It is as much a statement about her as it is about her nation that Hawanatu Foday is called “mother of the crazy people.” She is a forty-seven year old nurse whose speciality is mental illness. She has no shortage of patients.
Foday works in the Kenema Government Hospital, a long and bumpy bus ride from Freetown, the capital city of her beleaguered, desperately poor country, Sierra Leone. Sierra Leone, which sits on Africa’s Atlantic coast tucked between Liberia and Guinea, is a nation of some 8.5 million people and a legacy of suffering that can feel beyond imagining. The nation, long a British colony that achieved independence in 1961, has endured a bloody civil war, an Ebola outbreak, environmental disasters, and all manner of trauma. It ranks a dismal seventh from the bottom out of 189 countries in the Human Development Index. The average life expectancy is fifty-four.
Given all it has and continues to endure it is not surprising that the one category in which Sierra Leone assumes a leading place is in mental illness. The World Health Organization estimates that a staggering twelve percent of the population, four times the global average, suffers from some form of mental illness.
Yet in all of Sierra Leone there are only two working psychiatrists; one is a military psychiatrist; the other, a young psychiatrist, works at the psychiatric hospital in Freetown. It is left to fourteen locally-trained mental health nurses to hold the country together. Sierra Leone spent almost nothing on mental health until 2016, and there was no official dedicated budget line. About half of the entire health sector workforce was not paid that year because the government didn’t have the money. And until the Ebola outbreak, no mental health units existed in the country.
What meager resources the country provides are supplemented by intermittent international aid and professionals like Hawanatu Foday. She is the sole mental health practitioner in the district of Kenema, home to 200,000 people, where she functions as nurse, doctor, administrator, and pharmacist.
Her office is tucked in a labyrinth of buildings housing male and female medical wards – all clearly labeled. While the surgical and medical wards are thronged with people sitting on the steps outside the hospital waiting for their next-of-kin, the mental health unit is almost isolated. The exterior gives few indications of identity, until you look closely and spot a poster with tiny words on the side wall – “Mental Health Brief Assessment Tool,” a flowchart asking a series of questions outlining how to recognize symptoms and seek help.
Foday smiled as I entered. She was at her desk, dressed in a white knee-length dress and matching white ballet flats. Her unbraided hair was pulled back in a rigid ponytail that stuck out from one side of her head. “Here we are consulting every day,” she said. “There is no doctor,” she thumped the books on her table. “We have books to read.”
She pulled out the few books she had: a Mental Health Gap Guidebook published by the World Health Organization, a Nurses’ Dictionary, along with a well-used manual, “Where There is No Psychiatrist.” She consults these books, she explained, because in the entire district, there is nobody more qualified to turn to. She sees up to thirty patients a week.
One morning alone some ten patients dropped into her office – an unusually high number due to the Christmas holiday season. Often, patients displayed signs of problems – emotional outbursts or rocking. Foday pointed out the ones who appeared normal were the relatives or neighbors picking up medication for patients who avoided the clinic fearing the stigma of being identified as mentally ill.
On a white mahjong paper pasted on the wall, Foday had drawn up a table with black marker, keeping tab of the number of patients she saw each month, which averaged 110 cases, the vast majority with such severe disorders like schizophrenia. There were, at most, two cases of depression and anxiety a month. What’s striking was that the global prevalence rates showed the opposite trend: schizophrenia affects only one percent of the population as compared to five percent for depression.
The military psychiatrist, Dr. Steven Sevalie, told me that the figures reveal a reluctance to seek help by those who suffer from trauma and depression because those conditions are easy to hide. “Depression is much less dramatic, in our language, we call it ‘spoil heart,’ he said. People don’t go to the hospital for that. A depressed person is seen as weak or lacking in religious faith. But the clearly psychotic are taken to the hospital because they cannot be managed at home.
“Because of the stigma around mental illness, the last thing they want to do is to be seen going to a psychiatrist,” he said. Patients with the most visible symptoms – violence, involuntary shaking, appearing naked in public, or speaking incoherently to themselves – were targets of gossip and discrimination. That’s why only the most desperate saw Foday, in search of medication to control those symptoms. Foday said all her patients had visited countless traditional healers before deciding to set foot into the mental health unit. She was their last resort.
Patients trickled in slowly one after another. One young man sat silently by his caregiver while waiting his turn. Foday explained that he was mute. Another patient looked downcast, and when I tried to make conversation, burst into uncontrollable sobs. Foday remained unflappable.
It was ninety-eight-degrees and the only ventilation came from an old-fashioned louvred window. She had purchased the office standing fan with her own money because the one donated by USAID was long broken. On a side table, a flashlight was charging, so it could be used to illuminate the adjacent toilet which lacked a working light and plumbing. A water bucket was used to flush. Near the entrance, another water bucket on a table had a basin underneath to collect wastewater, so that patients could wash their hands – a legacy of the Ebola crisis, when hand washing was promoted. Foday sat on one of the benches outside her office while we waited for more patients.
“My worst moments are when my patients’ relapse,” she said. “ They do not come for their medication and their condition comes back. “Ah,” Foday said, giving a long and audible exhale, her brows furrowed, “I feel bad.
“But when somebody comes and says ‘Nurse Hawa, thank you,’ I feel very good.”
A middle-aged female patient stepped into the unit. Foday’s face warmed into a smile as she greeted her by name in a voice that managed to exude authority and tenderness at the same time, the way a firm mother might speak to a child. She reached forward and grabbed the woman’s hands for a few moments, asking how she had been. In a short time, Foday caught up with the latest struggles in her life, how she spent her days, and whether the medicine she last prescribed had worked.
This is what Foday spends most of her day doing – “talking therapy,” she calls it. “We talk to each other like family members,” she said. Before leaving, the patient dug into her purse and pulled out a crumpled 10,000 Leonean note – equivalent to $1. “You deserve so much more,” she said to Foday, but that was all she could give.
