Chains

Jon Lascher: Welcome back to Unchain; I’m Jon Lascher, executive director of PIH in Sierra Leone. Thanks for joining us as we continue to explore the past, present, and future of mental health care in Sierra Leone, and the transformation of the country’s only psychiatric hospital.

In our last episode, we learned about three of the most decisive periods in Sierra Leone’s history--the Atlantic slave trade, British colonialism, and the civil war. But history isn’t just a thing of the past--it impacts the way we live today So we begin this episode with the question: How did this history influence how the Sierra Leone Psychiatric Teaching Hospital was built--and how is this history still present within its walls?

To answer that question, I sat down with possibly the most authoritative figure on the topic in Sierra Leone.

Dr. Edward Nahim: My name is Dr. Edward Nahim, I'm consultant psychiatrist. I've been working for the ministry of health for the last 40 years. I'm still on contract, I'm working up until now.

Jon Lascher: Dr. Edward Nahim was, for a long time, Sierra Leone’s only psychiatrist. That’s right--one psychiatrist in a country of 7 million people.

He began working at the Sierra Leone Psychiatric Teaching Hospital 40 years ago. And even now, in his supposed retirement, Dr. Nahim still sees patients there.

Dr. Nahim knows basically all there is to know about the hospital through his decades of work there, but also through research of the facility’s history.

Dr. Edward Nahim: This is the first psychiatric hospital in all of black Africa, south of the Sahara. So, as you can see, it's a very important hospital by the British then. It was meant for, you know, asylum that they brought from the United States, from England and so on. And they were treating patients from all of British West Africa then. So as you can see, it's a very important hospital and it's the first hospital in Sierra Leone anyway.

Jon Lascher: This is the very first hospital in Sierra Leone?

Dr. Edward Nahim: That’s right, very first hospital in all of Sierra Leone.

Jon Lascher: Do you know who built this hospital?

Dr. Edward Nahim: Well, it was built by the British then as I said earlier, you know because they were our colonizers and they were in charge of Sierra Leone then, and they built this hospital. And all the nurses and doctors were all British, there was no black doctor walking here during those days, all British, until they left. They handed over to government, the Republic of Sierra Leone, then the governor general and so on before, you know, we took over.

It was a hospital for asylum, you know, freed and recaptive slaves, when you are freed, they brought them to West Africa to Sierra Leone, and then they kept them in this hospital, they were treating them here. In fact, the first name of this hospital was Kissy Asylum. They went to Kissy Mental Hospital, and now to Kissy Psychiatric Hospital, Sierra Leone's Teaching Psychiatric Hospital. So as you can see, it has a very good history.

Jon Lascher: He’s a singular figure in Sierra Leone, who did work no one else was trained--let alone willing--to do. And he did so, according to most people’s memories, with great empathy and care. In short, Dr. Nahim is a household name in Sierra Leone.

Dr. Ismail Rashid: Dr. Naheem is also legendary in Sierra Leone. Uh, for the longest while, (laughs), I think it was the only qualified, um, uh, psychiatrist, that we had in Sierra Leone.

Jon Lascher: That’s our friend Dr. Ismail Rashid, African history scholar and Vassar College professor, from last episode. Dr. Rashid was a student at Fourah Bay College in Freetown when he met Dr. Nahim; when he wasn’t at Kissy, Dr. Nahim ran the student health clinic.

Dr. Ismail Rashid: So from, uh, essentially the 1980s that I got to know about, uh, Dr. Naheem, all throughout the 1990s, throughout the Sierra Leone civil, uh, war, uh, Dr. Naheem really stood out as somebody who was very patriotic. Somebody who, uh, in the midst of that, uh, during the civil war, when people, uh, with mental health, were not a major focus, uh, of health, uh, practitioners in Sierra Leone, uh, Dr. Naheem, uh, continued to serve the focus on mental health issues, and also trying to keep the hospital going under very difficult conditions.

Jon Lascher: Difficult conditions is an understatement. During the civil war, rebel soldiers attacked the hospital, destroying its structures but--tellingly--initiating no contact with patients. Dr. Nahim was, of course, there through it all.

Dr. Edward Nahim: The rebel war came to this hospital and burnt down all the places where the nurses lived, and this office where I was also, where I am right now was burnt down. Yes, this office, it's a newly built office as you can see for now, but it never went to the wards because they were afraid of patients. They thought the patients, if you talked to them, you'll get mental illness, so they avoided them. So as you can see, they actually destroyed the hospital.

Jon Lascher: And, who, were, were any of the staff here working throughout that period that the rebels came and burned down the hospital or did everyone flee?

Dr. Edward Nahim: Well, most of the staff remain with the patients on the ward and disguised themselves as patients. As I said earlier, the rebels were scared of patients because they thought if you talked to patient, you'd get mental illness. So the staff was in the ward with the patients and you are taking care of them, feeding them, giving them medicines and you know, looking after them. And, they, there was no problem with that.

Jon Lascher: The civil war left Kissy Mental Hospital in tatters. But then there were the every day difficulties that existed as routine, regardless of what was happening just outside the walls of the hospital. Dr. Nahim just mentioned one--why rebel soldiers avoided patients at all costs, and how staff kept themselves safe when the war arrived at the hospital doors. As is true around the world, stigma against those living with mental health conditions has long persisted in Sierra Leone.

Here’s Dr. Rashid again, who grew up in Freetown.

