Insights from the Singer Sewing Machine
My dear Friends,
Is there a connection between the development of the Singer sewing machine and the development of the YouBelong Uganda new pathway of care for people with severe mental illness? After reading the book, Singer and the Sewing Machine A Capitalist Romance (Kodansha International, New York, 1977), my answer is YES! I am interested in what you, the Friends of YouBelong, think about this.
We want to help create a mental health system in Uganda that has social value. A system valued by the community because it is helpful, easily accessible, low cost, and provides a range of supports when different problems arise to keep people functioning, to keep families together, and to assist in developing a stable, well-functioning community.
Monsignor David Cappo
Co-founder and CEO
From all accounts he was probably not a very pleasant person, but he had a gift for making things happen! Perhaps his greatest personal gifts were vision, salesmanship, and the skill of implementation.
Contrary to popular belief, Isaac Singer (1811-1875) did not invent the sewing machine. There were various attempts at its invention, in the 18th and 19th century, but these inventions made little public or commercial impact. The genius of Isaac Singer was to take a cumbersome, impractical, unreliable (frequent breakdowns) and costly machine, and transform it into a practical, user friendly machine, and to reduce its costs so that it was accessible to ordinary families. Singer turned the sewing machine into a product of value for the needs of families.
The sewing machine became a social good. He produced the Singer Sewing Machine to such a scale and marketed it so successfully, that it achieved international recognition. (I acknowledge that much of this can also be said about the invention of the automobile or the typewriter). When I read the Singer book it occurred to me that there were many parallels between what Singer did and what YouBelong is trying to do in developing a new pathway for a balanced and community-focused mental health system in low-income countries like Uganda!
So how did Singer achieve this?
Singer adapted the sewing machine with innovations to make its mechanism more practical, its moving parts more reliable and less prone to breakages, and he made it easy to use in the family home. To achieve mass production, he introduced a production line system using interchangeable parts. As well, with prowess as a great salesman, he was able to attract investment and to promote his sewing machine in the media of his day. With the advent of mass production, his sewing machine reduced in cost, and to make it even more accessible to ordinary families, he introduced one of the first hire/purchase arrangement schemes.
What lesson have we taken from Singer and applied to the work of YouBelong?
The core of the Singer strategy was to give value to the sewing machine – not so much monetary value, but social value. The Singer Sewing Machine filled a need within the family household. Low cost, reliable, accessible, easy to use, and an overall financial saving to the family budget regarding the making and the maintenance of daily clothing.
YouBelong has a somewhat parallel task to the Singer strategy. We want to help create a mental health system in Uganda that has social value. A system valued by the community because it is helpful, easily accessible, low cost, and provides a range of supports when different problems arise to keep people functioning, to keep families together, and to assist in developing a stable, well-functioning community.
THE MOVEABLE PARTS
In shifting the mental health system in Uganda from an asylum-like institution/mental hospital, with next to no mental health services in the community, to a balanced system of care between short-term hospital care and longer-term recovery in the family, with community mental health services, YouBelong is determined to enhance the well-being of individuals, families, and the Ugandan community.
Singer Identified the ‘movable parts’ of his ‘machine’ and got them working reliably in an integrated fashion. In turn, YouBelong needs to identify the ‘movable parts’ of the mental health system (‘machine’) in Uganda, and to enable them to function at low cost with ease of access and use, to make the system ‘family friendly’, and to ensure that all these movable parts are sustainably integrated into one working ‘machine’. As there are ‘gaps’ in the current ‘machine’, additional parts need to be built and introduced.
What are the ‘moving parts’ that we need to identify in our Singer mental health ‘machine’, and what is the main issue we need to address to get them functioning as part of the ‘machine’?
1. The person experiencing severe mental disorder in a low resource setting. This person has near to zero mental health support outside of mental hospital care. Consequently, if the person is being discharged from hospital, the likelihood of relapse and readmission are very high. Moreover, if the person with severe mental illness is not admitted to hospital, she or he languishes in the community, remains without adequate care or support, with inevitable disability and/or death. In either scenario, we need to build a community-based mental health system of care – a new pathway from hospital to family and community.
2. The families of the person experiencing severe mental illness. YouBelong is using its unique pre-discharge planning tool and its empowerment model to help families to support their recovering family member at home.
3. The National Mental Hospital in Kampala, Uganda. It is a 550-bed hospital with over 950 inpatients. The hospital is overcrowded and under-resourced with no control over who is admitted and when they are admitted, and no resources for discharge planning and preparation of families for ongoing support. YouBelong will train and support some dedicated hospital staff in our discharge planning tools to expedite the discharge process from the hospital.
4. Outreach Clinics from the National Mental Hospital. These clinics are of a very small scale but can be nurtured and scaled up as part of the empowerment plan for family support. YouBelong plans to train outreach clinic staff in patient follow up and family empowerment.
5. The government Health Centres in geographic districts in Uganda. These Health Centres provide primary health care that does not include mental health. YouBelong has begun to train health workers at these centres in mental health support so that not only discharged patients can access the service, but other people in the community experiencing mental health disorders have a resource for their need.
6. Village Health Teams (VHTs). These volunteer VHTs are part of local communities, but they have no training or role in mental health support. YouBelong’s plan is to mobilise them to contribute to community-based mental health support by training them in mental health care and, as a result, linking them into the overall health system. As well as VHTs, a new cadre of support is being introduced by the government in the general health system, namely Community Health Extension Workers (CHEWS). We will target this group of workers in mental health training as well, thus connecting and integrating them into the broader mental health system.
