Holly Hylands in Tanzania- Reflections from a Mental Health Nursing Student

 

Holly Hylands is a Third Year Mental Health Nursing Student at the University of Brighton. Here Holly writes about her placement experiences  in Tanzania.

Mambo/Jambo! Afya Ya Akili

The pace of life in general is a lot slower in Arusha, Tanzania. We were told that whilst working with Dr Pascal in the community we should not expect things to run on time, and for it to not always run smoothly. The locals say ‘pole pole’ which means ‘slowly, slowly’. A concept you have to get used to quickly in Arusha.

Me and Mia (training psychiatrist) tried to be as non-judgemental as possible, and to really embrace the traditions of Arusha. It could be very difficult at times. Our Doctor who we were working with, had the opinion due to religious beliefs that being gay, and that abortion was wrong, and that sex was purely for procreation and nothing else. He explained to us that politics are still very corrupt, but the prime minister which is the first female one they have had is working hard to try to change this, it seems as though she is very liked.

My first week;

Day 1; I arrived at 2 am the day before orientation, getting only 5 hours of sleep before it began. Our introduction to the concept of ‘pole pole’ (slowly) came when the event started 2 hours late. We explored the town, visited local places, and took care of our phone setups. The first evening was spent getting to know each other, followed by an early night. I felt warmly embraced by the hostel and had a positive feeling from the start.

Day 2; Firstly, we went to a local radio station to help raise awareness around mental health to the local people. The main topic was around the effect of children being raised by their grandparents and the importance around parent interactions with their children. The doctor I am working with explained it is common in Tanzania. We spoke about how as the World modernises and people work more, how more help is needed outside the immediate carers of children.

We then went to the clinic where Dr Pascal is based. The system is very casual compared to the UK. Dr Pascal provides his number to people and they can contact him direct, or even just turn up to the clinic. This seems very humble, and very different to the long tedious methods that can be discouraging for people in the UK. Dr Pascal could just hand out his number, this was very odd for me and Mia (American intern). There is no structure and organisation and a lack of assessment tools. It was uncomfortable watching people give no consent to numerous things including asking if it was okay for us to be there, anti-psychotic long lasting injections such as haloperidol (very often prescribed and given after one meeting) and private information being shared. Injections that were given including haloperidol were left on the side, in an open cabinet for anyone to see. The needles were also left on the table whilst the next consultation happened. It was also the same needle for drawing the liquid as injecting. It was also just Dr Pascal deciding, with no other input from professionals. It was hard for me and Mia to read some literature around sin and divorce and what they consider to be infidelity including pornography. Dr Pascal is religious; however, he did seem forgiving of most who considered he had ‘sinned’ a lot in previous years. Many of the things that people had done, would not be seen as negative in Western culture, there seems to be so much shame around natural human behaviours and wants in Tanzania.

The first patient we saw, was a female who has had 2 children with her husband. She has been diagnosed previously by Dr Pascal with postpartum depression. She has also been very paranoid, and has had delusions around her husband wanting to harm her, or thinking he has had an affair. She was prescribed haloperidol, however did not keep up with it therefore she relapsed and this is why she was at the clinic. She had her mother with her as her husband did not want her at home. It is a very relaxed atmosphere, as Dr Pascal phoned her husband during the consultation to hear his opinion.

The next patient seemed to be in a severe depression, potentially caused by trauma from a previous job. He had witnessed crime, fires, and the business had to close down leading him to return home. He had previously been prescribed medication. He appeared to be mute and did not want to shake Dr Pascals hand or communicate at all.

The next week we met this individual again and were able to get more insight into what is going on with him.