Foday used to make home visits to her patients regularly too, especially to the ones who failed to follow up at the hospital. The WHO provided fuel subsidies and a motorbike so that nurses could conduct the visits. But the fuel subsidies ran out in 2015 and the motorbike broke down, so she stopped most of the house calls.
What worried her now was the lack of medication. Psychotropics were not yet on the prescribed list of essential medications procured by the Ministry of Health and Sanitation. Years ago, that ministry had partnered with King’s College London to provide psychotropic drugs for three years. Foday still had leftovers from that time. Many were first-generation antipsychotics that come with a side effect known as movement disorders. This could show up as partial paralysis, spasms and tremors, the rolling up of eyes, the lolling tongue, a slowness of movement, and other troubling symptoms that Foday said caused further panic and distress among patients and caregivers.
Each month, Foday said she used some of her own money to purchase from private pharmacies in Freetown second-generation drugs, such as Olanzapine, Risperidone, and Quetiapine, which had lower risks of drug-induced movement disorders. Whenever friends were traveling from Freetown to Kenema, she would ask them to buy medicine for her, then recover the costs from those patients who could pay. Another psychiatric nurse who worked in a neighboring district, Martin Senesie, told me that any decent mental health unit in the country must have nurses who were resourceful enough to procure their own medicine. “All the medicine we have now was outdated in 2017,” he said. “How can you administer expired drugs to patients? Only the cost recovery system works.”
Over the next few weeks, Foday allowed me to show up at her office again and again to watch her work. Sometimes at the end of the day, she would ask, “What? You’re coming again? What else is there for you to see here?” – and yet she kept showing me more.
One afternoon around Christmas, Foday took me on a house visit to show me just how bad life can be for the mentally ill in Sierra Leone.
Things looked fine when we rode up on a motorbike to the gate of a large family house, where six cars were parked in the garage. Such an opulent fleet is a rare sight in Kenema, if not in the entire country where sixty percent of citizens live below the national poverty line. The family that owns the house is in the business of diamond mining and is one of Kenema’s most prominent. The street on which their home stands – Jabbie Street – is named after them.
The sitting room where guests are received was stuffed with heavy couches; a second living room had a large flat-screen television. Then the luxury stopped. Foday led me to an outbuilding in the backyard with peeling green walls streaked with black dirt and mold. On the bare concrete floor, a gaunt, shirtless man was folded up on a filthy mattress with no sheets. A heavy iron chain, about half a meter in length, fastened his left leg to the floor.
“Hello Musa,” Foday called out from the doorway. Musa Jabbie lifted the elbow from his eyes, turned his head slowly, and stared.
“How are you? You remember me?” she prodded. Jabbie’s one open eye continued to stare. He did not move.
“Musa, are you tired?” Silence.
“He doesn’t want to talk to me,” said Foday, resignation in her voice.
Jabbie’s ribs stuck out from his skeletal frame. Only a few essential items lay within his reach – a large black pail to collect stool and urine, a smaller red pail to hold water for washing, and a green cup for drinking. He was forty years old and had been confined to his own home for twenty years, after bouncing between the nation’s sole mental institution, the street, and traditional healers.
Jabbie’s older brother, Ishaka Jabbie, chatted with us in the sitting room. He told us that Musa Jabbie’s symptoms began in high school. He ran naked in the streets, throwing his feces over fences. He muttered to himself, believing that he was God. Foday said this was a clear case of delusion and psychosis, coupled with substance abuse.
“Once, I saw him at the petrol station,” Foday said. “He was begging for alcohol just like a child who is begging to eat rice.”
Like many Sierra Leoneans, the family turned first to traditional healers – more than ten of them. Jabbie’s mother even took him across the border to Guinea, where her family came from, and where traditional healers have a powerful reputation. For three months there, Jabbie took a treatment of herbal medicine and rituals meant to exorcize evil spirits. His condition did not improve. The family then turned to the only psychiatrist in Sierra Leone at that time, Dr. Edward Nahim, who headed the Sierra Leone Psychiatric Hospital, in Freetown. It was a place with a fearsome reputation, commonly known by locals in the Krio language as “Crase Yard,” which translates to the place for crazy people.
There they discovered another nightmare. The institution was more of a detention center than a place to treat patients. The 200-year-old facility, once known by its colonial name “Kissy Lunatic Asylum,” was established by the British as the first asylum in colonial sub-Saharan Africa. The Lunacy Act of 1901, one of the oldest mental health laws in the world that continues to be in force today, refers to the mentally ill as “lunatics” who can be involuntarily “detained” and “confined,” can have their property seized to pay for “maintenance,” and can be arrested and returned to custody should they escape. “Lunatics” also lose their right to vote.
By the time Jabbie was admitted, the hospital’s roof was leaking and the windows were giving way. Patients used chamber pots and the floor as toilets. The in-house pharmacy was running out of medicine. The beds were filthy, hole-ridden foam mats, partially covered by sheets so old they were more like rags. Patients at risk of hurting themselves were chained by iron shackles and let out only once a week to shower. If you end up in the Crase Yard, people say, you are a gone case.
His family decided to bring him home. If he were to be under lock and chain, better in his own home. “We don’t like seeing him passing around the streets. People are watching him,” his brother said, “That reflects badly on us.” Ishaka Jabbie told me that when agitated, his brother would even attack his relatives, but the chain kept everyone safe. This was the second room they have placed him in. He destroyed the first.
Foday found out about Jabbie’s plight from a neighbor. With medication donated by King’s College London, Foday visited his home every other week to make sure he was taking the pills. That was during the time she had fuel subsidies and a working motorbike. Foday persuaded the family to let Jabbie free, assuring them that the medication would keep his behavior under control.
Within months, Jabbie’s condition seemed to improve. He was able to hold coherent conversations. But once Jabbie was let out of the chains, he would roam the streets and beg for drugs and alcohol, triggering a relapse.
Jabbie’s family was at their wits’ end. With no way to control his condition, they chained him up again.
That’s when Foday gave up on the family. She stopped visiting them for a while.
