9 April 2014

Degradation of women in Uganda’s main psychiatric hospital

This is 2 out of a 3 part series about Butabika hospital, Uganda’s premier psychiatric facility, which I visited on 3 April 2014. The first post laid out how people are admitted and forcibly treated outside the ambit of a law, and how therefore people are unlawfully detained. The most memorable thing about the visit was the litany of gender-based discrimination which I saw, and that’s what I want to talk about in this blog post. The third post looks at how 'medical treatment' can constitute ill-treatment.

Bon apetite (c) MDAC

The ward consists of a building with some large dormitory rooms, all of which have prison-like barred doors which can be locked. Many women were lying in the grassy area outside the ward, which is surrounded by a metal fence designed to contain the ward’s patients inside it. That didn’t stop a few women from jumping over the fence, however!

Inside, about twenty women were locked behind in, rattling the doors, crying to be let out. “Muzungu!” they shouted with excitement when they saw me and my colleague Stephen Klein. “White man!” My colleague Eyong and monitors from Mental Health Uganda caused less excitement, which gave him an advantage of being able to quietly talk to the patients.



We knew from a previous visit that there were seclusion rooms, so at the beginning of our visit we had asked the hospital’s director to explain the circumstances in which seclusion is used in his hospital. They are used, he explained, when a patient is “violent and aggressive.” The staff then, “wait for the medication to work”. Nevertheless, when we looked in the ledger in the female admissions ward we read that one woman had been secluded because she was “stripping herself naked and restless”. The director told us that the hospital had a standard operating procedure on seclusion. He didn’t have a copy in his office, but he assured us we could find one on each of the wards. So we asked the nurses on the female admission ward (and the male admission ward for that matter) for a copy, and not one single member of staff had ever heard of any standard operating procedure, guideline, policy or any other written document on seclusion. “We learn the rules in school,” explained a nurse. But the rules were nowhere to be seen.

Not only were the rules nowhere to be seen, they were nowhere demonstrated in practice. We saw how seclusion is used arbitrarily, at the whim even of an untrained nurse, and it is not recorded. 

Inside a seclusion room (c) MDAC

At the time of our visit to the female admission ward, two of the six seclusion rooms were occupied. The door to each seclusion room was made from metal and there was no observation window. When the room was occupied the door was locked shut with a padlock. There was no furniture of any kind inside the seclusion rooms and the small windows are high up, meaning the occupant could only look at a tiny sliver of sky. On one side the concrete was elevated so that the patient could lie down without having to do so in their own urine and faeces. No bucket or latrine is provided. Urine flowed from under the door of the occupied cells.

Urine seeps from under the door of the occupied cells (c) MDAC


Before a woman is placed in solitary confinement, nurses strip her naked, ostensibly to prevent her from hanging herself, although there are no hooks in the rooms. As we passed one of the rooms the woman inside banged on the door. She could obviously hear us. The senior nurse told us that if she continues banging it means the medication is not working, so they would go in and give her another shot. 


Here you can see some seclusion rooms and hear a woman banging from the inside. But on a movie you can’t smell the urine and faeces © MDAC


Bloody hell

A woman came up to me and explained how she had been in the hospital for two weeks and wanted desperately to go home. She told me that on admission she was menstruating and she was still wearing the same underwear. “No washing your knickers. Why? Bloody, dirty knickers!” she said. All she wanted was some dignity and hygiene. And freedom. The hospital provides standard-form uniform – a long shirt-like garment in green (to indicate the fact that she was on the women’s admission ward), but provides neither underwear nor access to a washing machine.

I spoke with another woman who is the mother of five. She told me she wants to go home. Her oldest child is 12 and her youngest is 6 months. “I’m still breastfeeding,” she said as she exposed a nipple from under her dress and squirted some milk out  (it landed on the uniform of the patient next to her, who seemed not to mind at all). The woman told me that she wants to call her family but is not allowed. Nor is she allowed to make any phone calls or complain to anyone.


Bon appetite (c) MDAC

Food for no thought

We arrived on the ward as lunch was being served. This consisted a plateful of posho (maize flour cooked with water to a dough-like consistency) and somewhat-boiled beans. “It’s disgusting!” was the gastro opinion of one woman. Many others concurred, explaining that they never get vegetables or meat. Porridge is served for breakfast (not enough sugar was the feedback), and variants of slop are served each lunch and dinner. I saw patients complain to staff that they were hungry. Nurses turned to me and said, “They would say that, especially when there are visitors. The government is providing the food. Other hospitals don’t provide any food.”