He is mute at the moment. He did not want to engage at all. Me and Mia asked to have a moment alone with him as the other day someone else responded well to this. He speaks English well, so it was easy to communicate. I gave him a piece of paper with yes and no on it and asked him to point, he did not want to do this and started off by not giving eye contact. Me and Mia explained that our culture is very open, and we will not judge him for anything he tells us. We asked him a few questions about if he feels safe or scared and gradually he replied slowly saying no. As we asked more questions, he slowly started to reply more. He let us know that he misses his life in Nairobi and that he does not want to be here. He states he would like to get a job. He also informed us that his brothers bring him to the clinic against his will. We arrange that we will visit him from home, from now on and he seemed happy about this. We also asked if he wanted us to tell his brothers he is not happy here, and we did this privately afterwards. He said he felt like he couldn’t tell his brothers, and he would like it if we did. By the end of the session (before speaking to the brothers privately) we even got a smile from him which was lovely and such a change from the start of the session. It appears that a lot of people struggle with the ways here; once they have been integrated in other cultures they struggle with the idea of being in this small-town religious lifestyle. Finally, speaking to the man we met on Tuesday again who is mostly selectively mute.

The third patient was a family man who has been diagnosed with generalised anxiety disorder. He has not had any symptoms before the last 2 months. He has had insomnia and has been finding getting any rest or sleep impossible. He states that mornings and evenings are the worst. We spend some time explaining this may be due to when he has time to ruminate and get stuck in thought patterns. Dr Pascal, me and Mia explain that thought paths can be changed and try our best to install hope into him. He is able to laugh and joke with Dr Pascal. This seems lovely, and I personally enjoyed that he was able to bring the conversation from very serious to being able to make him laugh. Dr Pascal used various helpful metaphors to explain how anxiety can be consuming, and sometimes it’s best to learn we cannot control everything.

The fourth patient with a man who has just finished studying in the last few years. When he was younger, he took heavy drugs and had multiple sexual partners, it was sad for me and Mia to see he was concerned he had ‘sinned’ in his eyes. He is very concerned about what his family would think, and his church community if they found out. He has very little understanding of mental health and asked us if we can monitor his ‘brain frequencies’ to help diagnose him. He informed us he feels very lonely, and misses the social life and the openness of the people he met from his ‘previous life’. He seemed to want to travel more, and took a great interest in our cultures and asked questions around meeting people. I spoke to him about how in the UK we use social prescribing as a tool. We tried to encourage him to try to broaden his circle, and that he does not have to have everything in common with someone. He appeared to be relieved to inform us some stories that he has been storing due his interpretations of shame around these ideas. Dr Pascal has offered to add him to community groups online and suggested he tries to enjoy local activities when he gets to where he will stay.

Day 3; We visited a ‘sober clinic’ and talked to a schizophrenia-diagnosed person about his daily life, coping methods, and delusions since childhood. We discussed treatment options and shared an inspiring video on overcoming symptoms. He expressed hope and gratitude. Later, we discussed ways to boost confidence and enable a fulfilling life with Dr Pascal.

Day 4; Our first stop was a social centre. We met some professionals working and they introduced us to a lady who has been a victim of verbal and physical abuse. She had her 8-month-old baby taken away from here and her partner still had the baby with his family and she is currently living with her sister. She has had insomnia and her self-esteem is very low. We explained the importance of believing in herself and offered some advice about what could help. There does not seem to be any divide between social issues and mental health. We met her the following week, and once she was reunited she was very happy, and this seems completely circumstantial to me and Mia, however it is treated as a mental health problem and she was even prescribed anti-depressants which seemed inappropriate to us.

Day 5; Today we presented to the locals in Arusha who wanted to learn about how to manage their mental health in a family setting, Dr Pascal translated for me. I explained the importance of early interactions being positive and the importance of love and reassurance. I explained that I believe the most important tool in parenting is to be able to communicate well, and to remain as non-judgemental as possible. I explained how research suggests that being positively reinforced instead of being punished makes stronger, more confident, resilient and kind children. I explained I believe by surrounding yourself with positive people who also have these beliefs is infectious and how it is important to ignore and be able to put aside negative thoughts and remind yourself that it their feelings and thoughts and not your own. I explained how research conducted in the UK explains that the most important thing you can give your children is a feeling of safety, positive guidance and love. We explained that children learn from us, and how we represent ourselves to them can hopefully help them to be more content and happier.