“I saw that they are tired, they are not complying again,” she said. “I became like a burden and a hindrance to them.”
Down the street from Jabbie’s house lived another family with a mentally ill son. After visiting Jabbie with me that December day, Foday decided to skip the other patient. She was feeling too defeated and vulnerable. She felt that the mother had grown too defiant for a house call to be productive. Not today. Maybe another day.
“I can become emotional here,” she laughed sheepishly.
She told me later that when a mental health care worker or doctor comes to Kenema, she brings them to visit Jabbie, in the hope that they could provide new medicines or treatments.
Sierra Leone was born out of trauma. In the 1700s, it was a major slave-trading depot for British traders. When I visited a fishing village, where the old slave trading house still stands today, a blue painted sign nailed to a tree nearby still declared, “Welcome to Kent, Slave Port”.
At the turn of the nineteenth century, Freetown, then the capital of British West Africa, was christened out of a vision of establishing a territory for freed and returning slaves. But freedom did not bring peace and prosperity. From 1991 to 2002, the bloody civil war killed between 50,000 and 120,000 people – estimates from various official sources vary widely. Fueled by profits from blood diamonds, the rebel Revolutionary United Front used knives and machetes to amputate the limbs of some 20,000 people. The conflict left 2.6 million displaced.
The decade of war has scarred an entire generation. A 2000 psychological study by Doctors Without Borders found that nearly all survey participants suffered from starvation, nine in ten witnessed someone being killed or wounded, and seven in ten had their houses destroyed. Many were also tortured and raped – events that the study said cause traumatic stress and trigger mental health disorders.
Then from 2014 to 2016, the nation became a center of the highly contagious Ebola epidemic that wiped out lives so quickly that disease carriers were not alive long enough to spread the virus into a global pandemic. Finally, a string of environmental disasters, including floods and mudslides, left over 1000 dead or missing.
Yet in Sierra Leone, in 2012, the WHO estimated that only two percent of those with severe mental illnesses were treated. More recent data does not exist, but experts believe the statistics remain relevant today. “These numbers are still appropriate and the best available specific evidence for Sierra Leone,” said Julian Eaton, a British psychiatrist and mental health director of the Christian Blind Mission, which played a leading role in advocating for mental healthcare in Sierra Leone.
It is palpable how foreign assistance buoys the economy. Large billboards line the roadsides, advertising various NGO-funded development projects. “Road Development Project, Funded by the EU,” announced one sign. “Non-Formal Primary Education, Assisted by UNICEF, with Support from the Government of Norway and Sweden,” proclaimed another.
Daily living is a struggle. In the morning, I had to walk to a communal tap, wait in queue to fill a bucket of water, and heave it back up a dirt slope to the hut in which I stayed. The average Sierra Leonean home lacks running tap water. Fewer than twenty percent of the population has reliable access to electricity. Blackouts are common. The wealthy have back-up generators but in the poorer areas the nights are pitch black and stiflingly hot. But an especially long blackout during my month there sent the entire country into a diesel shortage. Fuel stations ran empty across the capital. Even the back-up generators went dead. Rumor had it that a Turkish ship that supplies energy had left the coast of Sierra Leone because the government hadn’t paid up. I was unable to verify that piece of gossip, passed down to me over cigarettes and cookies from foreign volunteers working in the mayor’s office.
Everyone, it seemed, had a difficult story to tell. A banker told me his in-laws’ entire family perished in a mudslide after the torrential rains of 2017. Someone else told me his family had escaped to Guinea during the civil war after his entire village burned down. Another told me how he barely escaped death at the hands of a rebel who spared his life after finding out that they were born in the same village. Outside a barber shop, there was a penniless twenty-year-old high school dropout, Alhaji Kanneh, who was looking for a job to pay for further studies. He introduced me to his friends in similar predicaments who all shared suicidal thoughts. He, too, felt helpless and kept going only by praying at the mosque five times a day.
Studies show that the stress arising from poverty alone already puts Sierra Leoneans at twice the risk of developing mental health problems. What’s more, according to the Annual Health Sector Performance Report published in 2016, nearly sixty percent of health sector funding comes from donors and NGOs. That figure is much higher when it comes to mental health. Psychotropic medication remains sponsored by donors, which usually fund programs in three-year contracts. Resources flew in after crises like Ebola, but when these contracts expire, funding dries up. So does hospitals’ access to medication.
Finally, there was corruption. The Sierra Leone Anti-Corruption Commission found widespread pilfering and reselling of donated drugs by healthcare workers desperate to augment their meager salaries. A report by Amnesty International in 2011 found “no proper record keeping,” management of drugs and supplies “extremely poor,” and inventory management “weak or non-existent.” In 2015, even a third of the budget allocated for Ebola intervention went unaccounted for.
Transparency International reported in 2019 that nearly half of Sierra Leoneans paid a bribe to access public services, including healthcare. Joshua Duncan, the founder of the Mental Health Coalition, an advocacy group that has been lobbying the government to dedicate more resources to mental health, said that things have not improved much in recent years, as donated medications still don’t always reach their intended users. When medicine was ordered, he said, pharmacies did not always dispense them to the nurses. He blamed poor management and lack of transparency. “They would say it was expired. I don’t know if they sell it.” There is no government ownership of the problem, he said, as mental health is seen as “an NGO-funded issue.”
In Freetown, I met a satirical cartoonist, Ahmed Sahid Nasralla, whose wife developed psychotic symptoms in July of 2019. He brought her to see Dr. Nahim, the sole psychiatrist in Sierra Leone for 30 years. The doctor injected Nasralla’s wife with chlorpromazine, a first-generation antipsychotic drug known to cause side effects like muscle spasms or partial paralysis for one-fifth of patients. For two months, his wife could not move independently. Her tongue lolled and drool ran down her face. She turned violent when Nasralla later tried to bring her to the hospital. She tore at his ears and tried to smash his head with a mug, shouting that she was not crazy. When he finally managed to check her in, the new psychiatrist there, Dr. Abdul Jalloh, turned her away because she was causing disturbances in the ward.
