Cooperation in Mental Health: An Intalian Project in Nicaragua

Author(s): Benedetto Saraceno, Fabrizio Asioli, Alessandro Liberati and Gianni Tognoni
Source: Caribbean Studies, Vol. 21, No. 3/4 (Jul. - Dec., 1988), pp. 91-100
Published by: Institute of Caribbean Studies, UPR, Rio Piedras Campus
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Benedetto Saraceno,
Fabrizio Asioli,
Aiessandro
Liberati,
Gianni Tognoni

InMental
Cooperation
Health: an Intallan
Project InNicaragua
ABSTRACT

over the last four years

acquired
report on the experience
in
a
Mental
in Nicaragua.
of
Health
program
cooperation
developing
the
The philosophy of "transfer" which
program and the
inspired
health
of
Mental
framework
system is discussed
Nicaragua's
general
the
of
activities
the
results
with
cooperation
including a
together
workers
in
six
health
and
mental
for
teaching
supervision
training
for primacy health care workers, an
modules, a mental health manual
survey of the practice of the 15 existing psychiatric
epidemiological
the key aspects
of the general reform of
services. Besides
discussing
the psychiatric system after the revolution the paper focusses on the
We

in urban
differences between organization and patterns of care seen
and rural areas. The traditional psychiatric concept of post traumatic
stress is criticized.
Introduction
Over the last few years health has increasingly become one of themain
focused of the attention of the international community for twomain reasons

(1):
-

it has

proven a dramatic

indicator of the quality of the North-South

relationship

- it one of the areas

is
where the medical and lay public opinion of the
to feel more explicitely a kind of moral obligation to do
North appears

somethingforthedeprivedpopulationof theSouth

are themost common attitudes, theymay

Although help and assistance
often underlie a precise ideology which sees the North-South relationship
in terms of a North bending over the South with compassion,
and trying to

adopt and simplifyitssophisticatedknowledgeand technologyto fitthe

limited capacity of reception of the underdeveloped

partner. Such an
attitude isevident inmost cooperation programs, even ifthe adoption of the
classical
"small is beautiful" approach
often gives positive sound and
to the intervention.The restrictive interpretation given inmost
appearance

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92

CARIBBEAN

STUDIES,

21:3-4, 1988

to the WHO policy of essential drugs is possibly the clearest

is stressed most often is the fact that a limited number of
what
example:
to cope with the very limited resources, while the
chosen
must
be
drugs
accent of the original definition was, and still is, on the affirmation that a
scientific answer to the majority of the
few drugs provide an adequate
needs of the population (2).
instances

as

The thesis we want tomaintain

follows:

inthis paper can therefore be formulated

1) the process of knowledge and technology transfermust be regarded

as an intensive research project: the organizational and cultural
countries impose a rigorous conside
constraints of less-developed

ration of what is transferred. The models, and the instruments of

therefore an object of research through, (not
psychiatry, become
before or after), the cooperation process.

2)

in the specific case of psychiatry the North-South relationship may

best be seen as a very productive and revealing contribution of the
South to the understanding and the practice of psychiatry inthe North:
the encounter with a psychiatry which is framed inproverty reveals the
poverty of psychiatry. The transfer process corresponds to the disco

for exportation
that is "naturally" available
very that the package
to
to
think
and
is
used
one
which
practice
routinely
psychiatry)
(the
far from being scientifically
is a sum of a series of "assumptions"
validated. The result of this research attitude is the rediscovery that
of doubts, which extend to theory, tools,
psychiatry is a cross-roads
practice

3)

(3-5);

the logical process which led to the "essential drug concept" proves
to psychiatry. An essential
to be perfectly applicable
approach
a
as
Italso
declares the reality
permanent object of experimentation.
the
and
with
what
results
implies the verification of whether, how,
and
related to the health structures, patients needs,
variables
intervention tools interact inthe concrete fieldconditions. The poverty
of the situation imposes a monitoring and surveillance, attitudes where
the adoption of epidemiology
7) becomes mandatory;

as framework of any routine activity (6

linkto psychiatry
4) along the same line, Primary Health Care' (PHC's)
does not appear and option but the obvious "conditio sine qua non" for
the continuity and not the
a psychiatric strategy assuming
care
as
most
its
appropriate reference framework (8
fragmentation of
10).

