The Kissy Lunatic Asylum was a building on a hill above the capital city. Behind the high walls, patients were kept in chains and it was built in the early 1800s. The screams of patients who had been treated with medication or therapy echoed out of the narrow, barred windows.
There is a wooden sign over the front desk of the outpatient department of the Sierra Leone Psychiatric Teaching Hospital. The shelves of the pharmacy are filled with drugs. Children bounce on a trampoline at a clinic. The first psychiatrists ever trained in this country will be six residents.
The transformation at Kissy is part of an effort to build a mental health care system from scratch in one of the least developed countries in the world. The residents work in the wards and see patients in the outpatient clinic. They are the only three in the country's entire health system, but a threefold increase from decades ago, when there was only one who paid the patients at Kissy a weekly visit.
The Covid-19 Pandemic has brought a surge in mental health problems and has drawn attention to the severe limits of resources to help. There are long waiting lists for appointments with therapists in high-income countries, but the shortage in the developing world is something else.
Mark van Ommeren, who heads the World Health Organization's mental health unit, said in an interview that there could be situations with one psychiatrist for every million people.
The lack of personnel to study and diagnose mental illness makes the actual scope of the burden of disease in developing countries something of a mystery. The head of the new teaching program surveyed the noisy line that spilled from the clinic into the courtyard and declared it a tragedy and a wonderful thing. Anyone over the age of 30 has lived through a civil war, an epidemic, mudslides, and now the disruptions of Covid, and they are all examples of human resilience. He said that most people have absorbed the traumas. Not everyone.
There is a lot of depression and psychopathology that goes with disaster. The wards are full. I'm going to take it to the entire population. Many people with depression, phobic states, and personality disorders will pass you by if you go through any market. This is just the beginning.
People used to bring their family here when they felt they couldn't care for them at home because of paranoia or psychosis.
When he arrives at work, he sees that patients and caregivers park their cars and motorbikes out front.
There are only three physicians for every 100,000 people in Sierra Leone, which is less than in the United States. Efforts to build the health system in the country are focused on physical health and primary care, as they are in many countries in the global south. Mental health care is not seen as a luxury.
Mental health is rarely mentioned in the curriculum of medical schools and nursing colleges in developing countries. Post-traumatic stress, depression, and schizophrenia are not taught to be diagnosed or treated by graduates of infectious disease programs.
Since the end of the civil war in 2001, the World Bank and international donors have poured money into the health system of Sierra Leone. Malaria and maternal mortality are chronic problems that the country is making gains against.
It took some help to get Kissy, named for the neighborhood where it is located, from an asylum to a teaching hospital.
Partners in Health and the Sierra Leone health ministry worked together to rehabilitate the hospital. The bars were removed. Plumbing, electrical wiring, and a giant suite of generators were installed by workers to make up for the poor service of the municipal power service. Patients were given fresh bedding in lieu of mats on the floor.
The head of nursing said that they unchained the patients on the 18th of August.
Mr. Braimah has worked at the hospital since 1998 and is known as the Matron. He studied in Nigeria and then turned down a job offer there to come home and offer his services at the health ministry, which dispatched him to the asylum.
He was both a nurse and doctor at Kissy for many years, and he was responsible for a changing roster of people who came to work there. The standard of care involved physically restraining patients and injecting them with heavy sedatives when they could be obtained.
It was difficult to feel good about the work they were doing.
The unchained patients no longer raged and threw the contents of their chamber pots, and students expressed interest in doing proper training rounds at Kissy, after the Partners in Health investment.
Before her first day at Kissy, a nursing student said her parents bombarded her with warnings. On her first day in the women's ward, she found that patients were not threatening her with violence. Some people sought her care.
On a recent day, a young patient named Aminatta brandished a bottle of orange nail varnish and offered to do Ms. Conteh's nails. From a crowded low-income neighborhood in the city, Aminatta came to Kissy with a depression that had never been treated. After a couple of months at the hospital, she smiled and held her own hands out for Ms. Conteh to do the polishing.
In the airy ward behind them, some patients lay unresponsive in their beds, while others did their laundry at a standpipe and tried to engage nurses in a lively discussion about topics including lunch, visitors and the possible return of the messiah.
Partners in Health does not usually work in the field of psychiatric care or in capital cities, it focuses on delivering services in the most underserved parts of the countries where it works. The country director of the organization visited Kissy in 2016 with a few colleagues.
It was clear that we had a moral imperative to be involved after we walked in.
The organization and the health ministry will work together to rehabilitate Kissy. A significant shift in perception of mental illness as a public health problem was involved in the effort.
The ministry hired a Nigerian doctor and a Sierra Leonean Psychiatrist to be the faculty for a few medical students who were willing to work at the clinic.
Over the course of four years, Partners in Health has spent over two million dollars on renovations at Kissy and earned accreditation as a teaching hospital. A soccer field, an occupational therapy center, and a playground have been added to the complex.
The organization's co- founder, Paul Farmer, died recently. In a conversation with a reporter shortly before his death, he said it was the most fantastic story he had ever heard.
He was horrified to learn that he had been posted to Kissy and was expecting a short stay.
Some patients were calmer and more engaged with each day, and he began to see the power that mental health care had in helping people who had been trapped in illness for years. He is close to becoming the first domestically trained psychiatrist in two more years.
In Ethiopia, there is a reminder of how long it may take to get a residency program up and running. There has been a program to train psychiatrists at the university for 18 years. Seven of the first group graduated in 2006 for a country of 115 million people. There are now psychiatrists in most of Ethiopia's major hospitals, a once-unthinkable level of coverage, thanks to the program that has grown steadily since then. That is one Psychiatrist per million people.
The need for access to mental health care is not a priority for health policy in Ethiopia or anywhere in Africa, according to Dr. Wondimagegn. Stigma feeds the idea that there is nothing to be done to help a patient who suffers from a mental illness.
Ethiopia's model includes psychiatric education for nurses and community health workers who will be the main points of interaction with the health system in rural areas. Building mental health into primary care is advocated by the W.H.O.
The rehabilitation center at Kissy will bring addiction treatment to Sierra Leone for the first time.
We have such high rates of substance abuse, have we ever wondered why it was happening? These people are not healed and have children. What do you think will happen?
Children were turned away when kissy turned them away. Dr. Allieu's clinic has helped put programming about mental health in children on radio shows.
Dr. Allieu said that they could do a lot here.
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