When Foday began studying mental health in 2012, she did not intend to make it her career. She was working in the operating theater of the Kenema Government Hospital when her supervisor tapped her to undergo a mental health diploma training funded by the European Union. It was the first training of its kind in Sierra Leone. Foday and her colleagues didn’t think it was useful since there were no mental health positions in the hospital at that time. But she didn’t have enough seniority to turn down the assignment.
Although she had set her eyes on the more prestigious ophthalmology department, Foday grudgingly moved to the capital for the eighteen-month program, not quite knowing what it entailed. That year, her marriage was crumbling and she was under great stress. She took sleeping pills regularly. Some days she could not bring herself to class. Midway through the year, she wanted to drop out. Her classmates took turns calling her every day to check in. It dawned on Foday that she was suffering from the very symptoms of depression that she was learning about in school. With the support of her classmates, she graduated. Her own battle against depression opened her eyes to the value of mental health intervention.
But the sentiment was short-lived due to the fierce stigma linked to “crazies” and those who treat them. When she returned to the surgical unit of Kenema hospital after her training, colleagues expected Foday to “clean up the mess” of a mentally-ill destitute, known only as Robin, who slept at the entrance of the operating suite.
He drooled and laid in pools of his own urine and excrement. Foday said the judgments from her colleagues were devastating. “Everybody started stigmatizing me alongside Robin,” she said. That’s when colleagues started calling her crase man e mama. “They thought I would one day be like my patients,” Foday said, because of her exposure and frequent interaction with the mentally ill.. Even her grandmother was “freaked.”
“She was insinuating that I should start taking the drugs that I give to my patients.” When Foday left for maternity leave, no one took care of Robin. He died.
Then in May 2014, the country was struck by that Ebola epidemic. International NGOs swooped in and recognized a major need for psycho-social support for survivors and their next-of-kin. Ebola became a major turning point which pushed mental health to the forefront of national healthcare priorities.
The country’s military psychiatrist, Stephen Sevalie, told me that before the crisis, twenty mental health nurses were trained alongside Foday, but there were no resources to deploy them. They returned to their former postings and continued doing the same work they had done before the training. With no hint of irony, he added, “Fortunately, the Ebola outbreak occurred.”
That’s when King’s College London partnered with the government to provide mental health intervention. So did CBM, which worked with the Mental Health Coalition to pressure the government to open mental health units across all parts of the country.
“We negotiated with each district’s health management for an office space, ‘You give us an empty room, we will equip it for the mental health nurses,’” Joshua Duncan from the Mental Health Coalition told me. Finally, a national mental health infrastructure was created – a breakthrough. Foday rose to the vanguard of the new system.
She started out as a one-woman show with a broken chair and not much else. In January 2015, she moved into her hard-won private consultation room. Since then, two of the twenty-one nurses certified with the mental health diploma have died, one in childbirth and the other from Ebola. The numbers dwindled further due to lack of career prospects. The government had not recognized the mental health diploma as a specialist accreditation, so the nurses had no path to rise up the ranks. Soon, the numbers fell to fourteen, as a fifth of the nurses defected from the mental health track, either to pursue a second degree, or to become a midwife, a nursing track that can lead to the coveted rank of matron – the highest rank in the profession.
The lack of career progress threatened to undo what little progress was made in mental health. There was no reliable performance evaluation, so nurses began playing truant. But aid workers told me Foday stood apart. She was the “star nurse,” Hege Lind, a mental health specialist with King College’s Sierra Leone Partnership told me. Foday’s district saw the highest caseload – sometimes five times as high as those in other districts. Several experts believed this was testament to the hours of work she put in, and the outreach work she did, rather than abnormally high case rates in her district. Foday opened the doors of her clinic six days a week, except on Christmas and New Year’s. During the holiday season, government offices closed for three weeks and I saw some of Foday’s colleagues from other departments pack up and go home to their villages. Foday’s salary and rank remained stagnant for six years. She earned less than $250 a month.
“I felt so let down, being stuck in one position, having no way forward,” Foday said, her head nodding brusquely to the emotional cadence of her speech. “I asked myself, ‘Am I really going to stay in mental health?
“But when I look at those patients, I think, ‘if I leave, where will they go?’ It is so hard for me to detach myself.”
Last December, the government finally accredited Foday and three of her colleagues. The Mental Health Coalition’s lobbying efforts, along with declining numbers of mental health nurses, helped move the needle. Foday got a $60 a month increment. That was all she needed to stay.
Foday was no stranger to trauma. She had watched five siblings die when they were infants. She grew up in a polygamous household of thirty. Mealtimes were a battle of fastest fingers. “We used to run for the food,” she said. “ If you’re slow, the food will be gone.”
When the Civil War broke out, Foday fled her village, Komende Station. In 1998, before the war ended, her father died of a heart attack. Foday was twenty-four. She became the breadwinner of the family, working for an international organization, Medical Emergency Relief International (Merlin), and with her salary, put three siblings through school. Five years after the war ended, Foday got a nursing scholarship which led her to her current career. Looking back, her fate had been shaped by her six-year-old self, who had insisted on going to school.
“I wish I could say I was dressed one morning in my beautiful uniform to be taken to school – No, it didn’t work that way,” said Foday, conjuring up the dreams of her childhood.
Only one child from each wife got to attend school. That spot was reserved for boys, but the older boys in Foday’s family had died, and Foday became the only child ready for school in her family.
“I followed my stepbrother by myself,” she said. “I packed all of my belongings and went outside the compound. My parents didn’t want me to go. But I ran all the way to the school. The teacher asked for my name. My father caught up with me to withdraw me from the school but the teacher said, ‘No, she has come. She will stay.’”
When the war broke out, Foday had nearly finished secondary school, but many of siblings and stepsiblings had to drop out. “They decided to go to the mining area,” she said. “When you see them now, they didn’t learn skills, they will be mining the rest of their lives.” It is an intergenerational poverty that is hard to escape, Foday said, because they have their own children and families now.
