In South Sudan, stigma and underfunding plague mental health care

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In South Sudan, stigma and underfunding plague mental health care

Juba, South Sudan – On the side of a road a man stands by a wall ready to fight. He picks up a piece of broken glass to defend himself. 

The white cloth around him falls off and he is now bare-chested, facing five policemen. They are wearing medical gloves. 

“I don’t want to go. Leave me alone,” the man yells.

Dr Atong Ayuel, one of only three practising South Sudanese psychiatrists in the country, watches the scene unfold.

Since 2015, she has led a project supporting mentally ill homeless people, providing baths, fresh clothes, a medical check and long lasting anti-psychotics if necessary.

“It’s okay. Leave him alone. We don’t force anyone to come,” Dr Atong* tells the police and then boards a bus.

As part of the initiative, Atong, with a group of psychologists and policemen, hop onto a Juba’s Teaching Hospital bus three days a month and look out for people to help.

Dr Atong Ayuel makes sure a homeless man who refuses to partake in her project is left alone, since participation is voluntary [Jasmin Bauomy/Al Jazeera]

They treat 20 to 30 homeless patients with mental conditions a month. Over time, many have become willing participants, with some returning to families and jobs, but that’s not always the case. 

After being treated at hospital, they are usually returned to where they were picked up.

“We don’t have the infrastructure to keep them,” Atong says. There are only 12 beds and two nurses in the mental health ward at the hospital she works at.

Aside from overseeing the GEMS (Goats, Education, Medicine and Sustainability) – funded project, Atong, 40, treats hospital patients and people around the country, and heads the government’s mental health department.

The two other practicing psychiatrists are Dr George Nazario and Dr Richard Wani.

George treats patients at Juba’s main prison and the outpatient clinic. Richard works at the hospital and University of Juba.

After reaching the hospital, the homeless get a haircut, a shave, the opportunity for a bath, fresh clothes, a medical check and long-lasting anti-psychotics if needed [Jasmin Bauomy/Al Jazeera]

As the director of the mental health department, Atong develops policies for the country’s 12.5 million people, many of whom are trying to recover from the trauma caused by decades of conflict and displacement.

South Sudan suffered two civil wars before it won independence from Sudan in 2011, and is only now regaining its footing from its own civil war that lasted from 2013 until 2018. The country’s three practicing psychiatrists and 29 psychologists are all in Juba.

After independence, the South Sudanese government had to create a healthcare system from scratch. Thirteen years later, Atong and her colleagues are still struggling to provide mental healthcare. 

The Juba Teaching Hospital is the only public medical facility that provides psychiatric care; the availability of psychotropic drugs is inconsistent and limited. 

If the 12-bed ward is full, or if a patient is not eligible to take a bed, the mentally ill are often detained in Juba’s Central Prison.

One of the psychologists sits in the bus with the homeless to conduct preliminary medical interviews and assesses their mental health [Jasmin Bauomy/Al Jazeera]

Others are transferred to prison from medical facilities or taken to the detention centre directly by family members. 

In May 2016, according to rights group Amnesty, the prison held 66 male and 16 female mentally ill patients. 

While those numbers have dipped, Atong expects them to rise once again given the lack of resources.

Outside of Juba, psychiatrist Jairam Ramakrishnan, a New Zealand doctor who works for Doctors Without Borders (MSF), has been based at a clinic at a Protection of Civilians (PoC) site in Malakal, in Upper Nile State, a highly contested area, for more than a year.

“On a monthly basis we get anywhere between 30 to 40 new patients,” he tells Al Jazeera. 

Including follow-up consultations and first visits, there are about 250 mental health cases a month. 

The site is home to about 25,000 displaced people. When the United Nations force in South Sudan (UNMISS) established the camp after an outbreak of violence in 2014, improving living conditions wasn’t a priority.

Psychologists and policemen drive through Juba three times a month to pick up and care for mentally ill homeless people [Jasmin Bauomy/Al Jazeera]

To recover, Ramakrishnan says, patients need “basics like food, housing, safety, security, education transfer and employment. […] So, even though a person may have a good chance of recovery from an acute severe mental illness”, it is difficult to provide a setting where this is possible. 

