By Kemo Cham
Sierra Leone has joined the growing list of countries whose governments are pushing to abandon the practice of chaining people with mental health disorders; but campaigners say the move, which is part of an ongoing reform of the country's mental health sector, is just a tiny step in a long journey.
They are particularly concerned about government funding, which they say is crucial to fix the effect of decades of neglect of mental health issues in the country.
Freetown, the capital, is home to Africa’s oldest mental health hospital, which is the only facility treating mental illness in the entire country of over seven million people. Located in the east end of the city, the Kissi Psychiatric Hospital was established in 1820 as an asylum, and it was later transformed to a hospital. It has, for over the last four decades been run through foreign donor support, yet it still struggles with issues of overcrowding and shortages of antipsychotic drugs.
But the 150-bed capacity hospital is most notorious for the practice of keeping patients in shackles, which the authorities blame on challenges of man-power, security and medication.
Until 2016, Sierra Leone relied on only one trained psychiatric doctor, Edward Nahim. He recently retired after over 40 years of service and was succeeded by Dr Abdul Jalloh, who is the brain behind implementing the ‘Chain-Free Initiative’ across the country.
Jalloh was sent for overseas training in psychiatry to take over from Nahim. Jalloh says ending chaining as the mainstay of treatment in Sierra Leone is his number one priority.
In November 2017, eleven months after taking charge of Kissi mental hospital, Jalloh received visitors from the US NGO, Partners in Health. The result of the ensuing partnership is the project that entails the rehabilitation of the hospital's decrepit structures. Three of its 10 wards have already been completed, with intense work ongoing in the fourth. Each of the completed wards has a TV set. A handful of the patients had what Jalloh called a ‘soft restrain’, a soft, padded cuff strapped to their ankles, a far cry from the chains previously used.
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The Chain-free Initiative is a World Health Organization (WHO) campaign launched in 2006 as part of its strategy of realizing the dignity and human rights of people with mental illness. It calls for provision of technical and financial support towards hospital reform, improvement of domestic conditions for people with mental illness, development of community care programmes, and raising mental health literacy in both communities and among health workers.
Severely ill mental health patients often need to be restrained to prevent them from hurting themselves and others. In the developing world, especially in Africa where tight health budgets often sideline mental health, chaining is the commonly preferred mode. It is even more common in homes where opinions are shaped by superstitious beliefs and mental health disorders are often associated with witchcraft.
“Many people are physically or emotionally damaged as a result and it is humiliating indignity to the person who is subjected to it,” states the WHO website.
The Mental Health Coalition (MHC) of Sierra Leone – a consortium of organizations involved in mental health service provision, academia and advocacy – has been at the forefront of calls for reform of the sector in-country. Its founding member organisations are the University of Makeni, City of Rest, and the Community Association for Psychosocial Services (CAPS).
MHC was borne out of a donor-funded program in 2011, the ‘Enabling Access to Mental Health’ project, which was managed by the three organizations. One of its objectives was to set a self-sustaining coalition that will advocate for people living with mental health issues.
Edward Munda Jah, a project manager with the coalition, said the last nearly seven years of advocacy have yielded some results, pointing to the establishment of the Mental Health Steering Committee, which led to a mental health unit being created within the Ministry of Health and Sanitation.
The unit has since been upgraded to a directorate, called the Directorate of Non-Communicable Diseases and Mental Health. A National Mental Health Coordinator was also appointed.
All this, said Mr Jah, represents major progress which needs to be backed up with more actions.
“Health is a government’s primary intervention. Even if donors or partners are coming in to help, the government should be able to take up its responsibilities,” he said.
Fueling factors
The rehabilitation of the Kissi Psychiatric Hospital is just one of the latest outcomes of the coalition’s continued advocacy, which has also seen about 20 medical personnel, including doctors and nurses, trained for the first time on mental health issues.
Dr Abdul Jalloh was one of two doctors trained at specialist level in South Africa. The second, Stephen Savally, works with the Ministry of Defense and is attached to the 34 Military Hospital at Wilberforce Barracks.
Mental health units have been created in all the districts across the country, with at least one mental health nurse attached to the main government hospital in each district.
"When the nurses have a case they cannot handle, they consult with me," explained Dr Jalloh.
The young doctor said already there are indications that the reform is working, noting that between January and August this year, the patient population in the hospital has dropped from 150 to 65.
“It means that the medications are working and the staff is continuing to do their work,” he said.
Jalloh’s goal is to transform the center into one of the best in the sub region by 2019.
But, he admitted, this will require not just an increase in the annual allocation of funding by the ministry but also a regular one.
The hospital is not covered by the government’s free healthcare program, yet its services are free.
While funding is not directly mentioned in the new government’s ‘New Direction’ manifesto, it does include promises to “develop mental health treatment and care facilities in Freetown and build new facilities in the provinces.”
Expertise is another major constraint for the hospital. Jalloh is assisted by three mental health nurses. His predecessor, Nahim, comes in three times a week as consultant. A third psychiatrist, a Nigerian doctor contracted by the World Bank, comes in twice a week.
“There is no social worker, no psychologist, no occupational therapist, and no addiction expert. These are crucial professionals,” Jalloh said.