“Those of us who have survived, you have to really carry a burden,” she said. “.We fought for our family to stand up.”
In 2014 Ebola killed Foday’s younger brother, and her mother became suicidal. Foday had to protect herself from the infectious disease, counsel her mother remotely, deal with the burden of being a mental health nurse in public health crisis, all while taking care of her newborn, who was delivered on the very same day in the same hospital where the first Ebola patient was admitted, the same hospital where she worked.
“Imagine your grieving mother,” she said, “and you’re telling her not to come to your house, how painful is that? I felt so guilty. Being a nurse, I couldn’t care for my brother because by then I was breastfeeding, and I was afraid of contaminating my son. I took care of my baby until my hands were weak.”
Foday was at home on maternity leave when she first heard the news that her brother had died. She remembered that moment clearly. Her phone rang. It was a colleague. In the background, she overheard someone else saying, “No, don’t tell her the news yet.” That was how she knew the worst had happened.
She fled her house and ran all the way to the church. She didn’t want her neighbors and landlord to find out, for fear of being driven out of the house due to the stigma attached to Ebola victims and their next-of-kins.
At the church, she met other church members and elders. Still, she hid her secret.
“I didn’t want people to feel pity for me. I didn’t want people to touch me,” she said. “I didn’t want people to cry. I tried to hold myself, but my phone was lying there on the chair. Phone calls were just coming in and I said to myself, ‘Wow, indeed it is true. My brother has gone.’
“The church elders asked if we had any prayer requests. I told them finally that I lost my brother and they should join me to pray for him. But instead of joining me to pray, they all joined me to cry,” Foday laughed at the memory.
When she went back home, friends and family came to offer condolences, but the landlord chased them away, not wanting the shared housing compound to be quarantined if it were suspected to have contained an Ebola victim. “We were sidelined. When people came to grieve, they could not enter the room and they had to stand outside.”
Foday asked everyone who wanted to mourn to go to her mother’s house in the village instead. “When I got there, there was a whole crowd and I got scared again. Gathering. Touching. Transfer of disease. You don’t know who to trust. I wrapped my boy so tightly to my back. When I got down off the motorbike taxi everybody tried to hold me. People were coming to take my baby and I said, ‘No. Stop.’”
That was the moment her newborn son became known as Baghala, which means “untouched” in Mende. Her nursing instincts kicked in. She admonished the crying crowd.
“Everybody was crying. I took my time to calm them down and quiet them. The young man is gone now, but the question we must ask ourselves is who is next? It is a nightmare. We can never tell. So please, let’s cry consciously and we should not touch.’ People were looking at me as if I were so strange.” But her caution kept her family safe. After that, she said, she went to the back of her mother’s house to cry, alone.
“When the crisis was over, and they started allowing gatherings to take place again, we decided to have a memorial for my brother. That was the day I didn’t know how to control myself. The tears were just draining. I told my heart, ‘No, you stop now.’ Then the tears say, ‘No, I will flow more!’” Foday laughed. “I cried for the rest of the night; I couldn’t stop myself.”
While Foday’s neighbors thought she was cold-hearted, her former patients remember her fondly. An Ebola survivor, Alieu Sheriff, who lost two family members to the disease, first stepped into the hospital with post-Ebola health complications. He was withdrawn and hesitant to answer the doctor’s questions honestly. He intentionally left his identity card at home, because anyone identified as infected by Ebola is shunned. Sheriff tried to hide his condition, but “Hawanatu is too smart,” he said. Foday invited him to attend weekly group counseling sessions with other survivors. Eventually, he started socializing again.
Another Ebola survivor, Mohammad Yilah, told me Foday had a particularly good way of talking to people. “There were other volunteers at the post-Ebola clinic, but the way they approach you and talk to you sometimes makes you more furious. They judge your problems. Hawanatu is a professional.”
The mental health unit is seen by many as a last resort. Stigma keeps people away. Foday knows that nearly all of her patients have sought treatment from traditional healers before turning to her in desperation. Healers are, after all, much more common than mental health professionals. According to the president of the Traditional Healers’ Union, 36,000 healers are registered across the country. Kenema district alone has 1,346.
Traditional African medicine dates to pre-colonial times and is still a dominant source of healthcare for millions of Africans. Healers are treated with respect and are seen as custodians of indigenous knowledge. The centuries-old tradition, deeply ingrained in the Sierra Leonean psyche, is difficult to dislodge. A caregiver who wanted to check his wife into the psychiatric hospital told me he faced hostile resistance from her family, who preferred traditional healing sessions, even though they cost much more than the free treatment at the mental health unit.
I tracked down Yusof Abu Bakar Sheriff, a healer who had treated one of Foday’s patients, until the nurse intervened with her family to get her to leave. Foday refused to go back with me and disagreed with some of the methods but said “This is a national problem.” “I don’t want to go there to make trouble.” She saw herself as helpless against the deep-seated distrust towards Western psychiatric medicine. She had rescued the young patient, Saidu, who was in tears and extremely thin. Foday diagnosed her with depression with psychotic features. With the help of the Reverend Father, Foday persuaded Saidu’s husband to get her out of Sheriff’s place and bring her to the government hospital for treatment. At the healer’s place, Foday says, patients are fed only with two or three pieces of boiled plantain each morning so virtually starved. She witnessed patients tied to logs, and those who could not pay for treatment were forced to work on farms.
Sheriff works at Mantehun Village, some thirty minutes’ drive from the city center. Sheriff was at the mosque in a nearby town for Friday prayers. His apprentice, Abdullah Lahai, showed me the huts made from mud and covered with tin or straw roofing, that served as the treatment center. There was no running water. As I chatted with Lahai on the verandah, women wandered out from surrounding huts to wave or listen to us talk. Some were incoherent. The translator could barely make sense of what they were saying.