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MENTAL HEALTH

INNICARAGUA

93

The transferrabilityof these Statements intopractical actions will be better

seen through a review of the experience acquired over the last fouryears in
of the development of the health care
Nicaragua, where the circumstances
a
as
whole
have created an unique situation of
the
and
country
system
interest for psychiatry. We anticipate that at least some of the lessons we
learned there could be of broader interest for other countries and could
ease
interactions between developed and less developed countries in this

field(11).

2. General framework
The Somoza dictatorship had leftto the victorious Sandinists-led

revolution
of 1979 a dramaticallysimplified
heritage (12).

popular

Apart froma rudimentary circuit of private care for the very fewwho could
in one structure, the national
afford it, psychiatry was concentrated
of
where
three
psychiatric hospital
Managua
psychiatrists were incharge of
were
whom
of
132
chronic
400
in-patients
(more than five years of
institutionalisation). The custodial model

in its fullexpression

was

the rule,

withpatientsdefinitely
cutofffromtheir
environment
and extensiveuse ofall
the traditional concentration
intensive use
treatments,

tools (physical restraints, electroconvulsive

of pharmacological
with no
sedation),
rehabilitation programs. Psychiatry was distinct from the health care system

(13).

In the early months of 1980, drastic modifications were already on the

agenda of the Ministry of Health, where an ad hoc department was set up,
and prioritywas given to the observation of psychiatric care models of other
countries as a basis fora reasoned planning of the new system. The model
of care which
is progressively
emerging pivots on decentralization
of care into 15 community mental health centers, activation of the resour
ces of general hospital as referral centers for emergency, avoidance
of
long term psychiatric hospital stays, a substantial proportion of chroni
cally institutionalized patients having been
years and relocated at home (14-15).

discharged

over the last four

3. Background, objectives, methods

The basic difficulty in the development of psychiatric care as outlined
above
in the
lays clearly in the limitation of specific skills available
country. Of the few psychiatrists in practice, even fewer were willing to
role and methods. There
accept a profound revision of their established
was no tradition of decentralized work, in an interaction closer with the
community than with the hospitals.
According to the overall philosophy of the Nicaragua health care system,
a team approach, with no strong hierachical
relationship, had to be favou
red. As can be seen we tried to pivot our intervention within the
general

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94

CARIBBEAN

STUDIES,

21:3-4, 1988

framework of the health policy. The characteristics

of the poverty and
war were
in
favour
of
the
other
the
characteristics,
ignored
largely
in the fields of
atmosphere of social mobilization and creative enthusiasm
health and education.
We chose inother words towork ina frameworkwhere the stress problem
and risk conditions were, together with the poverty and war, the general
condition around which the country was
implementing its project.
This choice characterizes other projects in Nicaragua and the conceptual
framework of many analysis: the Essential Drugs Program developed
by
WHO and the Nicaragua Ministry of Health has been developed
taking into
account and stressing the "context wich certainly reflects exceptional
external political, economic and military pressures'^
6) but at the same
is "an example of what should be done
time the fact that Nicaragua
towards Health for All by the Year 2000": the unfavourable conditions
created by the aggression must not hide the favourable context offered by

theNicaraguan UnifiedHealth Service (SNUS) (16-18).

done

In thewords of Halperin and Garf ield: "in just three years, more has been
inmost areas of social welfare than in50 years of dictatorship under

in housing, nutrition, sanitation, and

the Somoza
family... these changes
inhealth care thatwe have reported point
education and the developments
to a broad and profound change in the nature of Nicaraguan
society" (19).