Dr. Ismail Rashid: So Kissy, which is now part of, Urban Metropolitan Freetown, uh, was just on the periphery of, uh, Freetown. The city when I was growing up, was from Cline Town to Congo Cross. Uh, and that, in itself, tells a story about how the society viewed, um, uh, mental health.

uh, hospital on the periphery of the city, dealing with people who are socially stigmatized. Uh, if people had mental illness in their family, it was stuff that they usually kept, uh ... Me- people with mental health or mental illnesses were either kept separate in rooms, locked away from public view. Or if the, their parent or the families couldn't take care of them, they were left alone to roam the street of Freetown, uh, and was seen as people, uh, with, uh, problems. Uh, usually unkempt, uh, without much social support.

Jon Lascher: Now we want to make clear that mental health conditions can affect any and all of us, regardless of where we were born, where we live, or how much money we make. But history gives us a window into how mental health conditions can go unaddressed and deepen in severity over time.  

Centuries  of colonial and economic exploitation paved the way for Sierra Leone’s civil war--a war that left the country further financially devastated, with families living in extreme poverty. And that’s combined with the theft--the active impoverishment--the country continues to endure. For centuries, American and European powers have stolen Sierra Leonean resources for their own exclusive gain--from human beings throughout the 19th century, to diamonds today.

All this has led to more than half of Sierra Leone’s population living on less than $1.90 per day. And this poverty has taken a toll on mental health. The government doesn’t have much money to spend on health care, and funding mental health is often forgotten in the face of scarce resources. --ut Meanwhile, poverty exacerbates the suffering of those living with a mental health condition, often preventing them from access to care.

Dr. Ismail Rashid: Sierra Leoneans are fond of saying that, Sierra Leone is a very wealthy country. Uh, yes, Sierra Leone is resource rich, but in real terms, is Sierra Leone is a very poor country in terms of the available, uh, uh, uh, financial resources...

What we've not been able to do is to convert, uh, our human potential, is to convert, uh, our resources, uh, into resources that would be able to generate sufficient sustate, uh, self-sustaining or sustaining wealth that, we could use to invest in those crucial areas. So within the limited resources that we're able to generate on a yearly basis, we have had to make choices. We have had to make choices.

So, in that cruel, uh, choice game, is mental health does not rise up, uh, to an area which commands a lot of resources. Uh, even when it's visible, it's not seen as an area where nationally or globally, a lot of resources and money, uh, should go.

Jon Lascher: From day one, the hospital that would become the Sierra Leone Psychiatric Teaching Hospital was in dire need of resources. For centuries--in the wake of slavery, throughout the colonial period, into independence and the civil war-- the facility lacked even the most basic of necessities: Electricity. Running water and plumbing. Decent wards, where patients lived and clinicians worked. A consistent food supply. And, critically, the medications needed to treat mental health conditions.

Anneiru Braima: It was horrible. To say the least, it was horrible.

Jon Lascher: That’s Anneiru Braima, the matron--otherwise known as the head nurse--at Sierra Leone Psychiatric Teaching Hospital. When Braima was earning his nursing degree, he had to do a two-week rotation at the hospital in the early 90s.

Do you remember- do you remember what it was like during that two-week period?

Anneiru Braima: Patients wear shackles. Windows, were run down. Doors, were run down.... Patients would urinate openly, because they had nowhere to urinate. Water was a problem. The doors- the place was... not too good. It was awful. It was not fit for human accommodation, to say the least. Yes. So. But, as I just felt, "Ugh. Let me just do my two or three weeks and then go. At least it is going to be part of my project while I'm in there. I'm going to tick the- the box that I came here." That was it, then. I had no intention of coming back.

Jon Lascher: Perhaps the most difficult part of working in the hospital were the shackles Braima mentions.

Anneiru Braima: There was difficult patient who were chained... Some patients... would develop a sore leg. Their legs would, because of the chains, would get swollen, and so medication was not enough.

Jon Lascher: Without access to medication or adequate clinical support, patients could experience bursts of violence, and prove dangerous to themselves, their fellow patients, and hospital staff. The hospital’s staff, too few in number, and without the tools and medications necessary to care for acute mental illness, resorted to chainining patients to their beds. A cruel practice, but one, it would seem, born out of necessity. They had few other options.

Now, years later, the memory of these chains is painful to recall. Though not nearly as painful as it was to use them.

Anneiru Braima: Because if you live in a therapeutic environment, even with the environment alone, makes you halfway feel better. The rest will just come. Medication will come, food will come.

But you come in an environment where you feel as if you are a slave, you are shackled... You- you- you- you- you feel you've been condemned by your relative. You've got to be- even if they give you cups and cups of medication, you're going to be difficult to- to- but when you come in an environment that's very friendly, you- you- you- it's not- it's almost similar to your home.

Jon Lascher: It is easy from an outside perspective to look at the crushing poverty of Sierra Leone and condemn the country for not doing more to unchain patients. It is common to think with a little hard work, commitment, and political will, the injustices that exist in poor communities would perish. This boot strap narrative falls short on even the most cursory investigation. In the story of Sierra Leone, or at least this one hospital, history repeats itself--or versions of itself, anyway. shackles have been a common theme, mostly used to subjugate the population, and in the case of the hospital, as a means of last resort.

So, how does this cycle get broken? How does the hospital become--literally and figuratively--unchained?

Join us next week to hear from more hospital staff, who’ve witnessed the hospital’s transformation--and undergone their own. 

Julianna Showers: Well, I thought that I must proceed because that's my job. No matter the circumstances, no matter the situation, I will try my level best. I decided to come back.

Jon Lascher: Continue to learn and explore more stories from Sierra Leone and PIH by visiting pih.org. Follow Unchain on Spotify; subscribe on Apple Podcasts and Google Podcast; or find us on YouTube under Partners In Health. Look for us @partnersinhealth on Instagram or PIH on twitter, and DM us your comments or questions.

Thank you for listening to Unchain; we’ll meet you here next week