Sierra Leone has been struggling to deal with the impact of recurrent traumatic events in the last three decades. First it was the eleven-year long civil war. Besides the trauma caused by the human rights abuse acts of the rival warring sides, the rebels were particularly notorious for drugging young people to have total control over their actions. Many of these youths ended up in the streets dealing with visible mental health complications as a result.
Very recently there was also the Ebola epidemic, and the mudslide tragedy in Freetown, which caused additional trauma to many.
But authorities say the largest fueling factor of mental health illness in Sierra Leone is drug abuse.
The majority of inmates at the Kissi Psychiatric Hospital, for instance, are said to be psychotic cases. According to Dr Jalloh, these people, who constitute 40% of the population, are mostly victims of drug induced psychosis. There are also schizophrenia and bipolar disorder patients, as well as neurotic cases like depression and anxiety, he said.
In 2017, WHO estimated that some 240, 000 people in Sierra Leone suffered from depression every year.
The Pharmacy Board of Sierra Leone recently warned against a surge of abuse of the painkiller, Tramadol, among youths. Even though it’s a prescription drug, Tramadol can be purchased cheaply and without prescription at pharmacies across the country.
Freetown is also home to some of the cheapest alcoholic drinks, like homemade gin and whisky, which are contained in sachets and can be obtained easily in the streets.
Lack of awareness
Lack of awareness in mental health at both the level of the public and hospital makes the situation worst for developing countries like Sierra Leone. This has led to stigmatization and discrimination, which experts say add to the trauma and worsen the condition of people with mental illness.
Consequently, it is common to see people considered as “mad” and shunned by their relatives and the rest of the community, roaming the streets of Freetown and other cities in shabby conditions. They eat from waste disposal bins and sleep in their feces.
It’s also common to see young men walking and talking to themselves on the streets in Sierra Leone.
Psychiatric nurse and learning disability social worker, Kona Seibure, says successive governments have failed to appreciate the severity of the problem of mental health in the country, which has denied many people the chance to early diagnosis and treatment.
Her organization, the Advocacy for Mental Health and Human Rights (AMHHR), operates in the southern Bo District, where it raises awareness on mental health issues.
Seibure worked as a prison psychiatric nurse in a young offenders institute in the United States where she realized that a lot of the black boys in prison had autism and mental health problems that were never diagnosed until they landed in prison. She also found out that most young offenders who presented with early onset psychosis, were taking drugs prior to their mental health problems.
"I reflected on this and related it to the situation in Sierra Leone. We had a war which a lot of young people participated in and got traumatized by. The drug problem in Sierra Leone is immense. I also knew that no form of psychological support was offered to them and the mental health service is struggling with Human Resources and poor services," she said.
Like in almost all health and social issues, many Sierra Leoneans tend to rely on traditional healing measures, which often tend to add to the problems of mental health patients, mainly because of the unconventional and painful procedures they are subjected to.
Paul Kai Kai, who battled a mental disorder over a decade ago, still dreads his experience. He recalled been tied for a large part of the day, covered with smoke, and had dirt robbed all over his body.
“You are smoked because they wanted to drive the devil out of you,” he said.
When Freetown came under attack by rebels during the civil war, many Sierra Leoneans fled to neighboring countries. Paul lost contact with his family, including his wife. He said that’s what triggered his illness.
After six months of ‘treatment’ by the traditional healer, Paul was told to go, that he was ok. His problem however continued on and off, until he heard about the mental health coalition.
Today Paul is a member of the Service Users and Family Members Association. The group, an affiliate of the coalition, serves as an advocacy outfit for people living with mental illness. They help refer patients to appropriate hospitals for check-ups.
The group also engages in outreach during which they try to send the message that mental illness is curable, just like malaria and other illnesses, once it is diagnosed early.
The outreach also targets the general public. Paul said this is important because mental illnesses get serious because people don’t take action immediately when symptoms begin to show.
George Bindi, a mental health counselor, stressed the importance of awareness as a key to addressing mental health issues. As a professional psychotherapist, Bindi has been involved in all of MHC’s efforts to boost the human resource of the sector. He said in all the trainings they have conducted, it came out clearly that even professionals do not understand what mental health was really about.
"Awareness is important to let the public know that the people we see in the streets called mad people are not just mental health issues, they are also social issues. They can be cured,” he said, stressing the coalition’s call for a referral pathway in the healthcare system and for people to feel that there is adequate treatment.
To ensure a lasting solution to these and many other issues around mental health, Bindi said, it will require actions that are based on the legislative framework of the country.
There is, for instance, the urgent need to review the 1902 Lunacy Act (the oldest mental health law in Africa), which the MHC says is not only outdated but also discriminatory and holds back the expansion of mental health services.
The coalition also wants the government to reinstate crucial mental health drugs removed from the national procurement list, and it wants a pathway to be carved out for people working in mental healthcare.
“We don’t want to see people, because of remuneration and lack of career path, give their back to mental health,” said Jah.
“There is so much stigma … and these people have taken time to study. If they are not encouraged, we will go back to where we come from. And that’s the fear of the coalition.”
© 2018 Politico 2018
