11 April 2014

Substandard clinical practice as a human rights abuse

This is the last in my blog trio about Butabika hospital, Uganda’s premier psychiatric facility, which I visited last Thursday (3 April 2014). The first blog post focused on lawlessness and the second on women. This blog post focuses on clinical practice and human rights.

Much has recently been written about ill-treatment in healthcare, including a phenomenally interesting book edited by Juan Mendez, the UN Special Rapporteur on Torture (I have a chapter in there, which was dramatically serialized in this and this and this blog posts!

When a human rights monitor visits a psychiatric hospital, it’s actually very difficult to figure out what to do with information about medical treatment. What, after all, is the relationship between medicine and human rights? How can a medically unqualified human rights monitor even ask questions about treatments? It’s a good idea to bring a doctor into the monitoring team. This was not possible for our Ugandan monitoring, so here are some tips about non-medics monitoring psychiatric hospitals.

Butabika Hospital (c) MDAC

First, medication is central to human rights in a psychiatric hospital. There are two important things which I always look out for: what and how.  

WHAT: The question is what is the medication? What type is it, how old is it, in what dosage is being given, and by what route (injection, intravenous, orally, so on). Then, what are the side effects (all medications have side effects – many of which are deeply unpleasant). ). I view side effects both objectively from what I see and hear (read this blog post about Moldova for an example of what I call “Haloperidol haze”) and subjectively from the interviewee’s own perspective. I get this information by asking the person about the medication and its effect on their body and mind.

HOW: The second question is the issue of consent. Here I want to find out answers to questions like: Do you want to take the medication? Do you feel you have to? What would happen if you decide not to take the medication? What did the doctor tell you about the benefits of taking the meds and the side effects? About alternative types of medication, and non-medication alternatives? Has the person been coerced into signing a ‘consent form’ rendering him a so-called voluntary patient in law? What is the legal basis for forcing the treatment on the person? So on and so on.

Human rights monitoring is about asking polite and slightly naïve questions. I dig and dig until the answer becomes clear, however incredible the answer seems. Then I ask different people the same questions to triangulate the information. Through this process of asking questions and documenting the answers, some sort of truth emerges.

Haloperidol injection credit: drugdiscovery.com


Dangerous clinical practices

I have serious concerns about the quality of clinical and nursing care in Uganda’s premiere psychiatric hospital, Butabika. Its mission is to “offer super specialized and general mental health services”. Our monitoring team didn’t see much super specialized care on the day of our visit. Instead, we saw dangerous clinical practice. Three examples:

  1. A trained nurse told us that there was a 16-year-old boy on the adult male admissions ward. This is itself concerning – a child should not be on a potentially dangerous adult ward. We were told that someone had filled out a piece of paper to get the kid transferred (the charge nurse of the children’s ward had not heard of this patient). The boy’s only diagnosis is autism, which the nurse explained, “is a childhood disease”. So what happens with the diagnosis once the child turns 18, we asked? “It turns into schizophrenia,” he explained. How do you treat autism, we asked? “It can improve, is best treated with antipsychotics,” he said. Such nonsense brings into serious doubt the competence of staff whose job includes making decisions about depriving patients of their liberty and prescribing medication including seriously rapid tranquilisation.
  2. Talking of which, the standard (unwritten) procedure for admitting a new patient is to carry out rapid tranquilisation. In Butabika we were told that this is usually done by giving 20mg intravenous Valium (Diazepam), 200mg Chlorpromazine intramuscular injection and 20mg Haloperidol orally. The Haloperidol is an on-going treatment.

    I asked a medically-qualified colleague in the UK about this. He told me that these doses, given in combination and at much higher doses than would ever be used in the UK, put an individual at serious risk of dangerous levels of sedation, respiratory compromise as well as fluctuations of the blood pressure and potentially fatal heart rhythm disturbances.
  3. We walked around Butabika during the day and saw numerous patients asleep on the grass outside. We saw several people in oculogyric crisis: a distended neck and eyes rolled back into the skull. The causes of this are usually overdose of neuroleptics. At the end of our visit we were near the front gate about to jump into our minibus when a young woman approached us in an oculogyric crisis. She was alone, so we accompanied her to a nurse who promised to walk her back to her ward. We are confident that this woman’s oculogyric crisis was caused by overmedication, because (a) we saw other people in oculogyric crisis during the day, (b) we saw many more people with other obvious side effects of over-medication, and (c) we saw drug charts documenting overmedication. An oculogyric crisis is an unpleasant condition and needs to be corrected with medication. It should not take a group of visitors to a hospital to point out to the staff that one of their patients requires urgent medical care.


Diagnosis and treatment => monitoring and advocacy

My diagnosis is that Butabika is a mental health service which needs an urgent injection of the rule of law. Not only are people arbitrarily detained, there is strong evidence of under-trained personnel practising dangerous medicine on people whose refusal of unwanted treatment is overridden, and who are not providing interventions to correct side effects to people who are rendered medically incapable of asking for help. Basic healthcare for somatic conditions is denied to people who are asking for such healthcare (see my previous blog post). Particularly where a person’s liberty is deprived, the state has an obligation to ensure that healthcare is provided.

Let’s ensure that Ruhakana Rugunda, the Ugandan Minister of Health is aware of the human rights abuses taking place on his watch. Please email him your concerns at this email address.