"How Will I Face My World?"

Jon Lascher: Welcome back to Unchain; I’m Jon Lascher.  Thanks for joining us again to explore the past, present, and future of mental health care in Sierra Leone, through the story of the country’s only dedicated mental health care facility: Sierra Leone Psychiatric Teaching Hospital.

In our last episode, we learned about all of the transformations that have taken place at the Hospital--both structural and personal. Not only were wards renovated, medications procured, and electricity introduced--people’s beliefs about what is possible, in Sierra Leone and at the hospital, changed, too. 

For our final episode of Unchain, we wanted to explore the deeply ingrained stigma around mental health that persists --not just in Sierra Leone, but around the world.

The hospital wasn’t always called Sierra Leone Psychiatric Teaching Hospital. Colloquially, it used to go by another name.

Julianna Showers: Well, at first we, the first name for this hospital is Kissy Crazy Yard.

Jon Lascher: That's our friend Julianna Showers, who we’ve heard from in the last few episodes. She has spent 36 years and counting working as a mental health nurse at the hospital--and she’s seen first-hand the damage that a nickname like “Kissy Crazy Yard” can do.

Julianna specifically remembers when patients stepped outside of the hospital and into the community, typically in search of food or water. When they ran into people living in the neighborhood, it was often tense, at best. And sometimes it even turned aggressive.

Julianna Showers: So some of them will take stone on hits the patients and the patient will retaliate. The patients will re- retaliate. So they get a lot of stigma when they go outside. People accuse them. People shout to them. "Get out, you're crazy. I don't want to see you here." 

Jon Lascher: Julianna would try to broker peace between neighbors and patients...

Julianna Showers: I will go to the community and advise people, let them not throw stone at the patient. Let them not provoke them, do it like provocation.

I will call the patient and advise him or her. Even if they call their, call them names, let me say this and crazy patient, crazy somebody, let them not say anything. Let them just walk in and come into the hospital or into their houses. I will not tell them to retaliate because they retaliate, it will cause more problem.

Jon Lascher: But fear, misunderstanding, and stigma run deep. And Julianna frequently worried that it would get even worse as residents living in the neighborhood around the hospital, instigated these hostile encounters. Stigma was built on stereotypes and misconceptions about people living with mental health conditions.  Such as, the stereotype that having a mental health condition increases the likelihood of violence and aggression.

This idea is false. But it has real consequences for mental health patients.

Aminata: Well, (laughs). As you have rightly said, the stigma that is associated with mental health conditions in this part of the world, our, our own reality. The reality is when once you... they've learned that you have received care at this facility, this mental health facility, you're stigmatized.

Jon Lascher: This is a person with lived experience who was once admitted to the Sierra Leone Psychiatric Teaching Hospital; she was discharged about two months ago now.

To take you a bit behind the scenes: We interviewed this patient a few months ago and were going to share her full story about what led to her admission at the hospital. But--very understandably--she was reluctant to share identifying information, such as her name. So we’re calling her Aminata.

Aminata: Why am I apprehensive? I still have a, a life in front of me. And being is that it's me, that when once you are admitted at this hospital, they class you as someone that has nothing to offer, someone that no one should listen to, somebody that does not speak sense.

And so you are stigmatized. So I'm just a bit worried that, that could affect me in a way because maybe after I would have left here, I want to pursue some other career, I want to pursue life, then that will come back to haunt me.

Jon Lascher: As a patient, Aminata knows that stigma all too well. It is sadly often unavoidable.

Aminata: Though the, the, the, the journey is still very far. It will change with time, because this has happened out of decades, hundreds of years of our existence, you know, our understanding, our cultural beliefs. Most people believe that when people suffer from mental illness, they, they, they have evil spirits, they are evil people. People say that to us. So for one to deal with those, those issues, it is really challenging. I cannot say it's insurmountable but it's challenging.

And I don't know how we'll get around that problem. Maybe more of sensitization, more education for, for the, for the populace, most sensitization, more awareness raising for them to know the conditions that are treated here. And how they are treated. And how those... the people that are treated in this facility should be looked at. And not only those here, those out there.

Jon Lascher: This is a point of passion for Dr. Abdul Jalloh, who is a psychiatrist and currently in charge of the Sierra Leone Psychiatric Teaching Hospital. In fact, for decades, he’s been an advocate.

Dr. Abdul Jalloh: Mental illness can affect anybody. It doesn't- it doesn't discriminate. It can affect any age, either child or adult. It, I mean, either- I mean- I mean, you are rich or poor, it's- it can affect anybody.

