Remodel to rehabilitate – The need for mental health aftercare and rehabilitation treatment in Malawi
A build or remodel is not typically what the doctor ordered to stave off chronic stress and depression; the process risks construction anxiety and expense and according to Walter A. Brakkelmans, an associate clinical professor of psychiatry at UCLA, “on a scale of 1 to 10, 10 being the death of a child and 1 a fender-bender, a remodel rates a 6 in terms of stress.”
But in Malawi there is a shortage of doctors with orders, and for Flomina Mawindo, a single mother of five in Che Mboma village, rebuilding a dilapidated house is her best shot at ensuring her own rehabilitation to home life after being discharged from Zomba Mental Hospital in Zomba.
Mawindo was admitted to Zomba Mental Hospital after familial and financial stresses set off a downward spiral into anxiety, insomnia and ultimately mental illness – she struggled with a husband who, until his death in 2004, encouraged thieves to steal from her to ensure she did not have the means to divorce him, in-laws who cursed her and her children and a son who stole from other villagers and skipped town leaving her to answer to the authorities and pay outstanding debts.
She began walking the streets at night, talking to herself and became increasingly violent when her children attempted to restrain her, and after initially being turned away from the Queen Elizabeth Central Hospital primary health care facility in Blantyre was admitted to the mental hospital in November of 2011. She was discharged in February of 2012, and is able to recall, with a shaking voice and haunted eyes, her experience at the hospital as one of “trouble and pain.”
“In the first ward, it was not good at all,” Mawindo remembers. “There were four or five patients in one room. The others would bite me, abuse me, and grab my food. I could not protect myself.”
Mawindo said the problems that made the hospital “like a prison” were caused by a shortage of doctors and nurses, an issue that was confirmed by a nurse at the hospital who said “the nurses are always there, but for example today we are only two nurses, and we have got 53 patients… For one or two nurses to look after 50 patients and provide the quality of care that they need? It’s impossible.”
Mawindo has been prescribed sodium valproate, a mood stabilizer which causes side effects which include fatigue, shaking and sedation and are immediately obvious in Mawindo. She is no longer strong enough to walk to the market to do business and has not returned to work since being discharged. Her eldest daughter Tadala absconded from primary school to care for the family until the Jacaranda School for Orphans stepped in and hired a caretaker.
Beyond the caretaker and maize meal donations provided by Jacaranda, Mawindo said she is not aware of any community-based services to help support her and her family.
In the absence of government-funded community-based aftercare and rehabilitation services, Mawindo said she plans to make repairs to a dilapidated house on her property and open it to renters or turn it into a chicken farm. She said with the supplementary income she will feel less stress about paying debts and providing food for her family.
She derives her motivation from the time spent at the mental hospital – not from therapy and positive learning but the fear of return.
“I was going through trouble and pain at that hospital,” she said. “I’ve decided I will never go back there again.”
According to Draft III of the Malawi Health Sector Strategic Plan for 2011-2016, in March of 2011 when the plan was published there were no mental health activities at community level, primary health care units did not provide mental health services, the treatment services provided by tertiary institutions were mainly for people with severe or acute mental health problems and the provision of psychological rehabilitation was limited.
The same report found that in 2011 only 1.5 percent of the national health budget was being spent on mental health and except for one or two districts, most districts spent none of their budget on mental health services apart from the procurement of drugs.