History of TAAPP in Ethiopia
The summary and history of TAAPP was provided by Dr. Clare Pain, University of Toronto.
Ethiopia, situated in the horn of Africa, has a population of approximately 77 million people. Up until 2006 there were only 10 practicing psychiatrists in the country, all of whom had been trained abroad, and three of whom are on faculty in the Department of Psychiatry at Addis Ababa University. The necessity for more psychiatrists has been recognized for the last 10 years and due to the remarkable ability, energy and determination of our Ethiopian colleagues, the psychiatry residency program opened in January 2003 to seven incoming residents.
The Toronto Addis Ababa Psychiatry Project (TAAPP) was created to meet the educational needs of this new three-year training program as well as the need of the Department of Psychiatry in Toronto, Canada, to develop international educational outreach expertise. The letter of agreement between the two Universities was signed in the summer of 2003, and the first University of Toronto educational visit took place in November 2003. Currently the residency training program has completed its third year, with 7 residents graduating and 15 Ethiopian psychiatry residents registered.
TAAPP was charged with bringing an academic curriculum of contextually relevant seminar and clinical material from the University of Toronto to teach to the residents in Addis Ababa. This curriculum was based on the needs of the new program and devised sequentially with each educational trip, flexibly pre-negotiated between the two departments and organized to include time for on-site clinical supervision of the Ethiopian psychiatry residents by the Toronto team. The supervised observations of patient care by the Toronto teams take place in the psychiatric wards, clinics and emergency department in Addis Ababa.
From November 2003 until July 2006, TAAPP has recruited and put together nine teaching teams, each one consisting of two University of Toronto psychiatric faculty and one University of Toronto psychiatry resident. Each team has visited Addis Ababa for a one-month period: there have been three trips a year.
At the end of three years, TAAPP has been experienced as sufficiently successful by both Departments of Psychiatry to expand the original mission to a TAAPP Phase Two. This will extend TAAPP for a further three years (for a total of 6 years) and have two goals. First, it will continue to supplement the residency training as originally negotiated for TAAPP Phase One, but provide two not three educational trips a year. Second, it will enable three new faculty members, drawn from the graduating Ethiopian residents, to acquire postgraduate training as leaders and educators in their profession. This component of Phase Two will train the new faculty both in-country and out-of-country. The new junior faculty members will work closely with visiting University of Toronto faculty to develop and teach the Addis residents for a month twice a year as their in-country training. Each new junior faculty member will travel, in turn, to Toronto for a 6 month educational block at the University of Toronto. This out-of-country module will aim to promote clinical training in the specialty areas of their choice, and will focus as well on the theory and skills involved in research, leadership, teaching and advocacy appropriate to the predicted needs of Ethiopia for psychiatry.
development following the successful involvement of TAAPP in the psychiatry
residency training program has been a recognition and exploration of the
Ethiopian psychiatric nursing needs. The University of Toronto nursing program
has been requested to develop a similar project with the Addis Ababa Psychiatric
Nursing Program to train B.Sc Psychiatry nurses and to assist the current
psychiatric nurses to explore a nursing role expansion. A preliminary visit to
set this up was undertaken in October 2005 and the first nurses’ training trip
is underway in July 2006.
This description has been taken from excerpts of “Pathways to Psychiatric Care in Ethiopia” by Dr. Yilma Yitayew Bekele, MD, FCPsych (SA). This is his dissertation submitted to the Department of Psychiatry and Mental Health, Faculty of Health Sciences, University of Cape Town, September, 2005 The aim of Dr. Yilma Yitayew Bekele’s dissertation is to describe the routes taken by patients to reach to psychiatric care in Ethiopia, and to investigate the factors that may contribute to delays on the pathway to care.
“Ethiopia is among the poorest countries in Africa. Basic health service coverage is about 48.5%. There are 10 psychiatrists and 122 psychiatric nurses in the country. This gives a psychiatrist to population ratio of 1:5,600,000, and psychiatric nurse to population ratio of 1:459,016. All psychiatrists are based in Addis Ababa; therefore, patients travel several hundreds of kilometres from their homes to find treatment there. Local people often seek care from local healers, but there is no working relationship between them and mental health services in the country.
In the Ethiopian setting, health is defined as a state of equilibrium among the physiological, spiritual, cosmological, ecological, and social forces surrounding man (Vecchiato 1993). Traditionally, mental illness has been attributed to supernatural forces such as spirits which enter a person's body, or the shadow cast by an evil eye (Alem et al. 1993; Araya and Aboud 1993). Modern psychiatric services are also very scarce, inaccessible, and relatively expensive to the majority of the population. Therefore most people go to priests, magicians, sorcerers and traditional healers to seek treatment for mental illness (Alem et al. 1993; Araya & Aboud 1993; Giel et al. 1968). Patients usually resort to modern mental health care service only after they tried and failed with all possible traditional treatments. It is also a common practice in Ethiopia to care for and provide support to the mentally ill by family members at home (Araya & Aboud 1993).
Perhaps differing beliefs about cause and treatment of mental illness, help seeking behaviour, fear of stigma, acceptability of psychiatric service and lack of awareness of the existence of psychiatric service in the country could also be some of the factors contributing to delay in help seeking.
At the psychiatric service; 42.5% of the study population received a diagnosis of Schizophrenia/ other psychotic disorders, 18.0% Epilepsy, 16.0% mood disorder, 10.1% Anxiety/ somatoform disorder, 6.3% physical problem, 2.9% cognitive disorder, 2.3% substance use disorders and 1.9% of the patients did not have their diagnosis confirmed.
who presented to their first carer with problems of fits/altered level of
consciousness, and who subsequently received the diagnosis of epilepsy at the
psychiatric service are the ones who experienced the longest delay along the
pathway to care. The deep seated cultural belief among most Ethiopians that
epilepsy, and for that matter any kind of mental illness, is caused by evil
spirits or some form of supernatural force could be one of the major barriers
for seeking early psychiatric treatment.”
