Sierra Leone has endured the ravages of civil war, then Ebola, and is now confronting the threat of Covid-19. Yet, some of the deepest wounds suffered by the people — including their grief and trauma — are invisible, and there is little recourse for treatment.
In 2012 the World Health Organization (WHO) estimated that out of more than 700,000 people suffering from mental health conditions, only about 2,000 received treatment. Mental health issues in the population have only increased since the devastating Ebola outbreak of 2014–15, and given that the country has only one psychiatric hospital to serve its population of approximately 8 million, the psychological fallout of the country’s humanitarian crises has been sorely neglected.
Rawya Rageh, Senior Crisis Advisor (senior researcher) with Amnesty International, has authored a report that calls for much-needed changes to improve mental health services in Sierra Leone. Released in May 2021, "They are forgetting about us”: The long-term mental health impact of war and Ebola in Sierra Leone draws from 55 interviews, including with war and Ebola survivors and mental health professionals.
Based in New York City, Rageh spoke to Tie u Orja about the challenges that have prevented mental health from becoming a priority in Sierra Leone. She also elaborated upon the parts that the government, donor agencies, and citizens must play to ensure that Sierra Leoneans can claim their “fundamental right to mental health”. Excerpts from the interview, which has been edited for brevity:
In your report you speak of a “massive mental health treatment gap” in Sierra Leone. Could you describe the problems surrounding mental health and the reasons behind it?
The Sierra Leonean governments throughout the years have taken some steps, in collaboration with international partners to build up a mental health system after the civil war and definitely around the Ebola crisis and its aftermath. But the reality is, that despite these efforts that have been undertaken and the policies that have been drafted, little has been done to tangibly translate these policies into actual actions. So, you have policies in place and several statements by government officials that address the importance of mental health, but there isn’t tangible commitment in the sense of actually creating the necessary budget lines and financing to support these commitments.
There is also insufficient support from donors, who haven’t been providing enough funding on that front. What you have is a health system where there are several barriers facing people who have mental health-related needs. Some of these impediments relate to the extreme shortage of skilled mental health professionals, the lack of budget lines as I mentioned, and the centralisation of services. So even the very limited services that do exist are highly centralised. They are concentrated in urban centres that are not accessible for people outside.
You spoke about the government’s acknowledgment of the importance of mental health. In terms of the budget, what is lacking?
There isn’t a dedicated budget line from the government to mental health. It is not clear how much money is dedicated from the government to mental health because the relevant budget line is not disaggregated. So, it’s not clear how much the government spends on mental health, but in our interviews, mental health advocates and professionals have made it clear that whatever spending there is, it simply isn’t enough.
Is this because there’s not enough awareness at the political level? Or are there other reasons?
I wouldn’t say there is not enough awareness at the political level per se. There is a mental health policy in place. The president of Sierra Leone also made encouraging remarks in support of mental health when they inaugurated the newly refurbished Sierra Leone Psychiatric Teaching Hospital. So, I wouldn’t say there isn’t political awareness. The issue has to do specifically with translating these commitments into action and creating the necessary budget lines to prioritise mental health the way it needs to be prioritised.
That said, while there is some level of awareness at the senior political leadership level, our interviews indicate that stigma towards mental health conditions cuts across — that it’s not just an issue at the community or general population level, but also among those in authority. Therefore, one of our recommendations is that not only should the government redouble efforts to support awareness-raising campaigns aimed at combating stigma and stereotypes around mental health, these campaigns need to target government officials and civil servants, not just the general population.
How are people who wish to seek support affected by this?
There’s only one psychiatric hospital in Sierra Leone, which is the Sierra Leone Psychiatric Teaching Hospital in Freetown. Other than that, there are mental health nurses that provide services in outpatient clinics in different centralised district hospitals around the country. What we are advocating for is community-based mental health care… where people can receive care in their communities.
What about people living in rural areas who wish to access mental health services ?
At the moment there are simply not enough mental health services that are reaching people in rural areas. Our research indicates that mental health services remain highly centralised and people who require care have to go to district hospitals, travel to district hospitals, where there are outpatient units manned by mental health nurses. That of course indicates that there’s travel expenses involved. Mental health nurses told us that they too do not have a specific budget to be able to travel to rural areas and provide the support that might be needed there. That is why we are calling on the government to expand its efforts, to train community health workers, to perhaps create also mobile teams to reach people in those rural areas.
Testimonies from the survivors that we interviewed highlighted the need for community-based interventions, how these interventions are limited, and how there are barriers for those who may want to access care. One person, for example, told us, “We need that kind of support in our community and that kind of counselling services so that people who have experienced traumatic experiences and people who are going through this kind of stress will be able to understand, you know… that there is a life, and they need to live it”. That was roughly what that one survivor told us in the interview. That is indicative that people feel the need and the importance of having these services in their communities.
How do the available mental health services cope with the needs of Sierra Leone’s population of 8 million people? There are only around 20 mental health nurses, two psychiatrists, and no psychologists in the public workforce.