Lahai, along with other traditional healers I spoke to, said “diseases of the mind” are caused by demonic possession or curses cast by jealous family members or rivals. The most common treatment is “smoking” or sitting in a hut covered in a black blanket over a steaming pot of herbs. The hot vapor is meant to chase away evil spirits.
When I met a support group for mentally ill patients at the office of the Mental Health Coalition advocacy group, a twenty-seven-year-old man who had received this treatment struggled to describe the torment he experienced.
“It burns you,” he said, haltingly. “The moment the healer covers me I have to shout. You shout, because at the instant of that first heat, you feel it inside. Imagine somebody push you into a fire, you just shout, ‘AHHH.’” The staff held him down by the shoulders, keeping the blanket in place.
Another common practice involves placing the patient on a straw bed, with an open fire underneath. The sweating process is meant to cleanse evil. A bipolar patient, Paul Kaikai, told me that he was nearly burned when a gust of wind blew the fire out of control. He managed to leap out just in time to avoid serious injury.
Patients are also prescribed “medicine water.” The healer copies a Koranic verse onto a wooden plaque and then washes the ink off with water. The patient then drinks the black runoff.
In severe cases, the healer asks for sacrifices. Caregivers bring a goat or other livestock, which is slaughtered with prayers and eaten in a communal feast. If patients cannot afford treatment, they must contribute labor as payment in kind. Lahai led me on a fifteen-minute walk down a dirt trail leading from the huts to a farm, where he said patients assisted with agricultural work and clearing bushes. Later in the day, back at the huts, I saw patients doing household chores, washing dishes and fetching water.
I asked Lahai if they chained patients. After some back and forth with my translator, during which he told us his boss had told him not to reveal too much, he led me back to the hut containing the heat furnace. This time, he pointed out a log which I had not noticed before. He flipped the log around; iron shackles were secured underneath. Lahai demonstrated how patients would be restrained by their ankles, sometimes for the whole day, to control aggression.
Before I left, I asked to tour the wards. Patients share a mud hut with local villagers. He led me to a big room, with a low bed on one side, and empty floor space on the other side. A blanket was rolled up to one side of the room.
“The patients sleep here?” I asked, pointing to the bed.
No, the patients sleep on the floor, he said. One of the staff or apprentices sleeps on the bed to keep watch over them. At this point, a young woman appeared, one of the patients who slept in this room. She said she was eighteen. At fifteen, she had been raped by her teacher, gave birth to a child, dropped out of school, and descended into despair.
“Have they given you any treatment?” I asked.
“Nothing. The medicine is not yet prepared.”
“Do you like staying here?”
“No.”
“Do you want to go home?”
“Yes.”
“Have you told your parents?”
“Yes, but they said I have to take the medicine first.”
A group of staff surrounded us. The girl curled herself into a ball against the wall. Lahai urged me to hurry up and wouldn’t let me ask more questions.
This was not the only time I had heard about torture, servitude, and even sexual abuse. Many mentally-ill patients I met recounted similar stories. Martin Senesie, the mental health nurse who works in Kailahun district, told me that such experiences are common among his patients. Foday recalled that when she rescued her patient from the Sheriff’s place, she saw another patient carrying an infant. Suspicious, she quizzed the healer, who admitted that his apprentice had impregnated the woman.
British psychiatrist Julian Eaton, who has worked in Africa for over fifteen years, said that families can be so desperate that they leave the fates of loved ones to the healers. “Parents don’t know what to do with a son who is aggressive,” he said, “and find solutions in traditional healers who say they can take the problem away, drug the patient up, or chain the patient.” The abuse is not just ineffective but damaging. “If you already have a mental health condition, and you are chained up for six months, have no food and water for a week, or get burnt and cut, this is bad for your mental health.”
A young man named Foday Henry Bangura, no relation to the Kenema nurse, showed me scars on his shoulders from a hot iron. It was branded onto his skin to prevent evil spirits from entering. He said he was chained a few hours every day, with shackles – “the kind they use on dogs.” When he got out of the healer’s place, he had to go to the hospital for burn treatments and a tetanus shot. Yet he completed the traditional treatment, with his mother witnessing it and staying with him throughout his two weeks with the healer, as they both believed it was the only way to cure his illness.
These customs often drive a poor family further into poverty. “There is an enormous amount of exploitation going on,” Eaton said. Parents with mentally ill children are duped with promises of miraculous healing for a very large sum of money. “Of course (the healers) don’t deliver. Parents would be told there is someone else a bit further away and more expensive with magical healing. These families would go bankrupt going from one healer to another.”
A typical traditional healing session costs as much as $80, an exorbitant price when the average annual income is just $1,240. Many patients end up indebted to their healers.
Eaton said that traditional healers had an important role to play in the past before the introduction of contemporary medicine. “The great majority of western pharmaceutical drugs have come from local traditional histories,” he said. But the knowledge has been diluted over generations, he added, as the passing down of knowledge and wisdom that used to involve decades of training from older healers has broken down, and some healers today “make it up as they go along for the money.”
One afternoon during a lull at work, I found Foday listening to a sermon on her phone. She looked up and smiled. On her desk, I spotted a book of Psalms. “I have one of these everywhere, “she said. “The only place I don’t have it is my kitchen and the toilet.”
When she first heard the news that her brother died, she ran all the way from home to church to cry. Today, Foday’s “talking therapy” sometimes involves reading Biblical verses to her patients.
According to the Inter-Religious Council of Sierra Leone, ninety-nine percent of citizens are either Muslim or Christian. Anyone who professes not to have a religion is met with incredulity. On the dusty streets, auto rickshaws and minibusses brandish colorful hand-painted religious phrases, like “Praise to be Allah,” or “God Never Twists Justice.”
Harold Koenig, a psychiatric professor at Duke University who is a leading academic on the role of religion in mental health, said that spirituality has long served as the primary way people deal with stress, trauma and loss, especially prior to the advent of Western mental health care, which has only been around for about 100 years.
