One in a Million

I watch her from the corner of the dusty clinic room. A baby hangs in her arms as she stares listlessly out the window behind the doctor.

“And how are you today?” asks Doctor Jeffrey.

A long pause followed by a heavy sigh. The sound of children wailing outside the flimsy clinic door.

“Mmm?” the doctor reminds her that he has asked a question. She shifts uncomfortably on the wooden bench and continues to look past him, as if the answer might be found in the dark grey sky.

Finally, she begins to answer. Although her response is muttered in Lugandan, her inner turmoil seeps out from every pore. Depression needs no translation.

The door creaks noisily as she is mid-sentence, tears welling in the corners of her eyes. A nurse walks in and slams patient files on the doctor’s desk.

“Doctor, you’ll need to hurry up. We have a line down the hall.”

Another sigh, this time from the doctor.  The nurse turns and walks back out into the hallway. I hear the muffled sound of patients asking her how much longer they will need to wait.

A scribbled prescription, an apologetic glance and the shouting of the next patient’s name tells the young mother that her time is up. She stands up slowly and shuffles to the door, stepping to the side as the next patient, a middle-aged man with dust-stained clothes, walks in. The mother disappears into the Wailing Baby Hallway, to return in three weeks for her next five-minute consultation. She is yet another walking statistic in Uganda’s struggle to provide mental health services.

The population of Uganda is about 35 million people. The estimated number of practicing psychiatrists in the nation? Thirty two.

In other words, there is less than one psychiatrist per one million Ugandan citizens.

One in a million. Those are the odds of seeing a psychiatrist in a country that has been the setting for mass killings by child soldiers, brutal dictatorships, widespread disease and poverty.  Although twenty percent of the population suffers from some form of mental illness, Uganda spends a dismal 0.7 percent of its national health budget on mental healthcare, compared to 10 percent in the UK and 5.6 percent in the United States.

And just in case that doesn’t take your breath away: The American Psychiatric Association estimates that there are 50,000 practicing psychiatrists in the US. If the United States was to lower its psychiatrist-to-citizen ratio to that of Uganda, it would need to be cut down from 50,000 to approximately 316.

Understanding the lack of psychiatric professionals in Uganda requires taking a step back to look at the nation’s broader culture. Stigma against those who suffer from psychiatric disorders is widespread; Uganda’s Mental Health Treatment Act of 1964 uses terms such as “idiot” and “imbecile” to describe people with mental health disorders and has not been revised since its creation. Some patients are skeptical of the pharmaceutical drugs that psychiatrists prescribe, preferring to take natural remedies given out by local healers. As always, money also plays a part. Psychiatrists typically receive lower salaries than “traditional” doctors, making it a less attractive field of study for medical students.

You’ll also notice that I am using the word psychiatry and not psychology. This is because psychological counseling in Uganda is even rarer than psychiatric consultations. Dr. Jeffrey, the physician from earlier in this post, explained that the preferred method of “dealing” with psychological issues here is to prescribe medication without providing additional counseling. Money plays a role here too: psychotherapy is often seen as prohibitively expensive – although I have been told that the typical cost for one hour of psychotherapy is less than $15 USD. When people have to choose between paying for psychological counseling and putting food on the table, they often (and understandably) pick food.

Despite these barriers, there are some great organizations advocating for better mental health services in Uganda. Basic Needs, a non-profit based in the UK with an office in Kampala, helps people with psychological disorders and epilepsy re-integrate into their communities by helping them find ways to contribute to their families economically. The World Health Organization is working with Ugandan doctors to study the mental health infrastructure in Uganda in order to advise the government on how to improve the system. Smaller grassroots organizations like Hope of Children and Women Victims of Violence (HOCW), where I am currently volunteering, have trained local residents to conduct counseling sessions with refugees.

Uganda has a long way to go before one in a million is a statistic of the past. Until then, it’s important that the government recognizes the implications of poor mental health services across the country. For example, take the link between mental health and the economy. Mental health problems hinder citizens’ ability to go to work, be productive and make a decent wage – thus lowering their ability to contribute to a thriving economy.

The ripple effect of mental health issues goes far beyond the walls of the psychiatric hospital (of which there is only one in the entire nation of Uganda, Butabika Hospital). It’s time to offer better odds to the millions of people suffering from a mental health disorder.

7 replies »

  1. Thank you so much for your careful reporting of the mental health situation in rural Uganda. It has been over a century since Freud first made the study of mental illness a part of the medical landscape. Let’s hope things go quicker in the developing world.

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  2. Uganda has about the same population as California. There are 60,000 licensed Marriage and Family Therapists and 4460 psychiatrists, plus interns, school psychologists, psychologists in California. It is estimated by the US Surgeon General that 1 in 25 Americans needs mental health intervention in their lifetime, and 1 in 10 need it right now. So, for California, with a population of 38 million, 3.8 million need services today. With approximately 100,000 mental health providers in the state, that amounts to 38 potential patients per professional. Of course, not all those in need of mental health services actually receive them, so it is easy to see why 90% of the licensed MFT’s in California work less than 10 hours per week.

    So, whereas Uganda is in desperate need of mental health professionals, California has more than enough. Sounds like a distribution problem to me. Why not give California professionals an opportunity to serve while learning in developing countries like Uganda?

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