"My Level Best"

Jon Lascher: Welcome back to Unchain; I’m Jon Lascher, executive director of PIH in Sierra Leone. Thanks for again joining us as we explore the past, present, and future of mental health care in Sierra Leone--specifically, the story of the country’s only dedicated psychiatric hospital, and its transformation from an impoverished facility relying on chains to keep patients and staff safe, to a dignified, well-resourced hospital.

Anneiru Braima: Patients wear shackles. It was awful. It was not fit for human accommodation, to say the least…

Jon Lascher: When we met Braima at the end of the last episode, he was a nursing student, doing a mandatory two-week rotation at Kissy Mental Hospital. The hospital was in such bad shape, that when Braima earned a scholarship to study psychiatric nursing in Nigeria, he packed his bags and didn’t plan on returning to Kissy hospital ever again.

But Braima did go back. As a psychiatric nurse, it made sense that he would return to Kissy, the only psychiatric hospital in all of Sierra Leone. Many other clinicians like Braima, who had gotten advanced degrees, never returned home and chose to work in other countries, where pay was higher and money could be sent back home to their families in Sierra Leone. Each of these personal decisions lead to many of the best educated Sierra Leoneans working outside of Sierra Leone, contributing to a shortage of healthcare workers in the nation’s health care system.  

When Braima returned to Kissy from Nigeria, he found entering the hospital was even harder than it was when he was a nursing student a few years earlier. Coming from Nigeria, where Braima trained in psychiatric facilities that were equipped with medications, staff, running water, and clean living spaces, Braima was frustrated.

Anneiru Braima: Initially it was not easy. It was challenging. When I came, the hospital was run-down, comparing when you just came from- to- fresh from another nurse country. And you come and see shackles. Pee and poo running here and there. No water. Place was stenching, and so on and so forth. It was, like... "I'm going to go sell all my- my literal belongings and go back." That was my initial reaction. But, then, I have to persevere, I have to serve my nations, too. However, decided to remain, and I think... I've been here ever since.

Jon Lascher: I heard similar sentiments from Julianna Showers, a nurse who began working at the hospital when she was 19.  Just like Braima, she was saddened by the conditions at the hospital and struggled to understand how she could be an effective nurse in such a context of scarcity. 

Her first day was, to say the least, challenging. Because of their diagnoses, some patients required medications to help manage their conditions, which if left untreated could lead to violent outbursts. The required medications were often unavailable in Kissy, limiting the care for patients, and putting the staff at risk. And so, while working with one patient her first day, Julianna was attacked.

Julianna Showers: Yeah, that first day. My first day. Some, one of the patient told me, "What are you doing here?" I said, "I'm here to work." "No, no, no, I'll kill you." That is my first experience. When I went home I was fear. A little bit fear. I don't want to come here at all. I don't want to come here anymore.

Jon Lascher: Like Braima, however, Julianna kept showing up.

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: And Julianna did more than just show up. She has been working at the hospital for 36 years.  She and her fellow nurses made countless sacrifices for their patients, doing everything they could to overcome the hospital’s lack of resources and help patients live with mental health conditions rooted in biology, poverty, and injustice. 

No amount of hard work and persistence can overcome power shortages, lack of running water, and an absence of medications.

Julianna Showers: Well, when I started working here, the place was very low. We don't have decent toilets, no decent bathroom, the ward is not decent and the bed also some of the patients lie on the floor. Some requested for clothes to put on. We bought them for them. The nurses and we did some charity, bought cloth, bought soap. We bought scissors to cut their hair. 

We counsel them. Say nice things to them. We tell them that we love them. We appreciate them. Let them not feel that they are neglected. Yes, we don't neglect them. We always welcome them warmly. 

We have so many depressive case, some of them lost their parents, some of the woman lost wome- women lost their husbands, some of the men lost their wives.

Jon Lascher: Clinicians like Braima and Julianna sacrificed and showed levels of resiliency that, as we’ve spoken about before, no health care workers should have to demonstrate. There were no quick fixes in Kissy when Braima and Julianna started working there. To solve the issues at Kissy Hospital, including the ending of the practice of chaining patients, a comprehensive, system wide approach would be required.  

The chaining of mental health patients is a human rights issue around the world. A report from Human Rights Watch--released in October of 2020--found evidence of chaining in at least 60 countries, across the Americas, Europe, Asia and Africa. Sometimes this shackling happens in the home, with families restraining their relatives; other times, as in the case of Kissy hospital, it’s institutionalized. 

Let’s be clear--chaining is a brutal practice linked to stigma around mental health and reflects the global issue of criminalization--rather than care--of people living with mental health conditions. It cannot be condoned, but we should at least try to understand why it happens. Chaining is often a last resort--a measure taken by desperate health care workers who lack access to medications and systemic support to properly care for patients. 