A twoyear fieldtraining
planwas accepted by theMinistryof Health,

after a feasibility evaluation. The initial

minimal fundswere obtained through
the cooperation of a few Italian solidarity groups, before the project could
enter the WHO supported areas of interest (the total cost of the 4 years

with7.000$). The goalwas

projectwas 44.000$;WHO Officeparticipating

to expose all the psychiatric teams inthe fledgling care network to intensive
run by members
courses
of the research group in close
2-3 weeks
collaboration with national representatives of the mental health sector.
A small number (five) ofmental health workers had also the opportunity
Italian psychiatric institutions to gain
of spending 1 -2 months in selected
direct experience which the organization of the services and to obtain
documentary material for pre and post graduate teaching. The search for
and verification of the "essential" are based on supervision of the team's

withthedata collected ina pilot

practicesand comparisonof theprinciples

epidemiological

survey of the practice of the 15 services

involved.

4. Results and products

4.1 Training
Training was successful and has so far involved 60 mental health workers
in six teaching and supervision modules. Because
the project was mainly

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MENTAL HEALTH

INNICARAGUA

95

care-oriented, and to strenghten the basic non-hierarchical organization

of the psychiatric work, a team approach was in fact adopted. The mem
two social
bers of each team (generally one doctor, one psychologist,
in
attended
and
worked
seminars
two-three
workers,
nurses)
jointly
areas:
main
six
addresing
1) theoretical and practical understanding of the relationships among
diagnosis, prognosis, treatment, outcome;
and crisis;

2) emergency

3) rehabilitation
strategies;
4) psychopharmacology;
5)

team

work

methodology

and

its

implications

for structural

organization;
6) need and feasibility of the adoption
in routine practice.

of epidemiological

instruments

Through many revisions and comments the teaching material used in

seminars has progressively grown intoa formal text (20) which was revised

and approved by theMinistry

of Health and distributed
notonly tomental
health services workers and to those in the PsychiatricHospital but

to emergency departments of general hospitals and, after a short

seminar, to primary health care centers (it is interesting to note that these
seminars were led by local mental health workers). The manual
is one of
the few texts available as an essential training tool in psychiatry in Less
Countries that has not been translated from another language
Developed
and - even more important - is not an "import" froman established world of
thought intoa fledgling system of care and values (21).
also

4.2 The study on services and patterns of care

The survey was conducted
in the firsthalf of 1986 and results presented
and discussed
at a national 3 days seminar attended by all the
project
their
participants who where thus given the opportunity of comparing
and
While
detailed
of
metho
training
practical experiences.
presentation
dology and results can be found inanother paper (22), we report here of the
essential of the survey.
A census

of all existing services conducted;

Managua's
pshychiatric
was
excluded.
Information on structural and organizational
hospital
aspects, care actitivies and professionals' characteristics
(age, sex, spe
cialty and weekly working hours) was collected. Participation was exce
llentas it is shown by the fact that inonly one out of 15
existing services
data could not be collected
of mental workers
because
refusal to
cooperate.

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96

CARIBBEAN

STUDIES,

21:3-4, 1988

Patterns of care were studied by reviewing diagnostic and therapeutic

care given to a sample of "new cases",
(i.e. patients firstseen by each
on
whether
services
they had or not a
independently
participating
on
Information
characteristics
(age, sex,
personal
psychiatric history).
reason
for
referral mechanism,
financial resources),
psychiatric history,
attendance, symptoms at firstvisit, diagnosis, type of treatment prescri
bed, drug type, dosages and schedules, data of follow up visit was sought
by one mental health worker in charge of the study in each service.
Standardized questionnaires and a simplified version of ICD 9 (field tested
during the pilot phase to integrate standard terminology and jargon used
in the country) were used.
From the point of view of general policy the survey confirmed that an
to
important shift in care provision from the Mental Hospital inManagua
the 15 community-based centers had occurred. This was also confirmed by

the findingthatno patientwas admittedto themental hospitalduringthe

index month

inwhich

the survey was

carried out.