This issue came across very strongly in the interviews, with mental health professionals saying the pressures are immense. There is a huge need and simply not enough mental health professionals and workers to provide the needed support. Health professionals told us that they are doing their best… given the limited support that they have. By all accounts, everybody who is advocating for better services in the country is calling for expanding the mental health workforce and also improving the support to the current providers. They need better support in terms of burnout protection, better physical conditions where they can work, access to psychotropic medication in order to be able to prescribe it to people who need it. These are all key things that are needed for them to do their jobs in a better way.
They need to be able to have better opportunities for career development. A lot of the mental health professionals feel that there’s not a whole lot that they can do in terms of promotions or, you know, improving their educational level because of the limited opportunities in the country. That said, our interviews indicate that mental health professionals in the country are committed to providing services despite the limitations, but they made a very clear call during the interviews that the government needs to do more to support them and improve the services that are being provided and expand the workforce.
What can the government of Sierra Leone do to raise awareness and incorporate mental health for those struggling?
One thing to point out is that obviously these challenges are not unique to Sierra Leone. They are common in countries with budgetary constraints and in low-income countries. However, mental health is not a luxury and there are ways, despite these budgetary constraints, to do more to improve mental health services, [for example], by explicitly requesting technical and financial assistance from the UN and other regional and international partners. One of the key goals of that assistance must be to develop a targeted plan with attention to financing and a human resources strategy to address the large gaps in access to mental health services.
The government should require specific allocations, a minimum of 5%, for mental health services from donors contributing to health and other development programmes.
The government of Sierra Leone should also work with international partners on testing and delivering evidence-based mental health interventions through existing community-based delivery platforms such as schools, livelihood initiatives, and programmes on nutrition, reproductive health, and teen pregnancy prevention. Integrating mental health services in such programmes has shown some positive results already in the country, namely the work done by researchers from the Youth Readiness Intervention. They have tested the delivery of mental health services through schools and livelihood programmes in several districts in Sierra Leone. Their studies have recorded positive outcomes, including, for example, improvements in daily functioning and interpersonal behaviours. So, there are good examples of ways to deliver evidence-based interventions in a cost-effective manner.
I would also like to point out here that donors, too, should do more by increasing their technical and financial assistance aimed at improving mental health services. They also need to be proactive advocates of ensuring that the government prioritises mental health.
What has the government done so far to expand mental health services?
Sierra Leone has a mental health policy and strategy in place. It has also undertaken steps to train health workers in mental health. A key missing component is a financing and human resources strategy to scale out services in a way that addresses the existing gap and there just hasn’t been enough investment on that front. Lack of investments in mental health is a global problem and Sierra Leone is merely one example. Meanwhile, our research shows that, even though it’s been limited, work on improving mental health services in Sierra Leone has yielded positive outcomes, such as having a cohort of 21 mental health nurses who were trained by 2013 and placed in various hospitals around the country. They played a really key and vital role in responding to the Ebola crisis, for example.
How can this be beneficial in the future?
When you have that system in place it can be extremely helpful in crises. One way for governments and donors to look at it is from a disaster risk-reduction lens — that if they put in the work ahead of a crisis, then it minimises the amount of work that needs to be done post-crisis. This is one thing to highlight. Then of course, as I mentioned, when you roll out evidence-based interventions in a human rights-compliant manner, you can have positive outcomes and donors really should consider making those investments.
There is also a return-on-investment value in doing so. Research supported by the WHO has shown, for example, that for every US$1 invested in scaled-up treatment for depression and anxiety there is a return of $4 in better health and productivity. So, investing in mental health is important not just in terms of fulfilling human rights and obligations, but also from the lens of social and economic benefits that matter to governments and donors. Currently, the figures are just really extremely shameful in terms of how little donors do provide in supporting mental health — globally, only around 1% of development aid for health has gone to mental health. Donors need to do better, and they need to be committed long-term to build and strengthen mental health systems in settings like Sierra Leone. That said, while scaling up services requires time and resources, it has been estimated that a core package of mental healthcare interventions would cost around US$3–4 per capita a year in sub-Saharan Africa. In other words, expanding basic evidence-based interventions in and of itself does not necessarily come at a premium.
What concerns did you identify in the way that the government deals with mental health support?
There are concerns that the government doesn’t take enough ownership, that there’s a heavy reliance on international NGOs to provide crucial resources, such as psychotropic medication. Some of the mental health professionals, we interviewed feel that the government needs to take ownership by creating a proper process of procuring those kinds of medication. They feel that in order to reflect a general interest in mental health services the government needs to create these necessary budget lines to actually finance the strengthening of the mental health system and improving the services. The feeling among advocates and those in the profession is that the government essentially needs to do more to translate its promises into action.
What knowledge of mental health did you find when interviewing members of the public?
There are many misconceptions about mental health, and stigma associated with mental health conditions. Common myths attribute mental health conditions to supernatural causes. Sometimes, people believe that you could contract mental health conditions, like some infectious disease. All of these myths, all of these issues around stigma really reflect the extent of the lack of mental health literacy and they highlight the need for more action to raise awareness.
