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Beating the Pacific blues

Off and on for the past five years the former NZ chief nurse has been island-hopping the Pacific helping nations create mental health policies and services. Fiona Cassie reports.

'Give a man a fish; feed him for a day. Teach a man to fish; feed him for a lifetime" is often quoted when talking about international aid.

But what if the fisherman is too depressed to fish?

Frances Hughes tells a tale of just such a fisherman - actually a fishing boat captain - living in a Pacific nation with no mental health policy, no dedicated mental health service and no budget for mental health drugs. So he just stayed home -undiagnosed, untreated and a burden to his village.

This nation in 2005 became one of the 14 Pacific members of the Pacific Mental Health Network, established by New Zealand's Ministry of Health and the World Health Organisation. Hughes facilitates the network that aims to develop mental health policy, services and clinicians in a region where mental health is often given a scant share, if any, of the limited health resources.

The fishing captain's nation is one of many Hughes has been working with. First facilitating a workshop to kick start developing a mental health policy, then upskilling health professionals working in community clinics and a budget allocation for psychotropic and anti-depressant drugs.

To one of these clinics came the captain - his depression was recognised, treated and medicated and he is back captaining his boat and bringing income to his village.

Hughes points to her fishing captain as an illustration of how allocating aid dollars to mental health provides both a moral and a financial return. She says discrimination and stigma means donors would rather spend their aid dollars on "top of the pops" diseases like diabetes and HIV or on sanitation - all important stuff - but mental health can end up getting nothing.

Hughes as a nurse and academic has long been a passionate advocate for mental health and all vulnerable populations. And as a former Chief Nurse of New Zealand she had already forged links with her Pacific counterparts when in 2004 she was asked by WHO to investigate the state of mental health services in the Pacific. That analysis showed a huge unmet need with usually no mental health policy, little to no funding, few (if any) health professionals with mental health skills, no legislation to protect human rights of the mentally ill and a considerable burden to families and communities through untreated mental illness.

The mental health services that did exist were of the old-fashioned in-patient variety that often meant detention without treatment - sometimes by default in jail, police cells or even shackles.

To Hughes it is simply an issue of human rights - the mentally ill should be able to get the same level of treatment and respect as given to other people with illnesses in their home nation. And with mental disorders making up an estimated 17-18 per cent of the burden of disease in the Pacific the issue of mental illness is not one that can be brushed under the mat forever.

The health ministers of the Pacific responded to the issue by supporting the establishment of the WHO Pacific Mental Health network. The network covers nations as diverse in size as Papua New Guinea and the Solomon's down to tiny island states like Tokelau and Niue. New Zealand's Ministry of Health mental health directorate and, more latterly, the New Zealand government's external aid fund, gave funding support to get the network underway and to employ Hughes as its part-time facilitator.

Hughes points out that New Zealand "punches well above its weight" as an international advocate for mental health with it currently being the fourth biggest donor for mental health aid in the world.

She also expresses some disappointment that Australia has not financially backed the network which she believes should be a bilateral project between the two neighbours.

Those who are backing the network are NGOs and professional colleges ready to send expert volunteers to support the Pacific develop both clinical skills and mental health policy and law. Such partners include the Australian and New Zealand Colleges' of Mental Health Nurses, the British College of Psychiatrists, Wonca (the World Organisation of Family Doctors), and the Australian and New Zealand College of Psychiatrists.

But before nurses and doctors are flown in the network first works with the nations who've invited them to help develop mental health policy to meet their specific needs. (Hughes takes pride that when the network began only one of the 14 nations had a mental health policy - now 80 per cent have a draft or final policy.)

Once a policy is underway, and a service plan drafted, the focus can turn to the "huge issue" of developing the right skills and getting sufficient funding to start building a mental health service - be it upskilling community health workers on outlying islands, purchasing anti-depressants or supporting the training of an island nation's first psychiatrist or mental health nurse specialist.

Hughes job is often to 'go shopping' or brokering partnerships between the volunteer professional organisations and the nations to bring in suitably skilled and prepared nurses and doctors to train local health professionals over an extended period of time - usually two years. So rather than people flitting in-and-out a country never to return, the aim is for a partner organisation to have regular visits over a set time to build relationships and provide continuity in training.

Building human resources rather than investing in bricks and mortar is also a focus of the network with the aim to encourage community care and self-care. To make successful community care possible, alongside building clinical skills the network works to overcome the stigma and discrimination that the mentally ill can face in Pacific nations.

Hughes has heard tales of a clinic nurse running in fear from a patient because she believed his agitation was the result of 'madness' rather than the machete injury he was seeking help for. There are still some nations where the mentally ill can end up restrained in shackles.

And she is aware that lack of skilled staff, drugs and community prejudice can also see mentally ill people locked up in jail for offences that could have been prevented by diagnosis and treatment.

Hughes reiterates her role is not to blame and shame and points out mental illness is not without stigma in New Zealand and Australia, where people with mental illness and addiction problems can end up inappropriately in prison.