however
Fromthepointofviewof theservices geographicdistribution

important inter-regional differences emerged. Most services (n=8) were in

fact located in the Capital's area where only one third of the population
related (though any causal hint can only be hyhothesized)
lives. Somehow
to this uneven distribution of facilities is their different pattern of contacts
with patients. Where more services were inoperation in fact we found a
(i.e. patients with repeated contacts with
greater proportion of "old" cases
them) while in rural areas, where services were quantitatively and qualita
tively understaffed, the proportion of contacts with "new" (i.e. patients not
yet known as psychiatric cases) was far higher. Quantitatively the old
cases ratio ranged from themedian value of 11 (range 4.9-2.0)
cases/new
in urban areas
As

to that of 6.7 (range 3-12)

in rural areas.

for patterns of patients care, only a short comment

on the few

findingsseems worthwile(Table 1) referingto differencesinpatternsof

care between

urban and rural areas.

While patients seen at rural services were, inthe aggregate, youger than
in terms of
those cared for in urban facilities other differences emerged
reasons forvisit and related diagnoses
indicating that a picture consistout
with "minor psychiatric disorders" was more frequent in urban services.
still in
inconsistencies
Finally, drugs prescription pattern showed same
urban services where antidepressants were prescribed with a frequency
largely inexcess
distribution.

to that one would

have expected

looking at diagnosis

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MENTAL HEALTH

INNICARAGUA

97

TABLE 1
Essential

findings

of the pattern of care study with

to the urban/rural
differences

areas

Urban

Age

-30 yrs

Income

Family supported

Reasons

for visit1

Family confict
% War related problems
Symptoms
% With anxiety and/or

depression

Diagnoses
% With neurotic

depression2
% With schizophrenia

Prescription
% Of antidepressant
1 The
Intervals

reference

Rural

areas

43%

57%

69%
27%

45%
49%

19%
9%

12%
18%

57%

44%

28%
4%

13%
11%

34%

14%

sources

% Self supporting
%

particular

probability of family conflicts was

and of war-related

(Cl) 1.09-3.8)
urban services.
2 This difference
this diagnosis

corresponded
in urban services.

to a 70%

doubled
problems

increased

(Relative
halved

rish (PR)=2.0,95%
Confidence
95% CI-0.23-0.92)
in

(RR=0.4,

probability

(RR=1.7,95%

CI-1.1

-2.7) of

5. Discussion
The experience which we described forNicaragua represents a situation
of which may be classified as original, interesting, ifnot
aspects
unique for the discussion of the relationship between a stress, a society,
and psychiatry.

many

The country represents and summarizes what can be expected from the
interaction of different types of Stressors: a two generations
long and most
repressive dictatorship, a state of war which has gone on for years, the
structural condition of a very poor developing country.
Because
of itssmallness, the country may be the object of a comprehen
sive observation to allow the epidemiological
evaluation of the interplay
between the needs of thewhole population (not only of subgroups) and the
overall project of a public health policy (23).
With the obvious exclusion of the "standard" and most of the times hidden
acute pathology which is expected
to occur within the army, what has

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98

CARIBBEAN

STUDIES,

21:3-4, 1988

in the pattern of care study can be legitimately considered

been observed
of a "stressed" society, and the overall
the full psychiatric expression
response given to it.Confronted with these facts, the model of psychatric
attitude and interventionwhich has been offered to, and even more which
has been developed within the above framework, is the result of a research
hypothesis generated not to respond to the "specific" request of a "spe
cial" condition but to the intrinsicexigencies of the rationale presented in
the introductory section: psychiatry as a scientific discipline has proven to
in so far as itsticks to an approach based on the separation
be "poor"
the technical understanding and management
between
of psychiatric
revision of the significance and role of psychiatry
and
thorough
problems
as a theory and as a way of looking at the interaction between health care
and society.