Entities such as the Mental Health Coalition– Sierra Leone, for example, is particularly active on that front. So, they have an ongoing campaign in collaboration with international partners to raise awareness. They go to communities, they travel across the various districts. Several other local mental health advocates undertake these kind of efforts. But a lot more needs to be done. The government definitely needs to prioritise mental health awareness campaigns and so do donors. Our interviews indicate that, unfortunately, donors aren’t supporting enough mental health campaigns — which are really crucial to improve the situation of people with mental health conditions or those perceived to have them.
How is COVID-19 affecting those who survived the civil war and the Ebola pandemic?
Several Ebola survivors we spoke to described having a persistent fear of death. Many said that when you survive Ebola you have this impression that you are going to die anytime because of the persisting physical and mental health impacts that continue even years later. Some of them also told us that COVID-19 was particularly triggering for them. They felt that they were going to face another, you know, outbreak, and it brought back the distressing memories of their experiences.
A member of the Mental Health Coalition we spoke to, for example, said that this came up in a church gathering where a woman who was an Ebola survivor and had lost several of her family members to it stood up one time and cried, expressing extreme distress at the advent of COVID-19. So far, COVID-19 fatalities have been very limited, and Sierra Leoneans have been relatively lucky on that front, but of course the psychological impact is still there and is still strong.
Sierra Leone’s mental health law is called the ‘Lunacy Act’, reflecting a 19th-century attitude towards mental health problems and which frames people with mental illness as dangers to society. How does this law, including the way it is labelled, affect the citizens of Sierra Leone?
Just by its name, ‘The Lunacy Act’ of 1902 is indicative of an extremely outdated and discriminatory framework of looking at mental health issues and disability rights in general. The reality is that the government of Sierra Leone [believes it is outdated and discriminatory too]. There have been positive steps taken from the government’s side in recent years. For example, they no longer practise shackling in the Sierra Leone Psychiatric Teaching Hospital in Freetown. Some of the outdated and abusive practises that could have passed under this law are no longer being practised in the hospital after certain steps of reform that the government, in collaboration with international partners, has undertaken.
A new legal framework needs to be in place. We understand that the government has taken steps in that direction, it’s just that the process is extremely slow. We’re asking them to expedite that process and to ensure that there’s a consultative process with people who are involved — including people with mental health conditions and their representative organisations — to reform and repeal that law.
Could you explain shackling?
Shackling is the practise of tying up or chaining people who have mental health conditions to restrict their movement. Our understanding is that this practise still persists in informal settings. We had interviewed several mental health specialists, researchers, and people involved in different NGOs in Sierra Leone, and practically all of them told us that they witnessed shackling in informal settings like homes or traditional and faith healing centres. That said, the government has undertaken some steps to end that practise. It has ended in the newly refurbished Sierra Leone Psychiatric Teaching Hospital as of 2018, I believe. However, a lot more needs to be done to crack down on this practise in informal settings. Significant awareness-raising efforts, for example, is one way to go. Effective monitoring mechanisms are also needed to ensure that this practise comes to an end.
How does the stigma surrounding mental health affect those struggling?
One of the issues that was very salient and came across during the research is that stigma around mental health remains pervasive in the country. This results in abuses against people with mental health conditions or those even perceived to have one. They are either excluded from the community or looked at as essentially having brought this onto themselves. As I mentioned, among the popular myths that exist is blaming mental health conditions on witchcraft and perceiving it as a punishment for bad actions.
Mental health professionals we’ve interviewed also told us that sometimes mental health nurses or a doctor who’s involved in providing mental health support would be referred to in a derogatory manner, such as calling them “crase man doctor” [meaning “crazy man doctor”].
How do you think the stigma surrounding mental health affect the mental health professionals that work in Sierra Leone?
Those we interviewed are extremely committed because they understand the importance of their job. Some mental health professionals said that even though sometimes there is this negative misperception about their work, they are really committed to doing their job. They look at it this way: when they put their effort and focus in their work, when they help people who need mental health support, and when people show signs of improvement, they believe that that in itself sort of plays a role of raising awareness, and that others will see that people who are receiving the necessary care and treatment are improving. Therefore, it helps alleviate the stigma and improves awareness and understanding about the importance of professional mental health support.
What positive changes could be seen if there is better attention to mental health?
One thing that we aim to highlight through our research is that a state of good mental health is not a luxury. Mental health is a fundamental human right. It’s a key component of the highest attainable standard of health… there’s no health without mental health.
Mental health is also a public good. That means that good mental health is crucial for people in order to be able to carry out key functions in society such as going to school, carrying out their job, having fruitful interactions with members of their family and community. So, essentially, it is key to having a functioning society and for economic prosperity.
The Maada Bio administration has a very promising human capital development policy, and they have an opportunity here to strengthen this development agenda by integrating serious investments in mental health into their strategy. This is really key in order to recover from a history of conflict and the ravages of the Ebola outbreak.
Photograph courtesy: Rawya Rageh. Cover graphic: Sunil Krishnan