“In some ways religion surpasses the benefit of formal mental health care,” Koenig told me. People cope better with change when “nothing else is as important as their relationship with God that will never go away.”
On Christmas day, I followed Foday to church. She met me at a road junction, looking sprightly in a colorful floral dress, her hair covered in a matching bandanna. She led me through a cluster of homes until we arrived at a large wooden hut.
Strings of glossy red, green, and golden paper cut outs of the Chinese word “Double Happiness” hung from the ceiling beams, along with red and orange pineapple lanterns. It was odd to see these decorations – typical of Chinese weddings and New Year’s – appearing in a West African church.
Foday walked straight to the front of the church and sat on the second row, in front of the pew. There was no electricity. The generator did not work that morning, so the service started without sound. During praise and worship, Foday closed her eyes and raised her head, singing, clapping, and swaying to the songs. When the segment ended, the church burst into a chatter of voices as everyone recited aloud their personal praises and gratitude to God. Midway through, the generator roared to life. The organ started working and the sound of drums burst through the speakers. The congregation began dancing to the music.
For those who can’t afford to pay for traditional healers, pastors and imams provide faith healing for free, or for gifts. The United Church of Assurance, located a few minutes’ walk from the center of Kenema, is known for its “deliverance service.” I visited the church one morning, and met seventeen-year-old Agnes Parseway. She spoke in a whisper and barely looked up from the ground. She came to the church in February 2019, after experiencing heart palpitations and confusion. Parseway showed me a scar on her arm where she had bitten herself, and more on her thighs where she jabbed at her flesh. She threw stones at people, tore off her clothes in public, and ate food from the ground.
Her parents first brought her to a traditional healer, who chained her for several hours a day, and rubbed herbs on her chest. Her ankles revealed scars from the friction of the chains. Parseway left the healer after a week, no better for the experience.
“Instead of saying that he could not cure me, he just said that I am a witch and if I don’t confess, I will die within a month,” she murmured, avoiding my eyes.
Her parents then brought her to a private hospital in Kenema, but the doctors said the problem was spiritual, not medical, because they could not find anything wrong with her. So, a neighbor directed Parseway’s family to the church. After praying with the bishop, Parseway made it her home, claiming that with the protection of the church, she has stopped her psychotic episodes. To express her gratitude, Parseway volunteers as a maid, cleaning and taking care of the church compound. The bishop told her that her aunt had placed a curse on her and it was no longer safe to go home. “It came to me in a revelation,” the bishop proclaimed, “Her aunty even confessed to it.”
As I was speaking with Parseway, a new patient came in. He was paralyzed on his left side. His brother held him up. We waited as another relative left to buy a bottle of olive oil for the “healing ritual”. Bishop Francis Jarfoi and his assistant pastor sang a song of worship. In a ringing voice, he shouted a string of prayers while the brother held open each of the patient’s eyes and mouth so the bishop could pour the oil into them.
“By the blood you are healed!” . . . “I release his tongue to talk!” . . . “In the mighty name of Jesus…I activate your tissue!” The Bishop beat the patient’s arm. “All your tissue and muscle will now be activated by the power of the holy God!” Beat. Beat. Beat. “I command supernatural deliverance! Remove any disturbance of the brain in the mighty name of Jesus!” The process lasted five minutes. The man remained paralyzed and unable to walk on his own.
Bishop Jarfoi turned to me. “This was a heavy attack,” he said. The man would have to come back every morning for more healing sessions, he explained. It could take weeks to fully recover.
Bishop Jarfoi said that seventy percent of the cases he sees result from curses or witchcraft inflicted by a “juju man,” or evil sorcerer. The other thirty percent involve trauma or emotional issues, stemming from marriage troubles, poverty, infidelity, polygamy, barrenness and abandonment. For these cases, he offers counseling.
I asked him how he could tell apart cases of spiritual attacks from the more mundane ones.
“The Holy Spirit reveals to me in revelation,” he replied.
The major gap in mental health treatment is filled by faith healers like Bishop Jarfoi and traditional healers like Sheriff.
Dr. Sevalie, the military psychiatrist, told me there is a huge market for them. “If I believe what I experience is witchcraft, I will go to the witch doctor,” he explained. “Superstition is very common. Imagine you hear voices talking to you, and there is nobody in the room, you might think that the angels have started communicating with you. You think ‘Finally, I’m receiving the anointing’, so coming to the hospital is the last option, not the first.” When hallucination is perceived as a sign of God talking, then going to see a pastor or imam is the most natural choice.
Yet the exploitation and human rights abuses of mentally ill patients is not unique to the traditional healing sector or to Sierra Leone. Eaton noted that abuse occurs as well in badly run psychiatric hospitals across the developed world but checks and balances exist. For instance, Britain requires a second opinion from an additional psychiatrist and further assessment by a social worker. It also has avenues to appeal against involuntary hospitalization. None of these guardrails exist in Sierra Leone.
Yet given the revered status that traditional healers hold in Sierra Leone, imposing a Western medical perspective without respecting local traditions would only fan the stigma and resistance towards a pathological view of mental health.
Spiritual and traditional healers still have tremendous value in “managing social justice,” Eaton said. “If you have mental health problems arising from a family dispute, or the use of drugs and alcohol or domestic violence, traditional healing systems can be quite useful in managing abusive behavior.” For example, healers can play a stewardship role in stopping a husband from beating his wife or finding meaningful ways for young people to stop abusing drugs and alcohol.
In 2019, the Mental Health Coalition worked with the traditional healers’ union to organize dialogues between mental health nurses and traditional healers. Duncan, the founder of the advocacy group, hoped that they could get traditional healers to refer cases of mentally ill patients to district hospitals, and to discourage harmful practices such as torture and chaining. But in the very first training, Duncan said, the healers came decked out in their costumes, and brought along their tools and concoctions of herbal medicine. They thought the nurses didn’t know how to treat “spiritual cases” and were eager to showcase their prowess.