1. Alem A,
J.L., Argaw M, Traditional perceptions and treatment of mental disorders in
central Ethiopia, in Year book of Cross-cultural Medicine and Psychopathology.
1993. p. 105-119.
We are excited to be working with the University of Toronto, Canada and the University of Addis Ababa, Ethiopian. This is a compelling story of international outreach and it is one hundred percent Canadian.
In our documentary we will explore social, cultural and religious beliefs concerning mental illness in Ethiopia. We will take a look at traditional methods of healing the mentally ill, from holy water to witch doctors and herbalists. We will also investigate the role of the Amanuel psychiatric hospital in the capital city of Addis Ababa, Ethiopia. Amanuel psychiatric hospital started as a treatment facility by Italian occupants, but once the Italians left, the hospital became an overcrowded insane asylum for the severely mentally ill. Dr. Mesfin Araya and Dr. Atalay Alem converted the asylum into a psychiatric treatment facility. Soon after they completed the conversion, they collaborated with Dr. Clare Pain from the University of Toronto and started a partnership that became TAAPP. We will look at the challenges that are faced in Ethiopia regarding mental health and the role that psychiatric care plays in a culture based on belief in evil spirits and superstitions.
The psychiatric training and work that is being done in Ethiopia by the University of Toronto staff has a local return, as well. There are many immigrants from Ethiopia, and other African countries in Canada. Canadian psychiatrists are learning the social and cultural beliefs of Africa and are able to use this new knowledge in Canada. As an example, there was an Ethiopian baby boy born in Toronto. His mother, who had immigrated to Canada, died during childbirth and the father was not known. The custom in Ethiopia is that the extended family would care for the orphaned child. Even though there were many family members in Toronto, no one would take care of the child. As a result the child was slowly starving to death and becoming unhealthier each day. In Ethiopia, the given name also carries significance, connecting the child with past generations. Without a name there is no sense of connection to his ancestors and with this broken connection there is no sense of responsibility for the child. Without parents this child had not been named. Once the doctor had realized that the neglected baby was nameless they named the baby. Immediately the child was recognized as a legitimate child and was accepted lovingly by his extended family.
amazing fact about TAAPP is that the psychiatrists from the University of
Toronto volunteer one full month unpaid in Ethiopia supporting this project.
During the making of this documentary we will have access to all of the members
of the TAAPP steering committee as well as all training teams that have
participated in the project since 2003. We will have access to the psychiatry
staff at Addis Ababa University while we are in Ethiopia, as well as psychiatric
patients and their families.
We are working with Dr. Clare Pain and other members from the TAAPP steering committee from the University of Toronto. We have also consulted Professor Michael Gervers regarding Ethiopian History.
¨ Complete the documentary narrative
¨ Shoot on location in Toronto:
o University of Toronto staff involved with TAAPP
o Toronto Ethiopian community stories of culture, beliefs and experiences
o Preparations for next teaching group to Ethiopia
¨ Travel with teaching group to Ethiopia
¨ Shoot on location in Ethiopia
o Addis Ababa University staff
o History of Amanuel Psychiatric Hospital
o Local life in Addis Ababa and rural villages
¨ Audio recording for documentary
o Complete translation for non-English interviews
o Record local musicians
o Edit documentary
o Record narration and voice-overs
o Add Ethiopian music tracks
o Review edit with TAAPP steering committee to ensure no misrepresentations
There are two set locations:
Setting A: Toronto: University of Toronto Staff
University of Toronto Resident
University of Toronto Returning Participants
Ethiopian Community in Toronto
Setting B: Addis Ababa: Ethiopian Hospital Staff
Ethiopian Community in Ethiopia
We will use three narrative voices to tell the stories.
Other University of Toronto faculty
Other Addis Ababa University faculty
Addis Resident (Ethiopian)
Ethiopian community in Toronto
Ethiopian community in Ethiopia
- Current traditional treatment available to the severely mentally ill in Ethiopia
- Cultural beliefs surrounding issues of mental health and illness
- The stigma of mental illness in Ethiopia
- The initiation of modern psychiatry in the country, including treatment availability
- Mental Health services outside the capital and the lines of referral of patients to Addis Ababa from outlying areas
- Plans for the broader development for psychiatric services in the country
- Other challenges involved in developing an integrated system of care for individuals and their families concerning mental health and illness
We would like to follow these story lines:
- The history of the Amanuel Hospital and how it became an asylum for the severely mentally ill
- The first psychiatric nurses in Ethiopia: their training prior to the development of the psychiatry residency program, their role then and their role now in the treatment of mental illness
- Dr. Mesfin Araya and Dr. Atalay Alem’s involvement and experience in the conversion of Amanuel Hospital into a modern psychiatric treatment hospital and psychiatry residency training site
- Dr Menelik Desta’s experience as the Director of the Amanuel Hospital
- The development of the first psychiatry residency training program in Ethiopia.
- TAAPP: background and overview of how Canadians became involved with the Department of Psychiatry in Addis Ababa University
- TAAPP training and preparation for teaching trips to Addis Ababa
- The struggles and challenges of western medicine from the Ethiopian perspective
- Addis Ababa University psychiatry resident’s personal experiences of training
- The University of Toronto psychiatry resident’s personal experience of a month educational elective in Addis Ababa
- University of Toronto’s teaching teams’ experiences in Ethiopia
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