The "experimental" results of the exposure of the Nicaragua society to the

listed have been observed and read therefore from
comulative challenges
two angles:
- as
indicators or descriptors of the profile of a particularly stressed
in
society, to be compared with what could be expected and described
other less or similarly stressed populations;
- as windows

into the understanding of the more basic

interactions
psychiatry as a science and society as the object of such
science, between psychiatric problems as sentinel events of disease
and the general project of a society where the
and societal processes
events take place.
between

The sketchy epidemiological profilewhich has been obtained inthe survey

readable with the criteria which can be used to describe and
standard
descriptive studies: urban psychiatry
epidemiological
interpret
is different from the rural one, a gradient of problems and interventions is
and complex urban setting and the
found between the more developed
environment: similar to what some
non-urban
less
developed
simplified,
to happen between more and less developed
studies have documented
countries.
is easily

The same data however can be consistent with a different interpretationa

itselfmore
dramatic overall stressing situation expresses
terms
which
in
"our"
mimic
and
closely
intensively
traditionally
or
the
or
of
is
absent
diluted
the
overall
where
project
society
psychiatry,

definite and

perceived with
to stress would
tric pathology
losers" appear

a high degree of ambiguity. Where the cumulative exposure

be expected to produce itsmore dramatic results, psychia
is at its lowest point of expression. The expected
"stress
to be "psychiatric winners".

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INNICARAGUA

MENTAL HEALTH

99

That is,the observed differences between town and country inthe peculiar
that an emotional surrounding positively
Nicaraguan
setting suggest

is crucial to coping with stress.

charged with personal and ideal meanings
A strong, positive personal emotional-drive may be the coherent response
ideal drive.
of a strong collective
to and consequence

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BIOGRAFIAS
*

is a psychiatrist, head of the psychiatric unit at "Mario Negri" Institute for

Saraceno,
inMilan (Italy). He has done extensive fieldwork in trainingmen
Research
Pharmacological
in Nicaragua
and Costa Rica and has been advisor of Nicaraguan
tal health personnel

Benedetto

Health Authorities. He is author of a Manual of Mental Health, inSpanish, for primary

health, care workers. He serves as consultant tomany governmental and international agencies
Institute representative on
inmatters of health care for the mentally ill.He is the Mario Negri

Mental

the Board

of the Italian WHO

Collaborative

Centre.

ServicesofReggioEmilia(Italy).
head of theOutpatient
Asioii isa psychiatrist,
Fabrizio
Psychiatric
formentally ill,he has been involved as senior scientist in
of Italian health agencies
project. His main areas of interests are psychiatric services, organization and
of psychiatric emergency.
management
Consultant

the Nicaragua

Liberati, had his M.D. degree in 1978. He spent a two-year training period inn the US
at the Department of Epidemiology of the Harvard School of Public Health. His main areas of
interest are health services research and health program evaluation, and in these areas he is
presently involved in several studies in Italy relative to the evaluation of quality of care inon

Alessandro

cology, in treatment programs

In this framework he has been

for people with drug-addiction problems and inpsychiatry.

involved in the training program incollaboration with the Nicara

guan governmentreportedinthepaperwith thespecifictaskof designingand conducting

the epidemiologic

Gianni

Tognoni,

survey.
is the Head

of the Laboratory of Clinical

Pharmacology

of the "Mario Negri"

are documented in
more
His interestsinthefieldofdrug investigation
inMilan, Italy.
Institute

than one hundred

controlled clinical

scientific articles

and cover

trials. He has been a member

(from 1977 to 1981), and WHO

and Arabian countries.

consultant

pharmacokinetics,
drug epidemiology,
of theWHO working group on essential

invarious

fieldmissions

and

drug
inLatina America, African,

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