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Broken Chains The Fate of Sierra Leone’s „craze man“

Text: Malte Werner; Photos: Olivia Acland; Ahmed Sessay, Amjata Bajoh, Ute Lederer contributed reporting

(edited version published by The New Humanitarian)

Kroo Bay is a mess. Especially during the rainy season when the downpour washes trash, debris and feces from the surrounding hills of Sierra Leone‘s capital downwards, through the shanties of roughly 7.000 people, and into the Atlantic Ocean. At least once every year the densely populated slum turns into a waist-deep sewer.

Now it’s dry season and the toxic brew has receded back into a river bed that meanders through one of the poorest spots on earth. Santigie Bayo Dumbuya stands on the river bank that consists almost entirely of litter while he watches kids playing between a dog carcass and human excrement.

“Our biggest problems are environmental and sanitary issues“, says the streetworker, and standing in this environment one is quick to agree. But these are just the most obvious problems of Sierra Leone – a country that was still recovering from a decade-long civil war when the deadliest Ebola outbreak in history struck West Africa. Dumbuya is well aware of the fact that another, barely apparent, but widespread problem is stopping the country from getting back on track.

Scars on the Psyche of Society

For two decades the traumas of war, poverty, diseases and natural disasters have burnt scars in society’s collective psyche. There are no epidemiological studies on the prevalence of mental health problems in the overall population of Sierra Leone. The World Health Organisation (WHO) estimates that ten percent of the population of seven million are affected, but due to an unknown number of unreported cases the scourge of depression, anxiety or post-traumatic stress disorder (PTSD) is likely to be much bigger. Ebola alone could have added 150.000 new cases to the list.

Professional help is hardly accessible for the suffering. For decades there was only one psychiatrist practicing in the country (now there are two of them) and treatment in the only psychiatric hospital until recently involved procedures like chaining since psychotropic drugs are hardly available. As a consequence 98.8 percent of those in need go untreated.

In the past, strong family bonds, social support within the community and traditional medicine have stepped into the breach. But the war and Ebola put these private safety nets to the test and at the same time amplified the stigma arising from mental illness. The consequences can be seen on the streets of Freetown. Mocked as “craze man“ in Sierra Leone’s lingua franca Krio (a country-wide spoken English-based creole) mentally ill outcasts roam the city.

The war left a traumatized country behind.

To understand what led to this unbearable situation one has to go back thirty years from now. When the Revolutionary United Front (RUF) started its fight against the Sierra Leone government in 1991, an eleven year long series of unimaginable atrocities against civilians unfolded. An estimated 70.000 died, half the population was displaced and masses of people witnessed the slaughtering of close relatives or had arms and legs cut off themselves. On top of this, tens of thousands of children were abducted, drugged and forced to become child soldiers. Girls were raped repeatedly and had to serve their tormentors as “bushwives“.

The war left a traumatized country behind. Moreover the fighting devastated schools and the medical infrastructure. More than ten years after the war, with only 136 doctors practicing in the whole country and not all hospitals back in action, Ebola swept in. During an 18 month period between May 2014 and November 2015 roughly 8,700 people were infected, nearly half of them died. Among the dead: dozens of doctors, nurses and midwives. Thousands of kids were orphaned by the virus, families lost their breadwinner and thus their livelihood. And Ebola-related stigma was massive.

Toxic Poverty

But the war and Ebola are not the only factors contributing to the high prevalence of mental health disorders. In a country like Sierra Leone, with more than half the population living in extreme poverty , daily hardship and misery trigger or amplify mental health problems. Destitution, hunger, violence, loss of a caregiver, emotional neglect and social isolation are what scientists call “daily stressors“. When they occur constantly and threaten life and survival, they are seen as“toxic stress“. Constant exposure to adversity results in repeat activiation of the bodily stress response. Without the access to soothing and support from caregivers this kind of stress becomes toxic. Like a slow poison it gradually damages the human psyche and is one possible cause for depression. For children growing up in adversity, “toxic stress“ can have damaging effects on learning, behaviour, and health across the lifespan.

If adversity was a place it would look a lot like Kroo Bay. On the litter-filled banks of the black-watered river you get an idea why every tenth child in this country dies before his fifth birthday. And Santigie Bayo Dumbuya might be the only one who sees a chance instead of just a problem in this 50 acres wide expanse with no electricity, running water or sewage system.

The baldheaded and round-bellied 36 year-old has started his own NGO, We Yone Child“ (Krio for „Our Own Children“) in 2009 and built a school of wood and corrugated iron in the midst of the slum. There he sits, wiping beads of sweat off his forehead, and explains what the hell made him set up a school in this god-forsaken place.

