in2mentalhealth

This is the start of a new series on this in2mhconnect website, the ‘Global mental Health Inside Stories’. In this series I want to collect and spread information/ideas from people active in mental health from all over the world and specially from low resource settings or fragile countries.
I hope this series contributes to more insight in the challenges and wishes from people active in these settings and adds to a more bottom up movement in global mental health.
Dr. Jibril I.M. Handulah, physician practicing mental health in Borama, Northern Somalia, is the first who is willing to share his insights and experiences with us. Which is fantastic, given his busy schedule.
Dr. Jibril Handulah’s answers on 10 interview questions are as follows:

Work location and some background information:
The Borama mental health clinic is situated in Borama Regional Hospital which is teaching hospital of Amoud University College of Health Sciences. Amoud Medical School was the first medical school in Somalia after the collapse of Siad Barre regime in 1991. Undergraduate medical and nursing students needed a mental health clinical rotation and this led to the faculty at Amoud to establish mental health clinic in Borama under my leadership and in partnership with Tropical Health and Educational Trust with academic and technical inputs from several psychiatrists in the United Kingdom.
I graduated from medical school in Somalia in 2009 and within two months started my clinical internship in the Borama teaching hospital and at the same time selected to be Mental Health Representative (MHR), a position that is supported by volunteer psychiatrists from King’s College in London. This college delivers mental health courses and exams in two medical schools in Somalia.
As the MHR I co-teach with psychiatrists, take part in exam settings and established mental health services in their places of work. I was the first doctor in this scheme who agreed to set up a mental health clinic with outpatient, inpatient and community based mental health. Currently I work with 2 doctors, 3 nurses, 10 female community health workers and a senior psychiatrist from Sweden who has a Somali background.
I have particular interest in addiction medicine, service development and delivery in mental health and academic psychiatry.

Brief country profile:
Somalia is a country located in the horn of Africa and is known for its chaos, instability and recently for its piracy and terrorism. The country has no strong central government for 22 years now.
The country has an estimated population of 10 million. It is divided into three administrative regions Somaliland, Puntland and South-Central. In September 2012, the country had its first internationally recognized government in Mogadishu. The Northern region self-declared republic autonomous region of Somaliland is a breakaway region and is in negotiation with the central government of Somalia. Al-Shabab militants are on the run in the southern Somalia.
Our country remains one of the poorest and most fragile states in the world. Somalia was singled out for its nature, but over the last two decades regarded as a failed state. This is reflected in the Somalia’s performance in every metric on human development. From the UNDP Somalia Human Development Report 2012 for instance: 82% of the population in Somalia is poor (75% in Puntland and 72% in Somaliland), Somalia is ranked 165 out of 170 countries in the Human Development Index, 54% of the population is unemployed and life expectancy at birth, according to the WHO is 48 for males and 52 for females.

Overview of work activities:
Borama Mental Health Clinic started in May 2011, funded by the THET, as an outpatient unit and a community outreach project in schools, prison, to primary health care units in the town and in maternal mental health wards.
By Mid-2012, Borama diaspora community and the Amoud university raised enough fund to build a 26 bed unit with an outpatient unit in Borama Teaching Hospital.
By June 2012, the clinic started to receive inpatient and outpatient patients.
By November 2012, the Amoud University and the Somali Swedish Research Association (SSRA), represented by a Somali Swedish psychiatrist who works at Karoniski Institute in Stockholm, Sweden, won a one year project from ForumSyd. ForumSyd is a Swedish international NGO in partnership with SIDA (Swedish Agency for International Development) in meeting the Millennium Development Goals number 8.
Our clients include school students, teachers, prison guards, Borama community members, hospital patients and all the patients in Awdal region in Somalia. We reached at least 3000 patients for direct treatment and counseling support and became a site to support psychiatry rotation of Amoud medical and nursing students.
Amoud Mental Health Clinic has been actively involved in several scholarly publications. One paper in Intervention reflected on my personal experience in setting up these services in Somalia (article behind pay wall) and one in Academia about the services in the schools (free download). There are several research papers either in press as the one in American Journal of Psychiatry on the establishment of the mental health ward and others.
I am editor in chief of the Amoud Medical School newsletter and a member of European Association of Science Editors for a year now. My academic interest also includes psychiatry research in Somalia.

The main challenges personally in work/study/life:
The biggest challenge for me is to get postgraduate training in both neurology and psychiatry. There are other challenges including social security with living standard which are so poor in Somalia. And I see a big threat in the brain drain in this country if this is not addressed well.

The main challenges for the organization(s)/colleagues/clients:
Main obstacles are sustainability, human resource and the financial limited capacity. Colleagues are discriminated against simply because they work in mental health which apparently affects people who would like to practice psychiatry. For clients, poverty is the main thing as most of them can’t afford medications to maintain their health.

The main challenges for the country regarding mental health care:
The biggest challenge, I think, is the reduced number of health care professionals interested in mental health practice in Somalia or have the clinical training in psychiatry, psychiatric nursing, occupational health or social work. There is a new faculty of social work in Hargeisa university which is quite encouraging. There is big need to train junior doctors in the country in mental health and neurology.

What should be changed in mental health care on a local or national level:
I personally believe that mental health advocacy and financing should be increased in Somalia. I would like to see that the Ministry of Health puts mental health and non-communicable diseases in their strategic plans at each administrative level.
Without higher level training in mental health it will be difficult for patients to get top quality care from their care providers.

What is the right direction for the global mental health movements:
The right direction is putting mental health on the agenda of global health. And to make it possible for departments in the developed world to develop exchange programs for those in the global South. This in order to transfer skills and sub-specialty practice like addiction medicine, child psychiatry, etc, to those who practice in the world’s remote areas.

What can ICT, mhealth and e-learning contribute to mental health care:
I witnessed how mental health e-learning has contributed as an end-user, and as a leader in the organizing of the teaching services.
As a doctor, I have been involved in e-learning in mental health since 2010. I have been coordinating mental health distance learning program for Somali interns, medical students and nurses through MedicineAfrica. This is a instant messaging based system with which clinical supervision is given to Somali health care professionals, not only in mental health but in other specialties in health as well.
MedicineAfrica helped me to master my skills in psychiatry as I got supervision from many colleagues at King’s College London, updated my research skills, leadership and service development capacity. It is for both clinical and non-clinical aspects of my pre-specialty training that ICT4MH changed my approach to learning. Recently, I have been involved in MOOCS (Massive Open Online Courses) sessions through Coursera too.
So e-learning is a powerful tool in education for those of us practicing in fragile states.

Other links and contact information:
Dr Jibril I.M. Handuleh, MBBS
Candidate, MSc Psychiatry, Addis Ababa University Psychiatry program, 2014
Amoud University School of Medicine
Shacab Area, Borama, Somalia
Email: djibril@amouduniversity.org
Personal website Dr Jibril Handuleh
Phone: 002522634453324
Dr. Jibril Handuleh on LinkedIn

With many thanks to Jibril Handuleh
Roos Korste, psychologist, international trainer and blogger.