And regardless of how a society views a mental illness - with some people still viewing it as a spiritual malaise with gods and demons playing a part - Hughes says a mental health system is not there to judge but to treat. "It's when traditional practices result in harm and abuse - that is when education, policy and processes are really important," says Hughes. "It's not okay to actually shackle someone and leave them to get rid of evil spirits..."

Education is the key. "A health worker at an outlying island will make sure that people take their anti-TB medication as they consider it important but there won't be anybody skilled enough to make sure somebody takes their anti-psychotics - so they relapse," Hughes says. The result could be shackles or jail. "It's so easy to discriminate if you don't actually know."

Ignorance can also result in a feeling of powerlessness. But training can empower as shown by this comment by a Vanuatu nurse after a training programme. "I saw someone who was suicidal a few weeks ago and I didn't know what to do so I prayed with her and sent her home. I know where she works so I think I'll go and talk to her about some of the things we know now."

Inevitably nurses are a major focus of the network for developing mental health skills in the Pacific. Hughes says this includes supporting nursing schools in the Pacific to include mental health competencies in their curriculum.

It is also doing a lot of work supporting primary health nurses in the community to work with people with mental illness and help rehabilitate them back into the community - a new role for most of them.
"When generalist nurses have a good understanding of mental health - so they aren't afraid and don't by default discriminate - they can provide good basic level care."

Ongoing professional development for nurses in the Pacific can't rely on the Internet, which is often both costly and unreliable. So the network has been encouraging mental health nurse college members to donate their spare psychiatric nursing journals to the Pacific. And Hughes also uploads to USB memory sticks useful materials - like informed consent forms, referral forms, powerpoint presentations and other resources - that nurses can safely store on a stick, often hung round their neck, rather than risk storing them on computer networks prone to failure.

Also helping Pacific nurses in their work is a new but well-tested Intervention Guide designed for primary care nurses and doctors working in the field which Hughes says is both a wonderful teaching tool and an effective practice guide (see sidebar).

Technically Hughes job is about .4 of a role but she admits the hours "fluctuate drastically" and proves it by sending Nursing Review an email in the wee hours - inspired by a middle of the night conference call - which is not an unusual occurrence when her two WHO bosses are in Geneva and Manila and constituent nations are spread widely across the Pacific.

Hughes has also had to become a savvy traveller after her five years of working with nations off the tourist map. The year started with a trip to the Micronesian-states of the Marshall Islands and Palau. Travelling to the US controlled region starts with a flight to Honolulu and then four hours to the Marshalls. From there to Palau is a five-flight, 16-hour trip of "up-and-down, up-and-down with each plane getting smaller". Coming up are trips to Kiribati and Papua New Guinea - it is common for her to visit eight of the network members each year.

Travelling in the heat, sometimes problematic sanitation and real threats to personal security through major civil unrest in some countries, means working in the Pacific is not always as idyllic as it sounds. And sometimes the injustice she comes across can be difficult to accept.

But she relishes her role and she can see change is happening. No-one expected it to be a quick fix but "gently, gently" in time Hughes believes more Pacific people, like the fishing captain, will be given the chance to be a productive and proud member of their community once again.

Pigs, fishing nets & veggie gardens

Purchasing a pig is not your typical therapeutic intervention. But Frances Hughes saw it as an important step in restoring dignity and rebuilding community for a forgotten group of the mentally ill in the Pacific.

There were 60 of them sleeping in cells in a concrete building without running water or working toilets. The facility had three nurses and ten orderlies but most clients had infectious diseases and questionable diets as a lot of the food intended for them was stolen along the way.

"This was two or three kilometres from the main hospital - the epitome of out of sight and out of mind,' says Hughes. But her job is not to shame and blame but guide.

So she started working with the hospital administrator and local community to turn things around. An old piece of mental health legislation was dusted off and the required six weekly inspections reinstated.

The local church was part of the inspection committee and church members started coming in weekly to ensure people were showered and washed. One of the PIMH Network visiting partners did some work upskilling the facility staff. And some funding was found for an activities program to not only re-engage the residents but also to bring the community to them.

That's where the pig came in. Village life on this island nation - like many others in the Pacific - centred around fishing, growing crops and tending your pigs. The status of your family depends on how many pigs you have.

So when Hughes found this out she spent half a day drumming up some funding so she could buy the facility its very own pig. It was both a status symbol and a therapeutic activity for the residents to be like other communities and have a pig to fatten and care for. Hughes believes the original pig had several litters before becoming dinner. But most importantly it was part of bringing some everyday life back to the facility and its residents.

In the same vein was getting some fishing nets - the facility was only a short stroll from the sea in either direction. The community was invited in to teach residents how to mend the nets - a normal part of village life and associating normality with the facility was good for both community and residents. The clinician built links with the community and elders of the church that saw some facility residents return to their homes and the facility numbers trickle downwards.

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