Week 2;

On Day 6, we visited a local office supporting budding entrepreneurs and met a woman who established a charity to raise awareness about dyslexia. She shared her journey of advocating for dyslexia recognition in schools and arranging informative sessions. As someone recently diagnosed with dyslexia, I related my experiences. She became interested due to her son’s school struggles, leading to his dyslexia diagnosis. We discussed my school life, self-esteem, and challenges faced without diagnosis. I explained my struggles in English and how it affected my grades. This encounter felt meaningful, given my family’s history of undiagnosed dyslexia. The charity’s work helps children understand their unique thinking style and dispels misconceptions about being “lazy or stupid.”

Day 7; During our day’s journey, we began at a local radio station discussing masturbation, which has differing views in this context and is considered a sin. Dr Pascal explained its effects on dopamine and endorphin release, leading to its addictive nature. In Tanzania, porn is linked to infidelity, complicating conversations about masturbation. We then visited a recording studio for positive mental health content, we had some professional photos taken here, and were instructed to hold a football. This was an odd experience, and me and Mia were left feeling slightly perplexed. Back at the clinic, we engaged with students researching cocaine’s adverse effects, reflecting on its impact in both Tanzanian and UK contexts.

Day 8; Spent the morning relaxing in the hostel and having a later breakfast. We went to visit the hospital for a quick look to gain some insight about how it works. We then visited one of the sites for the woman’s empowerment programme and learnt about how they do this. The main purpose is to teach English as it opens up a lot of opportunities for working in hospitality or travel and tourism. There is free child care so that the mothers can study. Then have education around health care and genital mutation. They also have skills lessons such as sewing lessons, cooking classes and crafts. They also have other various lessons on different subjects depending on what volunteers they have.

I then went to a local cafe and met an American Psychologist who just happened to be on the phone to Dr Pascal. I spent some time chatting to Charlie Smith about how it works here, our understanding of how it is managed here and the lack of education around mental health. He is here to educate people on mindfulness and is trying to reach people who may be able to use the techniques. He took my contact details and said he will let me know if he has any meetings in the next few weeks. It was interesting meeting another professional who had an outsider’s perspective. He had a lot of questions for me about patients, prescribing and the lack of understanding here, he had planned to do some education around

Week 3;

Day 9; We spent the day at a career’s advice day on a university campus. As we entered the campus a huge banner read ‘GET A’S, NOT AIDS’, an alarming entrance. The day was meant to inspire, and had different acts throughout the day and different speeches by various people on different courses at the university. Dr Pascal was invited to speak about raising awareness of mental health.

Day 10; This day was spent at Mount Meru hospital. Here I joined the hand over from the night shift to the general hospital. It shocked me that as there is a lot of palliative care they start by stating how many deaths they have had on each ward. It also seemed very different to what I know as they only reported any issues or problems they had presented. There was also speak of various tests that needed doing but the patients could not pay for them so how they can combat that, coming up with solutions. One patient had been prescribed a broad selection of antibiotics to see if that helped his condition as he could not afford a test.

After handover I explained I am a training mental health nurse, they walked me over to the mental health clinic and methadone clinic. This was very fast paced, and we saw a lot of patients in one day. There seemed to be little interaction with the mental health patients. One patient had his hands tied as his brothers had brought him in against his will, as he had tried to run away. He had been diagnosed with bipolar as they saw him running away as him being manic, however what I saw was a very depressed, trapped man.

It appears that after only meeting someone once they receive a very serious diagnosis, such as bipolar and schizophrenia if only one episode of what they consider psychosis has happened.

However, the doctor did explain that they do not focus on the diagnosis so much. During my time in Arusha, it concerned me about how quickly and often they prescribe anti-psychotics with every other patient being prescribed haloperidol with no explanation of any of the serious side effects or any follow up appointments.

One lady who visited had been experiencing what I thought sounded like night terrors, potentially due to something trauma related. I asked if anything traumatic had happened and before she could speak her sister in-law stated she did not know, and they quickly moved on. There does not seem to be many questions aimed at the patient, instead asking the family members who they are with. This feels very uncomfortable for me; however, I try to remain respectful and ask questions about that and try to aim them at the patient.

Through the meetings, different patients often walk in and out of the sessions which seems very odd and unprofessional to me. Again, I remain professional and open-minded as the locals here seem to find this usual.