A woman told me how she worked as a cleaner at another hospital and offered her professional analysis: “This place is so dirty, they don’t know how to clean it.” My amateur eyes and nose tended to agree.


Altruism is not management

The ward contains a total of 60 beds. At the time of our visit there were 131 patients. It seems that the hospital never actually turns anyone away. So if a relative brings someone and the staff think that the person is displaying some symptoms of a mental illness, they are admitted. No discretion is demonstrated. No assistance is given for families to care for their loved ones at home. There is endless demand of families wanting to abandon their relatives. We heard that some relatives give the hospital a fake telephone number so that they become non contactable. They don’t want to deal with the stigma of having a mad relative.

Abandonment is treated as ordinary. Butabika has become a symbol of stigma: it is the most important link on the segregation supply chain: it supplies a place to deposit people, and there is an endless demand. The system’s paternalistic (these people are ill and we can treat them!) verges on the altruistic (we need to save these people!) is fundamentally flawed. It means that most of the hospital is completely incapable of doing anything therapeutic let alone meeting basic standards of human rights. 

Sleep tight. Many more patients are stuffed in the ward than there are beds. (c) MDAC


Upstairs, downstairs

Overcrowding brings with it public health concerns. We saw not one single mosquito net, in a country with a high risk of malaria, even in the capital city. Lice are so endemic that a fumigation team comes round every two weeks. The fumigation seems to be useless as the lice persist. The reason is that the mattresses are uncovered foam slabs, and I guess they are completely infested with bugs. Another culprit is a lack of hygienic products (soap, shampoo, lice lotion, other toiletries). To try and solve the lice problem, the untrained nursing staff shave many of the women’s heads. This isn’t a problem for women who already have short hair. But many women come in with long luscious hair, which often gets tangled up because there is no oil or combs. Lice love it.

I spoke to a female and male nurse and asked them about the procedure. They were coy, but it was clear that they sometimes shave women’s heads by force. Human rights monitoring has no off-topic issues. It is not for the squeamish. So you can guess the next question we asked: “What about pubic hair?”

Yes, that is also shaved, the nurses said. We asked who shaves the pubic hair, and they told us that many times the women do it themselves. “Many times?” we probed. It turns out that the nurses shave some of the women. “A female or male nurse?” we asked. The nurses looked at each other: “Ideally a female nurse,” was the female nurse’s reply. “Ideally?” we asked, desperately trying not to cringe. “There are times when no female nurse is available. It’s like there are male gynaecologist: we are clinicians,” said the female nurse.

I was talking to a Muslim woman before speaking to the nurses, so I asked whether any attention is given to the cultural issue of a male non-Muslim nurse shaving the pubic hair of a woman who is Muslim. The nurses smiled. I think they wanted me to stop asking questions. 

Woman with a shaved head (c) MDAC


What are patients’ rights?

We asked the nurses how the patients know their rights. “It’s the job of the doctor or nurse to explain the rights,” said the male nurse. So does this happen in practice? No. The doctor doesn’t explain rights, so therefore nor do the nurses. We asked what rights patients had. “The patient has the right to know their illness,” he said. “They have the right to take medication, and the right to refuse,” the female nurse chipped in. She explained that if they refuse the oral medication, then the medication will be given by force, by injection. “What kind of right is that?” I asked, and my colleague elbowed me in the ribs for being cheeky.

Most of the patients here are not detained under any law. All of them who I spoke to desperately wanted to leave. And there’s a space on the form filled out for each patient which allows the person to self-discharge. So I asked the nurse whether the patients can leave. Yes they can discharge themselves. But in her 18 years at the hospital, she could not think of one single case where a person who wanted to leave was allowed to leave against medical advice. “If they still have symptoms, they need to stay” was the rule.

Being a human rights activist I get to go into the strangest places where I hear the strangest things. And then I get to leave, turning my back on people who cannot walk out like I can. So what we are doing is to make sense of the mental health system in Uganda in a human rights report which we will produce in the summer. It will contain recommendations to hospitals and the government on how people’s lives can be made a bit better, in line with Uganda’s international human rights commitments.

If you’d like to support our work in Uganda, or elsewhere, please contact me: mdac@mdac.org