Dumbuya knows what growing up in adverse circumstances means. He was twelve when, during the war, he got picked up by rebels and was forced to fight in the jungle at the Guinea border. Constantly under threat to be killed and stoned by smoking jamba (marihuana) mixed with gun powder he became a compliant subordinate and stayed with them for years. „Our brains were not normal“, he says and it doesn’t sound like an excuse but rather an explanation. Recalling his child soldier youth talkative Dumbuya turns tight-lipped. „Whatever happened: If you are alive, then it’s good for you“, he says sending out a deep-drawn sigh.

But the hard part didn’t end with the war. Like many other former child soldiers young Dumbuya searched for his way back into society. He ran through the official Disarmament, Demobilisation and Reintegration programme and went back to school. But his uncle’s family, with whom he stayed, wanted him to leave. „They were afraid of me“, Dumbuya says.

Many returning child soldiers as well as enslaved „bushwifes“ faced distrust, shunning, neglect or blatant hostility even from their closest relatives due to their wartime experience. Other than most of his former comrades Dumbuya eluded the downward spiral of wartime traumatization , social stigma and resulting mental health problems that led to the notion of a „lost generation“ , too disturbed and violent to function productively. “One thing that really helped me was the belief that I can still do something”, he recalls his struggle.

Tremendous Resilience

At the end of the war a group of scientists expressed their concern, that “the extent of psychosocial problems that results from this mass exposure to traumatic events may ultimately threaten the prospects for long-term stability in society” . The same happened after Ebola. These gloomy predictions never came true and there is a good reason for that: resilience.

Theresa Betancourt, director of a research program on children and adversity at Boston College School of Social Work, describes resilience “as an individual’s ability to adapt and cope with stressful life events” – such as trauma caused by war, abuse or rape. It’s not a fixed trait that a given child possesses and others don’t, but a life-long process. This process, as Betancourt writes in one of her papers, can be influenced by protective factors in the child’s environment, including supportive families, schools, and communities.

Since the civil war ended, Betancourt visited Sierra Leone multiple times to follow the path of life of war affected-youth in what has become a longitudinal intergenerational study. Her findings show that conditions like PTSD, depression and anxiety among victims of the war, especially former child soldiers, often persist into adulthood . Even though not all long-term consequences trace back to war related trauma, other risk factors for poor mental health outcomes (e.g. poverty) are often linked to wartime experiences.

“There are terrible circumstances, terrible adversities and the services are very weak, difficult to access and limited”, Betancourt sums up her impressions from more than a decade of work in the field. “But at the same time there is tremendous naturally occuring resilience that is set by strong collectivity, community ties, spirituality, culture and personal perseverance. It's stunning.”

At first glance Kroo Bay is anything but a breeding ground for resilience. The harsh living conditions often lead to child neglect, violent abuse or sexual exploitation. Encouragement and family support, main drivers for building up resilience in children, are scarce. Nonetheless people are trying hard getting on in the toughest of circumstances.

Education as an exit strategy? Not for everyone.

Besides close family ties it was education that helped war-affected children to overcome their trauma and become more resilient, as Betancourt knows from her research. And this is why streetworker Santigie Dumbuya set up a school for 200 pupils in one of the poorest neighborhoods in Freetown. “The people here don’t see education as necessity”, Dumbuya says wandering Kroo Bay’s narrow labyrinthine alleys where smoke from burnt plastics burns in the nostrils. “It’s the only way out, though.”

Education as an exit strategy? Not for everyone. “Education tragically becomes an unattainable luxury while income generation attains a towering significance largely powered by sheer necessity”, Betancourt states in one of her studies. Even though official fees for primary education have been abolished years ago, money for school uniforms, learning materials or direct payments to teachers are real barriers for poor families. Instead, child labor is widespread. Only half of the pupils finish primary school , only one third of the country’s population is able to read and write respectively. “Sadly, a landscape of loss often cultivates ongoing hardship”, Betancourt warns. With problematic effects on social life and mental well-being.

That’s why Betancourt decided, that all the observational research she has done for years, was not enough. She took matters into her own hands and designed an evidence based intervention programme called Youth Readiness Initiative (YRI) to help kids regulate their emotions, engage in problem solving and increase their personal skills. „The argument we have been making is, if you address the mental health needs of these young people who lived through significant life trauma they are going to take up life oportunities better“, she says. And success seems to proof her right. Children who took part in the YRI were six times more likely to persist at attending the school. And their teachers rated them having better performances and better attendance.

