Dr. Priya Kundu is a Psychiatrist and Pagenel Global Mental Health Delivery Fellow with Partners in Health (PIH) in Rwanda.

What is your current position?
My role in Rwanda is to build the­­ capacity of the mental health system there and to help smoothly integrate it into the primary healthcare system. What I generally do is work with the district mental health team, which consists of a psychologist, a psychiatric nurse, and three psychiatric nurses who work as mentors. We help to supervise general nurses who are delivering mental health care in both the district hospital and health centers within one district in Rwanda that PIH serves. This ranges from providing education and training for the nurses to seeing patients, going on clinic visits and treating patients in the hospital setting and the health center setting, to also working on programmatic work. We are transitioning to an EMR system in mental health, so I’m helping to facilitate the transition by creating forms that the team can use when they are accepting patients, so that it can easily be translated to an electronic system.

Can you tell us about your career path?
My parents are from India, so I come from a multicultural background, and psychiatry and mental health in general are very stigmatized in so much of the world. I felt that even in my family, it was very stigmatized and there wasn’t a lot of awareness about what mental illness or mental health really was.  Coming from that lens, I knew that I wanted to do something where I was working with vulnerable populations and spreading awareness about mental illness. In residency I had the opportunity to work with refugee populations, which sparked my interest in working with intercultural populations to build awareness and destigmatize mental health.

I knew I wanted to do clinical work. Global mental health is a pretty new field in global medicine, and not a lot of programs have it, and a lot of the programs that have it were very heavily research based. I wanted more of a clinical career, and this Pagenel Fellowship had both service delivery and an academic component, which was appealing to me.

What is your top career goal?
I would love to have mental health care available to everyone in a low-middle income country like Rwanda. We’ve decentralized it to one district, and it’s been successful, and we’re going to expand it to the two other PIH districts.  If that’s successful, it can be scaled up nationally. I would love to see something like that happen—for other parts of Rwanda and other countries to adopt a similar model.

What is the biggest challenge you have in your position or in meeting your goal?
I’ve seen patients who’ve been through the genocide. They were quite young when it happened, but they’re still experiencing the trauma from it. And I’ve seen some patients who are a product of rape from the genocide. Some of them are HIV positive, and its been a really big challenge for them to integrate in to society. But, luckily, where I work mental health has been decentralized for a number of years now. You don’t see cases that are quite so challenging, and they’re not turned away when they need help. They get referred to the one psychiatric hospital in the country. But there are still a number of challenges in administering mental health care in Rwanda:

Mental health and talking to someone who has mental health issues is very nuanced, so language is very important. Not speaking the local language and needing the nurses to translate for me means a lot of things get lost in translation when I’m trying to make an accurate diagnosis or trying to understand what that person is going through.

Secondly, because mental illness has only recently been addressed, people don’t really have words for it in their local language. They have a word that means sadness, and now its been used to identify depression, but there’s no real word for some of these more complex mental health disorders, so that’s been a challenge trying to really understand what the patient is experiencing.

There is only one psychiatric hospital in the country, and a lot of the newer medications are only available in that one hospital. In the district hospital where I work in a more rural area, we don’t have access to newer, safer medications with fewer side effects. We’re using very old medication and trying to work with the Ministry of Health to get more medication into our supply chain, but that’s been a longer process than expected. It’s been a struggle to use really old medications on these patients.  They experience side effects and don’t really have a lot of alternatives.

Patients generally go to a traditional healer first if they’re experiencing something unusual, and when that doesn’t work, they go to their church healer or religious healer, and if that doesn’t work, then they come to seek care at a Western hospital. By that time, the illness has progressed quite a bit, and they’re not really functional in their day-to-day lives, so we’re seeing cases that, if we had detected or treated them at an earlier time, they may not be so debilitated. Not being able to reach out to people because they have these preconceived notions about what’s going on and are seeking treatment from elsewhere has been hard. We’ve had some desensitization sessions with traditional healers and with church leaders, and were able to collaborate a bit, but there is still a belief and stigma about what mental illness is and if Western medicine is really helping the way that we think.  Though it’s evidence based, they may not think so.

There are a lot of patients who have substance use issues and children with developmental delays such as autism or mental retardation, or other cognitive delays. There are older people that are going through dementia. And not only do we not really have treatments for these patients, we don’t have any real services for them like rehabilitation or substance use services because our program is very small and we haven’t been able to build that capacity yet. Trying to address some of the co-occurring issues is also a challenge.

There’s not a lot of surveillance infrastructure when we give these medications. We may give a medication where the side effect is liver dysfunction, and we’re not able to check liver enzymes as routinely as we want because its expensive, and under the nationwide insurance, not all services are covered.

Those are the big challenges. Documentation, monitoring and evaluation, needs some work.

Why did you apply to GHDI?
My background is mainly clinical, I don’t have background in programmatic or systematic issues. I thought it was really important for me to learn about the bigger picture of why things are the way they are because I think when you’re a provider in a small district and you’re facing all of these challenges, you don’t realize how the challenges trickle down.

What impact do you think GHDI will have on your career?
This class has been really eye opening: learning about whole systems, how money is managed, how resources are allocated, how task shifting takes place. Reading a case and seeing how everything comes together for a country or for a program and seeing parallels and similarities with other programs around the world, how they operate differently but still achieve similar results; and, the discussions we have in each class, its really been powerful learning for me. Even if I don’t do global health work forever, I think its such useful knowledge to have.

What work have you been most proud of in your career?
Just being able to have patients come and seek mental health care. Maybe people don’t realize what a big deal that is because mental health is not as stigmatized in America, but in a country like Rwanda, a lower-middle income country, mental health is not on anyone’s radar. For people to actually seek out mental health care and bring their neighbors and family members and trust that our treatment and management is helping, I think that’s a huge achievement. I’m really proud that the Ministry of Health has wanted to expand it to other districts. Its really exciting for mental health, this field is only going to grow. There are so many refugees and there is so much conflict in so many parts of the world, and I don’t think people appreciate the mental and psychological stress that puts on people and how that manifests in so many different ways. Being able to recognize that and be proactive about treating that is really important.

What advice would you give to someone just starting out in healthcare?
Whether being a provider and actually treating the patient or working on a systems issue to deliver better care, every contribution is important and significant. Don’t be discouraged if things don’t go your way. We’re all in this together. Our end goal is all the same.