“Social aspects play a big role for mental illness and social support systems are very weak in a protracted conflict.” 

As well as battling for more resources, the few psychiatrists in charge also have to tackle misconceptions.

“Mental illness is a huge problem in South Sudan,” Atong says. “We have over 60 tribes in South Sudan with different beliefs.” 

Most communities believe in supernatural possession or punishment by higher powers, as opposed to accepting a mental illness diagnosis, Atong says.

A policeman is on the lookout for possible new patients. He is one of a handful of security forces that help Dr Atong find patients on the streets of Juba [Jasmin Bauomy/Al Jazeera]

Paradise Agaak Henry, one of Atong’s patients in Juba, has been diagnosed with schizophrenia. 

She is in her 20s, loves fashion and beauty products, and is a keen student enrolled in paediatrics at the University of Upper Nile. 

“What makes me sad is to see what my former schoolmates are doing now. Some of them have finished their universities and I’m still in my first year,” she says, mourning the time she spent taking care of her mental health. “The devil attacked me and I tried to die. I didn’t eat or drink for four days.”

Her neighbours took her to church where believers tried to rid her of what they thought was an evil spirit. 

“They just prayed and cried. They beat me.” 

Her family later brought her to hospital, where she spent two months in Atong’s ward.

“It’s a stigma to be diagnosed as mentally ill,” Atong says, “people believe that it runs in the family. So when a family member is diagnosed, it could be harder for other family members to get married for example.” 

People would rather be known to be possessed than have a treatable mental illness, she explains. 

Paradise is improving. Asked whether faith or the psychiatrist helped, she says: “First of all Jesus, and then Dr Atong.”

This is my country. It’s the country I have. We’ve had a bad start, but we’re committed to create a better South Sudan for all.

Atong Ayuel, psychiatrist

Stigma is not limited to patients.

Medical professionals who choose psychiatry are looked down on by their peers, Atong explains, and their salaries often don’t match their colleagues.

Atong had earlier chosen paediatrics, but changed track when she encountered a mentally ill patient, who ended up being sent to prison. 

Her colleagues were shocked to see her “waste her talent” after she graduated second-best in her year from the University of Bahr Al Ghazal College. 

There is also a lack of accessible training, but over the last two years Atong has managed to include psychiatry as part of the curriculum at the universities of Bahr el Ghazal, Juba and Upper Nile. 

In 2017, to help doctors at least identify mental illnesses, the World Health Organization (WHO) committed to supporting the country’s health ministry in training supervisors and healthcare workers across the country.

“However, due to limited financial resources to support procurement of medication, supervision of health workers and procurement of other materials, largely not much could be done until the fourth quarter of 2018,” Dr Joseph Mogga of the WHO told Al Jazeera, adding the organisation would offer further support this year.

Atong welcomes WHO’s support. She knows the lack of funds makes it hard to move the needle. 

The country’s 2017-18 budget allocated two percent to the health sector – or about $2.7m. None of that is currently allocated for mental health.

Atong is well aware of underinvestment in healthcare but small victories keep her going. 

“Since the current minister of health [Dr Riek Gai Kok] came into power, he put mental health as a priority,” she says. He established the department of mental health within his ministry. 

In 2014 South Sudan commemorated mental health day for the first time. 

“Even in Western countries, mental healthcare always lacks [lags] behind a little compared to general healthcare.” 

In a country where general healthcare isn’t easy to come by, “you can imagine how difficult it is to establish a mental healthcare system”, says Jairam of MSF. 

But there are promising plans for 2019. 

India’s Central Public Works Department (CPWD) has taken on the challenge of building a new psychiatric hospital in Juba, next to the current psychiatric ward.

Atong plans to create a mental health policy within the national general health policy. 

“This is my country. It’s the country I have… We’ve had a bad start, but we’re committed to create a better South Sudan for all,” she says before rushing off to see another patient. 

Doctors* are usually referred to by their first name in South Sudan

This report was made possible through a reporting fellowship from the International Women’s Media Foundation (IWMF) and local journalist Samir Bol

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