Powder and Cane

Given the quantity of mental health problems in the country, her efforts are a mere drop in the ocean. But those in need find other ways to deal with mental health problems. People in spiritually shaped Sierra Leone usually seek out David Conteh or one of the other 45.000 traditional healers. Conteh’s shrine is a not easy to find blue painted clay hut amidst a tangle of tin roofed houses and alleys on a steep slope aside the main road at the east end of Freetown. On his “Mortalman Garage” shine forth the bleached out letters “Bush Doctor”. The rest of the wall is decorated with paintings of diseases Conteh cures - be it love sickness, toothache or problems giving birth.

Conteh, a scraggy man in a golden Ronko, the traditional knee-length garb, sits in a tiny room packed with piled up tube-type? TVs as well as bags of powders, roots and leafs. For more than thirty years he mixes pastes and tinctures out of natural ingredients – like his ancestors did before – to drive away evil spirits.

How that works? Conteh walks over to a shed where a young man cowers on the door step. His name is Ibrahim and he used to be a teacher up to the day his girlfriend’s father cursed him, Conteh explains. He calls upon Ibrahim to stand up. A strenuous effort for the young man. Finally Ibrahim gets on his feet, standing crooked with a small bag of white powder and a spoon in his left hand. His right hand clutches his trouser waistband which is about to slip. “He made good progress, since he came to us”, Conteh says and tells Ibrahim to walk over. His patient roars. At one point, the healer is at the end of his tether. “Bring me the cane!”, he yells at one of his helpers.

The role of traditional healers in Sierra Leone is ambivalent. In a country without comprehensive health care they are the go to people for everyday problems. Cleansing ceremonies and other rituals are deep-rooted in the national cultural heritage. Same goes for the treatment of mental problems.

Until today there is the widespread believe that mental health problems are caused by witchcraft or demons as punishment for misconduct in the past. The local people call it „noto ospitul sik” – an illness that cannot be cured in a hospital due to its transcendental provenance.

Fighting a Medical War

“Providing mental health care in this country is a challenge, due to the beliefs of people”, says Rebecca Esliker, director and only employee at the institute for psychology at the university of Makeni in central Sierra Leone. “I wouldn’t want to blame them. The only thing they know are those traditional healers.”

The dainty lady, who looks far younger than her 58 years, bears little sympathy for the healers. In her research she speaks of a “medical war the country is currently fighting” between modern medicine and what she calls myths and beliefs. “Most of the time they are making it worse”, Esliker blusters. “They might be able to stabilize someone with mild conditions but not the severe ones.”

Esliker, who was born in Sierra Leone and went to university in Ireland and the United States, holds a long list of accusations against the healers’ treatment: financial exploitation of families, who vainly hope for curation of their mentally ill relatives; irresponsible use of psychotropic medication mixed with their herbs without knowing anything about dosages and side effects; finally: violence. “When they take someone to the traditional healer, especially these severe psychotic cases, they will flog them almost on a daily basis”, Esliker recalls experiences with her patients. “They beat them mercilessly because they say that’s the way to get rid of the devil.”

Since she came back to her home country three years ago, Esliker is lobbying to put mental health on the political agenda. She is part of the Mental Health Coalition (MHC) that worked on rewriting the national legislation with the telling name “Lunacy Act” from 1902. The MHC achieved a directorate for noncommunicable disease and mental health was established within the Ministry of Health. Besides, 21 mental health nurses were trained and sent to the districts to provide basic treatment and Esliker started a clinical counselling course for PAC (physician assistant - certified). “When we started with the course we had two students”, Esliker says and with a trace of pride adds: “This year I got six. So, it’s slowly getting better.”

Despite the little progress made, mental health still is not a priority for the government. In a strategic paper published by the ministry of health for the years to come mental health is not even mentioned once. A mistake, Esliker says: “Without mental health there is no health.”

To help as many patients as possible the MHC decided to include the controversial Traditional Healer’s Union in their efforts. Healers are now trained to detect severe cases and refer them to a hospital with a mental health unit - in theory. At the “Mortalman Garage”, on whose wall the word “crazy” is written next to painting of a chained man, bush doctor David Conteh assures the hospital had given up on Ibrahim and referred the patient to him. Their alleged diagnosis: noto ospitul sik.

Disclaimer: This project has been funded by the European Journalism Center (EJC) via ist Global Health Journalism Grant Programme for Germany.

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