A prisoner in all but name

“YOU WILL BE stunned by the suffering inside,” said Dr Abdul Jalloh, a psychiatrist at Kissy mental hospital in Freetown, Sierra Leone, as your correspondent arrived for a visit. He was right.

Opened in 1820, Kissy is Africa’s oldest psychiatric hospital and the only such facility in Sierra Leone. It has about 150 patients, most of whom were brought in by their families. Outside the wards, on the walls painted black and yellow, there are drawings made by patients. One is of a ladder going up the wall. Inside the sparse wards most male patients are chained to their iron beds. Several lie in the fetal position on the bare metal, or on what is left of a foam mattress. A teenager sits rigid, staring out of the open window. Some of the toilets are out of order, so the patients urinate and defecate in black buckets next to their beds, the fetid smell wafting through the hallways.

The two psychiatrists are overwhelmed, and the drug dispensary is bare. Eddie, a patient aged 30, says he does not feel safe, “especially after six o’clock”, when it gets dark. There is no electricity, and people from outside break in and steal his food.

Kissy may be horrific, but “the neglect of mental health is not a uniquely Sierra Leonean problem,” says Tarik Endale of the King’s Sierra Leone Partnership, an English charity working in the country. According to the world mental-health survey conducted by the WHO, between 76% and 85% of people with serious mental disorders had received no treatment in the previous year. Low-income countries spend an average of just 0.5% of their health budgets on mental health, with the vast majority of the money going on hospitals that are more like asylums. And mental-health spending made up just 0.4% of global aid spending on health between 2000 and 2014.

The neglect stems partly from the stigma attached to mental disorders. Kissy is known locally as the “craze yard”. For a doctor to choose to work there is seen as an odd and career-limiting move, notes Dr Jalloh. But mental-health problems are also neglected because they may be underreported. In a paper published in 2016 Daniel Vigo of Harvard Medical School and colleagues show that the Global Burden of Disease study ignores various personality disorders and does not count suicide and self-harm as mental-health issues. Dr Vigo reckons that mental conditions make up 13% of the global burden of disease (measured by DALYs), roughly the same as cardiovascular diseases and more than cancer.

Anti-epileptic drugs, generic antidepressants and psychotherapy for depression are all highly cost-effective, according to DCP3, which analyses the value for money offered by various health-care interventions. But providing such treatments in countries that, in effect, have no mental-health service is difficult.

One promising effort to develop these is PRIME, a project run by the University of Cape Town in parts of Ethiopia, India, Nepal, South Africa and Uganda. PRIME researchers are training nurses and community health workers in diagnosing disorders and following clinical guidelines, integrating this treatment with local primary-care systems. But resources are thinly stretched. Most of the countries where PRIME operates have less than one psychiatrist or nurse for every 100,000 people.

Back at Kissy hospital, Dr Jalloh and his colleague, Dr Bailor Barrie, are unimpressed by international donors. A huge sign celebrates an EU-funded project to refurbish five toilets, none of which is now working, mere yards from chained patients. “This is ridiculous,” Dr Barrie says. “They build toilets, have no plan, and leave.” Meanwhile the health ministry has stopped supplying drugs and new nurses. As he leaves a ward, Dr Jalloh notes: “The only difference between this place and a prison is that the patients have committed no crime.”