Jon Lascher: Since 2018, Partners In Health, the Ministry of Health, and Dr. Jalloh in particular have launched a number of efforts specifically to combat stigma about mental health conditions. Starting with the hospital’s name: changed from Kissy Mental Hospital, with its decades of baggage, to Sierra Leone Psychiatric Teaching Hospital.

The words “teaching hospital” are key here -- one of Dr. Jalloh’s greatest hopes is that more Sierra Leonean clinicians join him in the mental health care field.

Because when he started working at the hospital, he was only the second psychiatrist to take a job there.

Interviewer: And what prompted you to study psychiatry?

Dr. Abdul Jalloh: Wow. (laughs) Long story. Um, to start with, it was a- it was the result of, um, a love for humanity.

Because, um, during my fourth year in medical school, w- we were posted here. Um, in, like, on- um, a r- two weeks r- ro- rotation. So, um, uh, when we came, the state of the- of the hospital by then was very devastating, and pa- patient we- were being chained. And- and then, we had only one ps- psychiatrist, who was- who was in charge o- of t- t- treating them, Dr. Nahim.

So, um, um, I thought it fit that... I mean, someone has to take the challenge... to come and help humanity.

I told my colleagues in class that I'm going to do psychiatry. They thought it was a joke.

Interviewer: Why did your- your friends in school think you were joking when you said you were going to go into psychiatry?

Dr. Abdul Jalloh: Because, for them, ps- psychiatry... I mean- I mean, it's- it is not a- it has no money, and, um, and then they see, I mean, people w- with mental illness, that they don't get cure. So, uh- so, I mean, th- they say it's "so- so weird." Yeah.

Jon Lascher: The lack of resources available for mental health care in Sierra Leone made the field unattractive, even futile, to most aspiring clinicians. 

That’s something Dr. Jalloh has made his mission to change.

Dr. Abdul Jalloh: Imagine, um, for somebody to- to- to- to serve, uh, this hospital for 13 years. Alone. Uh, it- it's a lot. So, for me, what- what is my s- s- s- s- strategy? One is to lecture, in- in university, s- so that I can pass on to, um, upcoming doctors, and encourage them to pursue ps- psychiatry. Um, currently, I have, like, five medical officers that have been posted here in Kissy. And they are interested in pursuing psychiatry. So, my, um, uh, s- s- s- st- strategy is to, um- is to improve on the human capacity.

So, and- and- and then- and then, again, the students, they are showing interest. Yeah. And in- and in fact, so- so- some of them are even helping me to raise awareness, and to stand, um, up, against, um, um, uh, um, s- s- s- stigma and discrimination in the country. So, which is good. And we have even formed, um, a small association in the medical school, called, um... Sierra Leone Me- Medical As- um- um, Association for Mental Health.

Jon Lascher: And it’s not just medical students that Dr. Jalloh is influencing with his advocacy. The hospital recently welcomed the president of Sierra Leone--and this visit made a hopeful impact.

Suddenly, more people were arriving at the hospital for care.

Dr. Abdul Jalloh: This inc- increase is as a result of- of the visit of His Excellency. Because, before June 4th, we were having, like- like, I mean, 90... 8- 80-something patients. But- but- but wh- but when he- the president came to commission the hospital, now we have more people coming in. Meaning that there is an- um, there is an a- awareness now, and people are not ashamed again as before. They are coming for treatment.

Jon Lascher: With the hospital now better resourced, and becoming a national source of pride, slowly but surely, people’s ideas and opinions about mental health are starting to change.

Dr. Abdul Jalloh: Now people talk good things ab- ab- ab- a- about the hospital. They see, um, photos of the hospital. They see outpatient are getting better. Before, they used to have- they, um, uh, they used to see patient all over the community. But now all the patients are- are in. Well catered for. So, uh- so, and- and then, I mean, people... They- they- they have started to open up, uh, about mental health... in the country.

Jon Lascher: There’s a lot to be optimistic about. But more work has yet to be done. Enduring stigma will take a long time to reverse and will require a continued process of systemic transformation.

If the HIV epidemic taught us anything about stigma, it is that the best way to fight it, is to make sure everyone who needs care has access to it. Which is something Aminata brought up.

Aminata: People are suffering in silence. And you know what? It's not all the, the people that are with mental health challenges that are here. This place is so small to accommodate them. Of course, you see them in the streets.

