psychiatric diagnosis. It also allows the treatment team to monitor a patient’s adherence to medication and obtain information from family members who may not come to clinic visits.
As my time in Ayacucho came to a close, I knew that the intimate and authentic interpersonal interactions afforded by the home visits would remain a highlight of my time in South America. Moreover, these visits struck me as an essential part of COSMA’s model of providing quality mental health care to the rural poor of Ayacucho. Similar to the ways in which such global health NGOs as Partners In Health have shown that the use of community health workers is essential to HIV and tuberculosis treatment programs in developing countries, COSMA’s model of care demonstrates that the success of future global mental health interventions will depend on the provision of community–based, context–dependent, holistic mental health care. In other words, a small number of psychiatrists will have to work with primary care doctors, other health professionals, and trained community members to deliver evidence–based pharmacotherapy and culturally sensitive psychotherapy to people living in situations conducive to health.
While my time in Peru inspired me and helped prepare me to engage in the monumental challenge of such service provision, I left Ayacucho continuing to ponder the dilemma of simultaneously addressing the root causes of mental illness—namely the unrelenting political violence, poverty, and gender inequities that plague countless mind–bodies, communities, and societies around the globe.
Jordan Sloshower, a fifth-year medical student, is pursuing a Graduate Certificate of Concentration in Global Health from the Jackson Institute of Global Affairs. These graduate studies are focused on Global Mental Health and mental health care in post-conflict and humanitarian settings. At Yale Sloshower has pursued a qualitative research project on HIV prevention amongst female sex workers in southern India and completed clinical electives in Ecuador and Peru. He is interested in coupling clinical care with structural interventions in order to diminish suffering related to mental illness and various forms of violence, as well as to promote dignity and social justice. Sloshower is from Winnipeg, Canada, where he completed his undergraduate studies in bioanthropology at the University of Winnipeg. He pursued his master’s degree in medical anthropology at the University of Edinburgh where he wrote his thesis on the struggle for access to antiretroviral drug therapy in such middle income countries as Brazil and India. For more about his experiences in South America, visit http://www.ghjournal.org/jgh-print/fall-2012-issue/on-the-path-to-mental-health-in-the-andes-reflections-from-a-psychiatry-elective-in-urban-and-rural-peru/