Day 11; I spent some time speaking to some men who go to the methadone clinic daily, there are up to 700 people who visit the clinic daily. I spoke to one man who was very willing to be open with me, and chat to me about his journey.

He let me know that he started smoking cannabis at 16 and due to no education around drugs he was then introduced to harder drugs and eventually became addicted to heroin. He seems very hopeful that he has overcome his addiction. Patients are able to receive methadone up to two years from the clinic, with the idea that the dose gets smaller and smaller until they are ready to go without it.

I asked him questions about if there is education in schools now about drugs and explain we get education about the effects of the drugs, the likelihood of addiction and how they can affect our lives. He explained a lot of children do not get any education around this and that it is not talked about because people do not want children to know about it as it is a sin. We talk about how it can be better in the long run if people are educated before they use it and how it can prevent someone using drugs in the first place. There seems to be a great amount of help once there are addiction problems, but no preventative measures to stop people from using them in the beginning. Again, it seems that in Tanzania they are better at understanding the link between addiction problems and mental health issues, which is refreshing as I think the UK can be very judgemental of people with addictions from personal experiences whilst working on the wards.

Interestingly, there are people being treated in mental health with epilepsy. They receive medication from the general health department but will be monitored and seen by the mental health team after. Dementia, particularly Lewy body and also Parkinson’s disease are all ‘treated’ within the mental health services in the hospital, which seems very odd to us. The nurse we worked with explained its just due to it being a ‘brain disease’.

Day 12; Day on the Maternity ward; I spent a day on ‘Karen’s maternity ward’ however, there were no births that day. But plenty of woman who had given birth the day/night before. It was lovely to meet all of the mothers and their babies. Talking to other volunteers who had been working there, it sounds like some of it is quite difficult to watch. In Tanzania, culturally people don’t like to show pain, therefore the women are not allowed to make any noise during birth and it’s been seen often that doctors will cover the woman’s mouths if they do. Another volunteer told me recently there was a baby who was born breach and the doctor insisted she was not pushing hard enough and used pincers to twist the skin on her leg to try to force her to push harder. There are many people here who pay to go private and induce their labours so that it can be more planned, which sounds incredibly risky to me.

Various activities throughout my stay

My stay was at a little hostel just outside of the centre of Arusha. Here, I was staying with a group of about 20 other people mainly working in health care settings. It was such a good group of people, I have travelled a lot and stayed in hostels often and I do think this was one of my favourite groups of people I have met, I felt very lucky. I quickly became ‘Mom/Mumzy’ to a lot of them. They were a great bunch, ranging in age from 18 to late 30’s, and the hostel staff were amazing. There was usually someone who wanted to do something fun every night, and I really enjoyed their company. One night consisted of everyone playing hide and seek in the hostel, which was entertaining. I also loved speaking to some of the younger people and remembering the first time I travelled and how brave they are for doing this. I loved coming home and hearing about everyone’s work day, and what they had got to achieve that day.

On one of our first days for lunch we went to a 5* resort and had a beautiful view of mountains whilst we ate. Here we discussed our different cultures and what is expected of Tanzanian people, typically those who are of Christian faith. We discussed marriage values in our own cultures and a bit about personal family life.

My first weekend trip;

After breakfast we travelled to Materuni waterfalls. It was an hour or so hike in the mountains on a beautiful trail leading to the water. On the way, we spotted a chameleon and the local children were playing with them. The waterfall was beautiful, and we got to swim. After, we had a coffee tour where we watched the whole process of drying, roasting etc. We ate lunch there, which was all local food laid out in a buffet style and it was delicious. We head back to the home stay we were at this freshen up for dinner. We stopped at an amazing viewpoint of the sunset and Kilimanjaro. We ate dinner at a local restaurant which had a beautiful view of Kilimanjaro.

