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Letter Two


The Rains are due and there have been one or two false starts. The dust and heat in contrast to the deluges when I have been here during the season emphasise why it is “The Rains” rather than our British preoccupation with whether it is raining or not. There have been severe hail storms nearby – yes, hailstorms on the Equator. Uganda is on a plateau starting from 1000 metres and rising to over 5100 around its borders. It isn’t only French vineyards that can have their crops stripped by severe hail.



The psychiatric staff tell me that they have seen an increase in acute illness and re-admission of patients with chronic illnesses. There has been a shortage of psychiatric drugs since last November – now there are none. This, combined with poorer nutrition as the Dry Season continues, is leading to decompensation. When the government hospitals run out of drugs, it may be possible for patients with money to buy the drugs from pharmacies in town. There has also been a strike over unpaid wages in the hospital. The ward is part of Gulu Regional Referral Hospital and admits children as well as adults. Sheffield Mental Health Trust has an established program with the unit and has just helped the staff designate and prepare a specific room for children and their parents or carers. The role of carers in hospitals is crucial here. They provide the food for their family member. If you do not have an attendant, you will receive a bowl of porridge in the morning and rely on the generosity and kindness of the other patients’ carers if you are to eat more. A surgeon tells me on a visit to the surgical ward that his research is showing that delayed healing in wounds, which was thought to be caused by infection, show major pathology attributable to malnutrition rather than pure infection. There are insufficient funds to provide food: if the hospital did provide food, the anxiety is that they would be overwhelmed by people seeking admission – but I wonder how does a nurse, including on a psychiatric ward, contend with performing their role in a situation where one’s patients may simply have no food?


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Dr Okello James and I went to the SOS Children’s Village together. Surnames appear first in Uganda so I have become known as “Professor Adrian” which somehow feels more comfortable here where politeness and deference are the norm, but where the enormity of what people are grappling with is humbling. James has identified training funds to work with the Director, Sarah. From our discussion, a two-pronged approach emerges. I had suggested that monthly Work Discussion Groups could be a mechanism for James and his colleagues to learn more of the challenges of the [House] Mothers as well as giving a forum for sharing between the Mothers alongside support and teaching from the mental health team. I explain that it is a model frequently used in the UK and I agree to write a brief paper for them. In addition, James will provide 3 training days / year with the topics arising from the content of the work discussion groups.


Our first training day in January last year had identified the importance of supporting the Mothers in the face of sometimes difficult behavior and coping with the emotional impact of the work. On my last visit, Sarah had arranged for me to give a half day session, at very short notice, on the topic of the impact of the children upon their carers. I did manage to avoid feeling overwhelmed and useless in thinking about what the Mothers face on a daily basis: my experience in the children’s clinics and discussions with local colleagues is that a psychodynamic appreciation is useful to them in a very fundamental way. But would this translate from those locally with a tertiary education across into a group some of whose members may have had a minimal formal education?


I had used some rather “clunky” [as described by a UK colleague] animated powerpoint slides to give an introduction to Transference, Counter-transference, Projection and Projective Identification. I was lucky: there were no power cuts that afternoon. If the French Revolution had been delayed until the 21st century, the cry would certainly have been “Liberte, Faternite, Electricite”. With Sarah’s excellent facilitating, the session had progressed from there to discussion of the Mothers’ experiences and to consider some of the specific areas of difficulties which arose for them. The feeling at the end of the session had been good and the generous expressions of gratitude felt more than those which would come from politeness and protocol. This was confirmed when Sarah asked me to plan this next session to begin with the ‘diagrams with the black bits’ as a way of recapping. We arranged that she would discuss with the staff about what other topics they would like me to have in mind.


Sarah had also let me know before I travelled that she had been approached by an NGO to have discussions about their work. She had included me in the communications with them indicating that she hoped I would be able to join the meeting: I thought it was probably an implicit question of helping think about whether there could be a productive link as well as building on my ‘bridging’ function with the child mental health service. That meeting is tomorrow, to be followed by the training session with her own staff the following day….


Adrian Sutton

Gulu. March 2014


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