The dialogues seemed to have yielded limited results. So far, only fifty healers have participated in the discourse. While nurses told me that traditional healers are supposed to refer cases to them, healers I met told me the opposite. They too, claim that they are working with hospitals to get doctors and nurses to refer cases to them, since that’s their domain of specialty and no number of medical scans can figure out the problem of a patient hit by a “spiritual attack.”
In May 2017, after years of pressuring the government, the Mental Health Coalition scored a big win: the creation of a mental health directorate within the Ministry of Health and Sanitation. In June 2019, the government announced a four-year National Mental Health Strategic Plan, hoping to create a budget for mental health and psychiatric medicines.
But the government has an inconsistent record at keeping promises: the World Bank ranks Sierra Leone at 171 out of 193 countries in government effectiveness. The biggest obstacle, Dr. Savalie said, is the lack of political will which will only change with a major shift in how mental illness is perceived.
“People consider the seriousness of disease by mortality, but what we ignore is disability. At times, it’s better. If you are dead, you are dead. You are not eating anymore,” he said. “But when you are disabled, you are not contributing to the economy and you are taking from it. The government fails to consider that the biggest economic problems are the diseases that cause disability.”
Mental health must compete for limited government resources against urgent health concerns with deadly consequences. What’s worse, most healthcare professionals know little about mental health. With few advocates from within the medical community, Sevalie said, “It is not easy for mental health to survive that competition.”
Most improvements are often those pushed by NGOs. In December 2017, Sierra Leone’s only psychiatric hospital got a facelift from Partners in Health, the Boston-based nonprofit. The hospital now has constant electricity, fans, adequate medication, and wards that no longer reek. Chaining has been replaced by more humane chemical sedatives.
The physical makeover, though, is not enough to make up for the hospital’s dreadful history and reputation. Back at Jabbie’s house – the fancy abode that conceals a chained man – Foday encouraged the family to check the patient into a private faith-based institution called the City of Rest, run by a Christian pastor. It is the only other in-patient mental health facility in the country besides the Sierra Leone Psychiatric Hospital.
I asked Foday why she did not recommend the newly equipped hospital.
Without a pause, as if stating the obvious, she told me that patients who had been to the hospital before its renovations would never set foot there again, because it was a living hell for them. “There is no healing without trust,” she said.
The stigma towards the mentally ill may take a long time to change. Only eight of twenty scholarships for psychiatric nurses were accepted in 2019. “People think once you are working in mental health, you will become mentally unwell. People call you in Krio, “crase man e doctor”, or doctor for the crazy people,” Kadiatu Savage, the mental health coordinator of the Ministry of Health, explained, Many candidates offered the scholarship suddenly pulled out, she said, because their own families would not allow them to have anything to do with the “crase man”. The country’s first four-year bachelor’s degree for mental health clinicians only attracted two students.
But awareness of the problem is gaining and advocacy is coming from the most unlikely of corners – the nation’s twenty-three-year old beauty queen, Enid-Boston Jones. At fifteen, she was so depressed that she contemplated slitting her wrists. Now she is one of the nation’s most eloquent champions of mental health. “People don’t even know what depression is. If you are moody, we take it as if it is your personality,” she said. “I didn’t know that was a disorder.” That changed when she came across an article about depression online.
Jones’ journey as Miss Sierra Leone brought her to London to compete in the Miss World contest. A fellow contestant had a panic attack. It was the first time Jones had heard of such a thing. “Everybody was talking at once in the morning, it was too much for her and she freaked out. I live in a country where that chaos is a normal thing,” said Jones. It dawned on Jones that just getting through daily life in Sierra Leone, from dealing with the unpredictable shutdown of essential public services, to navigating the potholed roads filled with honking auto rickshaws and yelling drivers, was creating levels of stress that were not considered normal in countries like Britain.
She realized that winning the pageant, which may be disdained in the west as an objectification of women, actually gave her a platform. Jones has been using that platform on radio and other media to campaign for training counselors, a career that is nonexistent now. . She said the idea of speaking to a professional counselor is considered absurd in Sierra Leone. If you have a problem, you talk to your family or priest – or most often, no one. Jones plans to become a certified counselor herself.
Years after the Ebola epidemic brought renewed attention to the need for mental health care, projects expired, donor funding dwindled, and international experts left. Local nurses like Foday are the ones remaining to help struggling patients and they fear that until the next disaster strikes that gathers international attention, Sierra Leoneans may be left to fend for themselves.
Like nearly everyone of her generation, Foday still bore the scars of extreme poverty and a prolonged civil war. Her children grew up listening to her stories of broken dreams. She is determined that her trauma ends with her generation. Education changed the course of her life. Her daughter is now in university – a dream that Foday hopes to achieve for herself, even if it means becoming the oldest woman in class. “I don’t mind if by then there is more gray hair on my head,” she said. For her, a further degree could help justify a promotion, and hopefully get mental health recognised as a specialist track.
Reflecting on her journey, Foday saw herself as fortunate. “Above all, I still made it somewhere. I am just happy that my children didn’t go through all those things.” After a pause, she added, “I am victorious, I survived! That’s why I am always very thankful.”
Back at her office, Foday met with me for weeks, hoping to raise awareness about the problems of mental health care as well as the badly needed resources. On the very last day we spent together, she told me of her dream to pursue her studies. Perhaps someone would mobilize resources to help them all? A scholarship? Funding for the mental health care units? Or at least the medicines they so desperately needed?
For Foday herself, and the patients she inspires to see themselves as victors, her unwavering belief is the biggest key to their resilience. “Wear your scars with confidence, not shame,” she tells them. To keep herself going, as well as her patients, when things are rough, which they always are, she has hung outside her cluttered office a sign that reads: “MOTIVATIONAL!!!! I encourage you to accept that you may not be able to see a path right now, but that doesn’t mean it’s not there!!!!!”
Minmin Low is an award-winning documentary producer and journalist. She is currently a foreign correspondent in China and holds an MA in Journalism from Columbia University.