We woke up early to travel to Kikuletwa hot springs. The water was a lot warmer than the waterfall! The water was also very clear so we took some videos underwater. There was also a rope swing which was great fun. We had a local lunch here too. We then head back the hostel to freshen up and relax. In the evening we went to a restaurant about half an hour from Arusha centre called Rivertrees, it is next to the National park. Here there are monkeys, and you can hear the river babbling and all of the crickets and bird calls. Unfortunately, they said the monkeys are a lot more active in the day. We had a delicious meal here then retired home after a great weekend.

4-day Safari long weekend trip; This was one of the best weekends of my life, we started by going to Norongoro National Park. As we entered the park we were greeted with two giraffes, and some monkeys and warthogs. We saw so many elephants and so many zebras, wildebeests, and gazelles. We also saw some amazing blue-balled monkeys, who were extremely cheeky and stole our food when we stopped at a picnic spot.

Our second stop was Tarangire National Park – here on the lake we saw a lot of hippos. We also saw flamingos at the lakes edge. Our first night we stayed in white ‘Igloos’ in the jungle, which were very cosy. We had a beautiful dinner, and had some unexpected entertainment of local dancing and a fire show.

On our third day we went to Serengeti National Park; I have never seen so many animals in my life, the Serengeti was truly amazing, we saw the big five. We saw rhino from afar, too many lions to even count all with cubs. We were told it was the perfect season for seeing babies. We saw so many elephants with their babies, and none of them appeared scared of us, which was lovely. The lions and elephants did not seem threatened at all by us. We also saw a cheetah with three baby cubs. We saw hundreds of zebras, wildebeests, and gazelles. We also saw a lot of hippos, hyenas and warthogs. On the second night we camped in the Serengeti and there were so many stars, it was so clear it was truly beautiful. Our third place we visited was Ngorongoro Crater is a huge crater on our third stop on the tour, we had an amazing view of it as we drove into the crater, and could see elephants grazing as we entered. Our final stop was Lake Manyara was beautiful, and as we entered the national park there were so many monkeys. I got to drive in Lake Manyara on the final day of safari, which was great fun. We saw a lot of elephants with their babies here too.

After we finished work one day, me and Trinda travelled to Tumbili lodge which is a beautiful hotel and garden and we met Derek, Mia, and Jana. Here we had coffees, and a 5-course menu for only 81,000tnz (£27) each total. There was a beautiful mushroom dish, a soup, a spicy cauliflower dish, steak dish, and a passion fruit mousse. The gardens were beautiful and we were there for 4 hours (pole pole) but it was lovely to chat and catch up about each of our days and chat about our lives in different countries. We then spent the evening relaxing in the hostel.

One of the evenings after work a few of us visited Lake Duluti, where we had a drink overlooking the water then some locals took us out on a boat ride, where we spotted monkeys and Mt Kilimanjaro through the clouds.

On one of my days off we visited the local cultural centre, which had hundreds of local paintings and artefacts not just from Arusha, but all over Africa. It is one of the biggest in Africa. We found it unusual that a lot of the pieces were for sale, it seems completely inappropriate to me that people are able to buy such important pieces of history and items from peoples cultures to display in their homes.

On my final day working on the maternity ward, we visited a café for a late lunch. We then travelled to another hotel ‘Safari Lodge’ on the outskirts of Arusha National park with amazing views, and more great cheap eats. Enock (a local ‘indrive’ driver we had befriended) had given us recommendations around the area and we had taken him for lunch with us to say thank you as we had used his services a lot. We then went to a local waterfall which was beautiful, here we went swimming and hung out for a few hours. Later on, we went on a small hike which has a swing (that we were not able to use, due to a mix up with who owned the land) but we still had an amazing view over Arusha. We had whatsapp’d a local company, but Enock had driven us to friends of his on a local tour, but not explained this so this led to an odd encounter with the swing owner and them having an argument about if we were allowed there or not. We went to a beautiful restaurant in the evening for my final goodbyes with everyone, there was a live jazz band playing.

I then flew to Zanzibar for my final few days. Here I met up with my two new ‘sons’ and had an amazing dinner in a tree house style restaurant overlooking the sea. I also managed to swim with dolphins in the sea and snorkel with some beautiful fish in a coral reef. I only had 3 nights here, I spent most of that time relaxing and walking on the beach.