7. The Police. While the police force regularly removes people from the community to the National Mental Hospital when people display anti-social behaviour or from the family home if violent behaviour is associated with relapse, no training in mental health exists for this security cadre. YouBelong will train police officers in mental health and in handling violent people. Specifically, we will give them an understanding of the mental health and general health systems, so that, when other options other than hospital care are available, they will be in a position to discern the most appropriate place of referral and not ‘clog’ the hospital with people who could be better cared for at a less congested part of the system.
8. Traditional and Faith Healers. This community resource responds to cultural beliefs around mental illness and have a high level of community trust and involvement in providing a cultural response to mental health needs in the community. Although this group of people are not part of the ’conventional” mental health system, the reality is that approximately 80% of families first take a person with serious mental health disorders to traditional and faith healers for ‘prayers and treatment’. Given this reality, YouBelong perceives them to be an ancillary part of the mental health system. Accordingly, working with the ministry of health in Uganda, we will connect with those agreeable to collaboration, and establish productive dialogue in order to encourage them to refer people to mainstream mental health care.
9.The Local Council Authorities. These bodies provide approvals and governance at a local level. YouBelong works with them very closely.
10. The Ministry of Health (MoH). The Uganda MoH provides policy direction, approvals, and governance on the overall health system at a national level. YouBelong has a close working relationship with the Ugandan MoH and we envision that a key role of the Ugandan MoH is to ensure all the ‘movable parts’ are integrated into one existing system.
Besides these ‘movable parts’, YouBelong has identified two ‘cogs’ that need to be ‘realigned’ for better reliability in the system, namely, medication, and income generation.
Disruption in medicine supply
Regarding the first ‘cog’ in the mental health system, we must overcome disruptions in essential supply of medications. Interruption of medication supply can result in relapse amongst people with severe mental illness resulting in behavioural issues and hospital readmissions. In the short-term, YouBelong will stock its own medication supply, to be provided to health centres on an emergency basis, when government supply of medication is interrupted by budget pressures, corruption, or bureaucracy. While we recognise that this response is unsustainable in the long term, this fix will provide short term security for people with serious mental illness in the districts in which YouBelong operate, while advocacy to government occurs in parallel to address the medication supply problem.
Avenues to increase skills to earn income
Regarding the second ‘cog’, YouBelong aims to assist people returning from hospital care with meaningful avenues/referrals/linkages for increasing skills and engaging in income-generating activity, ultimately to improve their own wellbeing and for a regular income supply to address basic needs.
YouBelong’s goal is to transform the ‘movable parts’ and ‘cogs’ of the mental health system so that they are working effectively at low cost and working together in an integrated ‘machine’ that avoids breakdowns in operation, is reliable and accessible to the user, and is sustainable into the long term.
In Uganda, we are focused on implementation and also committed to the use of evidence-based data locally, and that emerging from global mental health work by pioneers and champions in the field, to inform our work.
Drawing from the lessons of Singer’s approach, YouBelong will adopt a strategy aimed at sustainability, whereby interventions involving the mental health system within low-income countries are low-cost, adaptable and flexible to local conditions, accessible and user friendly, trusted by the community, able to be quickly identified and address breakdowns in the system.
Up scaling will depend upon increased support from the government and its health system to recognise the importance of community based mental health care.
Furthermore, the system needs to be regularly monitored to ensure the ‘movable parts’ are integrated into the OVERALL health system. The mental health system needs to be valued by the local community if it is to be a successful institution of Ugandan society. It will only be valued if it reaches out to people in need and their families, offering them genuine care and effective support that is easily accessible. Therefore, marketing of a balanced system between hospital care and community care will be a critical component of the YouBelong approach to build community trust in the system. This marketing needs to emphasise that services are accessible, available, that they are welcoming, and not overly bureaucratic, and that if a person or family is not at the right part of the system, they will be referred and helped and supported into the correct area of care. Such an approach will help reduce the level of stigma associated with mental illness in African countries.
A final aspect of the Singer strategy, and perhaps one of the most challenging in low income countries, is the need for scale. Up scaling will depend upon increased support from the government and its health system to recognise the importance of community based mental health care. Hence the need to invest in generating evidence for the YouBelong approach through implementation research.
Also, keeping the system at low cost can help facilitate this goal. Making sure the system works efficiently, and guiding the hospital to move more towards inpatient care for people in acute stages of serious mental illness, while people at other stages of illness can be referred to less costly and more appropriate local level services, will have a positive impact on scale
Ultimately, empowering families to be active agents in the support of family members recovering from serious mental disorders, utilising the primary health system to broaden into community based mental health support, mobilising the police as a referral agents in the system, expediting outflow from the hospital and reducing inflow into the hospital will not only increase the quality of the care of patients with severe mental illness but also reduce numbers in the hospital, thus contributing to keeping costs low.
Isaac Singer’s story is not presented as a gimmick. It is another way of trying to understand the enormity of the problem in developing mental health services in low income countries, such as Uganda. If we are to bring about major changes to produce a balanced and integrated system for mental health services, a breakthrough is needed not only in Uganda, but in other low-income countries in East Africa. And this breakthrough might just be possible through the YouBelong approach. In Singer parlance we need to build a bigger ‘machine’ and we need to build and assemble it piece by piece into an integrated, low cost, reliable, and balanced system of care. And we need to build this machine with wide vision, aimed at producing a very important ‘social good’ for Uganda, and indeed, for Africa.
The moral imperative of human dignity, human rights, and the reduction of inequality needs our response.
We need initial investment to bring our vision to reality
With your assistance, YouBelong can kick-start the transformation of the overall health system to actualize the necessary changes in national approaches to mental health. We are confident we can achieve our vision, but we need financial support and the expertise of a wide group of people with wisdom and compassion. We look forward to you joining us on this journey.