Child Psychiatry in Laos

THE LAO WAY

It is no easier to characterise the ‘The Lao Way’ in a few words than it would be to similarly describe the ‘Australian ethos’. Nevertheless foreign visitors to Laos are immediately struck by this. It has an effect on health services in the same way that our Medicare system could be seen as an expression of Australian egalitarianism. The Lao view is less materialistic, less ‘technophilic’ and without doubt less ‘time critical’. For example, all attempts I made to specify ahead of my departure, the time of meetings at Mahosot Hospital proved in vain. The only reply I had to numerous attempted contacts was an eventual letter assuring me that my visit was welcomed. I simply had to turn up to the Psychiatry Department a couple of times, and see what happened. On the second occasion, after waiting a while, my Lao colleague arrived, informing me that she had been told that I'd arrived. It didn't take long to dawn on me that our habitual obsession with deadlines was our burden, and they were blessed to be free of it.

Commentators see the Lao as less economically aggressive than their Thai, Chinese or Vietnamese neighbours and see the Lao as emphasising calm contemplation and composure, including when faced with adversity. A common expression is ‘bo penyan’, which means ‘Don't worry. Accept it.’ Imposing one's personal emotions on others, especially anger or frustration is considered poor taste, and rudeness is a behaviour the Lao find incomprehensible.

MENTAL HEALTH SERVICES

There is only one psychiatry department in Laos, in the capital city of Vientiane. It is located in the largest hospital in the country, Mahosot Hospital. This is a rambling compound of one or two storeys, mainly early 20th Century buildings and one larger building from the 50s. It lies on one bank of the Mekong, under towering mango trees, giant frangipanni and bamboo (and the odd eucalyptus). The psychiatry building is a dimly lit space with accommodation for about 15 patients. The plaster is cracked, and paint is peeling off the walls. My host was Dr Choulamany. She is one of three psychiatrists at the hospital, who trained respectively in France, Germany and Hungary. Her office was a small room, perhaps 21/2 to 3 metres square, with a desk, a mattress on the floor for a patient to lie on and a couple of rickety chairs which I was warned to sit on carefully. There were a couple of contemporary psychiatric texts left by visitors, but no psychiatric library, no journals and of course no computers or Internet access. The psychiatry department does not have a telephone, but messages will be relayed from the one at the main reception. A dozen or so patients, a couple of nurses and perhaps some visitors sat outside in an atmosphere of calm and good cheer. There was none of the tension that so frequently pervades our own acute psychiatry units.

Psychotropic drugs are limited in range. Amitriptyline and traditional antipsychotics are available. Tegretol is used to treat Bipolar Disorder and Epilim can be bought in Thailand. Lithium is not used because there are no serum level estimations, and its use is hazardous in the tropics where diarrhoeal diseases are common. No ECT is available.

These three psychiatrists are the total number for the whole of the country, but are only able to serve the population of the local province, since transport is just too difficult to allow patients to travel to attend the hospital. Nearly all medication has to be bought by the patient's family so only a few wealthier families can afford both travel and medication. Elsewhere, more educated people might consult a local doctor for help with mental health problems. The doctors’ skills are limited but hopefully will improve in the future, now that the psychiatrists are teaching at the University.

Elsewhere, people I spoke to either accepted that there was no mental health service, or sought assistance from the Buddhist temples. I was aided in understanding this system as I was accompanied by an old friend, a Buddhist monk born in Laos but resident in Australia for over 20 years. The temples are the traditional cultural and welfare centres in every town and village. The monks provide counselling, shelter and food for the needy or disabled if they have no family support. Some temples also specialise in making traditional medicines. The monks also encourage the community to treat the mentally ill or disabled with compassion.

CHILD AND ADOLESCENT PSYCHOPATHOLOGY

The psychiatrists at Mahosot Hospital see some children and adolescents, referred by the three or four paediatricians (only five in the whole country), but there is no child mental health service beyond this. Nevertheless, there are some particular features apparent. Perhaps the most important child psychiatric issue is iodine deficiency. It is easy for us to forget that 400 million people are affected worldwide by iodine deficiency [2], and it is probably the world's most important single cause of mental disorder. Laos has been the most severely affected of any country. Cretinism is thus relatively common, though its prevalence has never been measured. Perinatal hypoxic brain trauma must also be common, given an infant mortality rate of 125 per 1000 live births plus a high stillbirth rate, and a maternal mortality rate of 660 per 100,000 births (1995 World Bank figures). Dengue is common in towns, and cerebral malaria in the countryside, but children mostly either succumb or recover. Opium is widely used for medicinal purposes, and villages might have a couple of opium addicts who are tolerated and cared for. However, intravenous heroin use is rare. The psychiatrists in Vientiane only knew of one case, an Australian boy from a Lao family who had got into trouble on the streets of Cabramatta, and had been sent back to the old country to get straightened out! They thought anxiety disorders and suicide among the young very rare, though conduct disorders, once also unusual, were starting to cause concern in the capital. I was greatly surprised to see an article on forensic child psychiatry in the newspaper, but there it was, and it exemplifies this concern.

