Last month I was lucky enough to attend a University Seminar organized by the Global Mental Health Program at Columbia University featuring Christina Borba, PhD, MPH, a current Director of Research for the Department ofPsychiatry at Boston Medical Center who spoke about her interest in women with schizophrenia as a specific patient population and her past and present research efforts in Western and Eastern Africa. Dr. Borba has been using her expertise in randomized clinical trials to introduce more complex research methods in less economically developed countries. While conducting the studies focusing on schizophrenia, she stays motivated to improve the skills and competency of local scientists and healthcare professionals in the long-run. In other words, instead of giving a man a fish, Dr. Borba is seeking international partnerships and striving to teach a man how to fish.
While serving as the Director of Research at the Massachusetts General Hospital (MGH) Division of Global Psychiatry Dr. Borba managed to establish collaborations in Ethiopia, a country that stands for a particularly interesting case study of recent mental health care development. In 2001, it had only 9 psychiatrists for a population as large as 75 million people but right now there are over 50 psychiatrists, around 100 psychiatric nurses and a specialized psychiatric hospital in the country. While simply transferring Ethiopian students to medical schools abroad definitely failed to develop educational capacity in a sustainable way over the past few decades, this impressive relative increase was possible thanks to the first Ethiopian psychiatry residency program opened by the Toronto Addis Ababa Psychiatry Project (TAAPP). Canadian faculty team travelled to Ethiopia, offering training and on-site clinical supervision that successfully boosted the availability of Western-style mental health care and integrated mental health services within the national system of primary care while respecting the local customs preserved in the communities. Interestingly, Ethiopian mental health professionals first reached out to Dr. Borba and specialists from the MassachusettsGeneral Hospital on their own which proves their appetite for further constantly advance their expertise in the field.
The most current project led by Dr. Borba in Ethiopia investigates the peculiar 5:1 male to female steady ratio among patients with schizophrenia which is unheard of in other parts of the world. In the past, she joined forces with local teams and performed placebo-controlled double-blind randomized trials with adjuvant minocycline as a potential treatment for schizophrenia or involving folate with vitamin B12as add-on therapy to reduce the symptoms of the illness. As emphasized by Dr.Borba, we cannot simply take the tools that are commonly used in the UnitedStates and forcefully apply them in the African countries.
Assessment methodologies prevalent in mental health care are much more context sensitive than those operating in monitoring of physical health and the cultural differences pose a major obstacle making even the most objective and transparent assessments inappropriate for a straightforward implementation into local research and clinical settings. A quality of life survey or the positive and negative syndrome scale for schizophrenia designed to measure treatment outcomes by evaluating a change in symptom severity cannot be simply translated into local languages as even the subtlest differences in understanding of idiomatic expressions, metaphors and cultural references can affect the measure of cognition and subjective perception of reality. The unfamiliar socio-cultural landscape also makes the establishment of ethical guidelines less obvious and more challenging. People of Ethiopia might have a very different sense of what is right or wrong at the moment and they usually consider it unethical to conduct clinical trials with people suffering from mental illness. The local cultural norms alter the understanding of informed consent so that theEthiopian families tend to have a greater collective agency in making decisions regarding the treatment plan or trial participation while gender inequalities often predetermine the access to psychiatric care. Ultimately, Dr. Borba and her collaborators had to face logistical problems such as a lack of proper infrastructure for drug dispending or systemic barriers such as multiple levels of clinical trial approval and complex import-export rules making the grant financial management troublesome.
However, despite all the challenges mentioned the team led by Dr. Borba recruited participants in a surprisingly fast manner, engaged many physicians and scientists and successfully trained a significant number of staff members including statisticians, project coordinators and nurses. Hopefully her culturally competent model for capacity building work will soon be extrapolated to other understaffed psychiatric settings in economically underdeveloped regions. Ultimately, Dr. Borba made it clear that a global approach does not indicate actions ignoring the local scale; a global approach must always consist of a sum of simultaneous and coordinated local efforts.