Now, it's not only those in the streets, they are in the offices, but they are afraid to, to speak out. They are afraid to even confide in a friend, that this is what is happening to me. So, they are dying in silence. They're dying silence. Why? Because of stigma, because of stigma. AIDS is killing people, because of stigma. Because people will be afraid to go for treatment. Why? They don't want to be stigmatized. Nobody wants his or her personality to be, to- to- to be challenged, or to be, to be abused. So, it's a real issue.

But, if the war is being won with AIDS, it will be won with mental health.

Jon Lascher: It took a long time for Aminata to feel hopeful again. Now, she offers support to other patients, living with mental health conditions.

Aminata: When I came here, one thing that Dr. Giallo said.

He said, "You have a lot to contribute to Sierra Leone."

He said, "So I will not leave you."

He said, "I will, I will be with you."

You see?

Jon Lascher: After being discharged, Aminata still travels to the hospital a few times a week to visit patients, listen to and advise them, and pray with them.

And even recently, while attending a funeral, she defended someone against violent stigma.

Aminata: Yesterday at the funeral, somebody that had mental, I- I'm sure had some mental problems, came to find food. And they told, uh, told them to cane. They wanted to beat him up. I said, "No." I said, "That man has rights. You should not beat him up. If you don't want him to eat your food, leave him." So, you know, I stood up. And that's how, he, uh, uh, um, they, they, they normally handle him. If I was not there, they would beat him and nothing would come out of it. So this is the predicament of people living with mental illness, or people me... living with mental conditions, it is tough.

Jon Lascher: It’s this mixture of hope and dismay that led Aminata to make the decision to speak here, too.

Aminata: If what I would say to you, what you will use as my story will help someone out there. Now in the future, then the- the- the- the repercussions, I take less. I, uh, because I pay more premium, I think it's, it's, it's, it's more productive for me to help shape another person's life or to help, to help someone out there come out of their situation rather than thinking of myself, that would be selfish, but stigma is real.

The sacrifice is worth making, because you are saving a life somewhere. You are giving a life to someone somewhere. And that is the whole essence of humanity, it's the whole essence of humanity. If you're in the world, you have all the riches, everything you have, but you have nobody to share it with, who will know that you are rich? Nobody. Who will celebrate you? Who will say thank you to you? So when you use your wishes to touch another life, that is real riches.

Jon Lascher: If Dr. Jalloh and Aminata had their way--if more people in Sierra Leone, and worldwide, experienced similar transformations --people living with mental health conditions would not have to fear stigma. They would have access to the tools needed to exist more comfortably within their own minds and bodies. Systemic barriers would be broken down. Communities would heal, together.

Slowly but surely, these shifts are happening. It is just a start, and this is certainly not a victory lap for the hospital or for mental health care, there’s still a long way to go. But to achieve the vision of health care -- including mental health care -- as a human right, a first step was required. If These modest investments over the last few years prove anything, it is that sometimes, you need to get started, and take that first step.

The people served by sierra leone psychiatric teaching hospital-- and its incredible team of clinicians, construction workers, pharmacists, cleaners, security guards, drivers, and administrative staff, will require more support for years to come. In short, we are just getting started--for, as Aminata says, the journey is very far.

In the weeks since her discharge, as she begins to build her life outside the hospital, one question has stuck with her. 

Aminata: How will I face my world? How can I go from here? Where do I go from here?

How will I face my world after here?

Jon Lascher: Perhaps the best answer is to turn those questions on ourselves: How will we shape our world so that Aminata can embrace hers?

[Pause]

This is our final episode of Unchain. Find any episodes you missed on Spotify, Apple Podcasts, Google Podcast, or YouTube, under Partners In Health. And explore more stories from Sierra Leone and PIH by visiting pih.org. Look for us at @partnersinhealth on Instagram and Facebook or PIH on twitter, and DM us your comments or questions. 

Thank you for listening to Unchain -- and thank you to the entire community of Sierra Leone Psychiatric Teaching Hospital for sharing your stories with us. This short podcast series would not have been possible without contributions from the Partners In health teams across Sierra Leone and the United States. Thank you especially to: Maya Brownstein, Umaru Sheriff, Alpha Sesay, Abubacar a.k.a. Last Man, Percy Davies, Nina Peskanov, Leslie Friday, Amy Pollard, John Ra, Zack Declerk, Bepi Raviola, Jeffrey Marvin, Phil Garrity, Yna Aggabao, Stephanie Smith, Francesco De Flaviis, and finally, to, Sheila Davis.

*Some names are changed for privacy