OTHER MENTAL HELATH ISSUES

Laos was caught up in the Vietnam war despite the efforts of Prince Souvannaphonuma to maintain neurtality. The Ho Chi Minh trail, which the North Vietnamese used for transit to the south ran through the esastern provinces of Laos. To hinder this movement, the Americans bombed Laos more heavily than any country has ever been bombed including Japan or Germany in WWII. In one incident, 692 Lao villagers were killed by a single bomb which landed at the mouth of a cave in which they were sheltering from the bombing. Apparently, if the planes couldn't reach their targets, they were unable to land again with a payload of bombs, so they simply discharaged them on Lao territory. Unfortunatly, about 200 people a year are still being killed or maimed by them. A particular problem is that the devices wash out of the hills in the monsoons onto previsouly cleared paddocks.

Following the victory of the Pathet Lao, a considerable number of people were sent to ‘re-education camps’. Although this seems to have been a modest campaign compared with the efforts of Pol Pot, it was very traumatic for the inmates and many of them died.

The Lao are well aware of mental illnesses, and there is a vocabulary of traditional terms to describe various presentations. These are catalogued in a remarkable account of ten years’ research from the 70s by a medical anthropologist, Westermeyer [3]. I can visualise him now, trudging up a muddy jungle hillside busily swatting anopheles, in search of a case of ‘Ba lu-ut’ (literally blood insanity), a severe psychossi, or ‘sia chit’ (lost mind), constant sadness with crying spells.

A recent paper in the Australian and New Zealand Jouranal of Psychology [4] alerted me to possible stigma towards mental illness, but illness, but despite questioning this was not at all apparent. A range of people from different backgrounds and occuopations gave me a similar response in discussing mental health issues. They perceived mental health problems as unusual, and ordinary anxiety and depression were not the concern they are in our society. Could it be possible that the mental health of the community (leaving aside major mental illnesses) is actually better in Laos? Perhaps life is less stressful and the civilising aspects of religious ideals are not yet exhausted.

CAN WE HELP?

There is a considerable effort by the international community, particulary Australia, to assist in Laos. The prospects are aided by Laos being a mainly peaceful country with a stable goverment, despite its poverty. An example of an aid programme with great prospects is the UNICEF iodised salt programme. Fortunately there are only five commerical salt suppliers in the country, and thus it has been easy to arrange addition of iodine over the last years. This has led to substanital increases in tested urinary iodine levels in towns, and surveys are now planned to see if this has also occurred in the more remote areas. In another pilot project, Save the Children Australia has organised a system for women delivering babies to have a birth companion so that they do not deliver alone. The companion has only a few rudimentary midwife skills but this has substantially reduced maternal mortality.

In practice it is not easy to conceive of programmes that can succeed when there is a lack of infrastructure, including organisational infrastructure we take for granted. For example, while a national mental health plan, however basic, would be regarded as a useful notion, there is a fair way to go before such an idea has priority or personnel are trained to develop it. At a more local level however, it might be possible to facilitate useful organisational links. For example, perhaps the psychiatric nurses could provide training for some of the monks in mental health, thereby linking scarce psychiatric resources with a widespread traditional resource. There is currently no liaison between the psychiatrists, paediatricians and the schools around behaviour problems, and this should be relatively easy to establish. In the area of childhood disability there is no special education at all. It might be possible to teach some signing or other communication programmes. Our psychiatry colleagues would greatly value the donation of an ECT machine, if anyone knows of an old one available, or donations of expired or sample drugs.

Laos is still a country of considerable charm, where making ‘merit’ is preferred to making money, and where peace of mind is more sought after than a ‘piece of the action’. One wonders how long this can last, when the population consumes a relentless diet of TV games shows beamed in from Thailand. But as the Buddha taught, ‘all phenomena are impermanent’, and the Lao, for the present, understand this.