In the case of Kissy hospital, which opened 200 years ago at the height of British imperialism, chaining was also imbued with the violent legacies of slavery and colonialism. It is unknown exactly how many patients were chained at Kissy hospital. But in 2018, the government of Sierra Leone in collaboration with Kissy Hospital leadership and staff, ordered the removal of chains and the end of chaining as a practice. And in a move to demonstrate the ambitions the country has for the hospital and the future of mental health care, the hospital’s name was officially changed from Kissy Hospital to Sierra Leone Psychiatric Teaching Hospital. And these weren’t the only reforms--structural, symbolic, or otherwise--that were made.

Alpha Sesay: I'm Alpha Sesay, I'm working for Partners in Health. I'm the site supervisor for the infrastructure team.

Jon Lascher: Alpha Sesay is one of the PIHers who worked with Sierra Leone’s Ministry of Health to begin to transform Kissy Hospital--to turn it into the well-equipped, dignified Sierra Leone Psychiatric Teaching Hospital.

No one is prouder of the improvements made to the hospital than Alpha. It’s evident to anyone he gives a tour to.

Alpha Sesay: Yeah. Um, also this is ward seven. Ward seven was a, was one of the worst ward before. Yeah, was one of the worst ward before...what we do, we do re-tile, we do the ceilings, we do also, um, which, you know, we do, um, um, electrical upgrades…

Jon Lascher: Alpha and the rest of the PIH team, in partnership with the Ministry, introduced the most basic and necessary of upgrades to the hospital: electricity and running water…modern psychiatric medications.

Alpha Sesay: There's a- there's a pharmacy. Before here were- the... bef- before the pharmacy that we have here, uh, was not- was not really good. But by now, I believe, we have one of the best pharmacy in here. And there's a- there's a store for the drugs, and the rest.

Jon Lascher: And a consistent supply of food, so that patients can eat three meals a day--with no shortages.

Alpha Sesay: Yes, there is the kitchen, so, like, for now, there's... the kitchen is very small, so, like, by- by January to February we been thinking of how we could expand it.

Jon Lascher: They also made improvements in terms of patient comfort and experience: new mattresses, furniture, and televisions for inpatients. The grounds were also landscaped so that patients and staff would have a pleasant environment outside the wards.

These may seem like small improvements, and many of them are,--but they’re actually part of a huge and necessary shift in how we think about and treat mental health. 

Globally, it’s estimated that 792 million people--or, 1 in 10 people--have a mental health condition. Yet governments spend less than 2% of their health budgets on mental health. PIH--in partnership with Sierra Leone’s ministry of health--is determined to change that. And the transformation of Sierra Leone Psychiatric Teaching Hospital is part of that strategy. 

And these renovations weren’t just about making life easier for current patients and staff. It was also about planning for the future, investing in a space for the next generation of Sierra Leone’s mental health practitioners. This is part of PIH’s mission around the world--we work to strengthen health systems and build pipelines of local professionals. Nursing and medical students should be trained in facilities that have medication, running water, and electricity. With this in mind, the team created new space to welcome rotations of medical and nursing students.

Alpha Sesay: But when PIH come in, we thought it fit that, "Oh, yeah, we need to have a lecture hall." Because, like, we be having students coming in, you know, for- for- for, uh, um, classes and lectures and the rest.

Jon Lascher: In all, the hospital is unrecognizable from what it was 197 years ago. And it bears little resemblance to the hospital it was just a few years ago. 

Unlike the Kissy hospital of decades ago, patients and staff in the renovated psychiatric teaching hospital now live and work in clean, welcoming and well-resourced spaces. Staff concern for their own physical safety is no longer top of mind. And people are healing in ways they never before had the chance to: there are now more outpatients than inpatients at the hospital. This shows how therapy, medication, and care is allowing people to reintegrate into their families and communities.

But transformations are always a process. And the psychiatric hospital’s has been no different. It’s still the only dedicated mental health facility in Sierra Leone, a country of 7 million people. The hospital--and country--still needs more psychiatrists, psychologists and counselors. And the work isn’t done -- not even close -- there are still improvements that must be made, from technology to medications to infrastructure.  Mental health care doesn’t start and stop in this one hospital. More investments are required in communities and in primary care clinics and rural hospitals around the country.

And so the hospital changes, little by little, but with an eye towards comprehensive and systemic fixes. One light switch installed; one antidepressant procured; one nurse trained, one life changed.

Here’s Alpha again.

Alpha Sesay: when I come, at first, I found it very difficult, because I've never had an experience in regards to mental health. I was, uh, I don't have any experience on how to handle these patient. You know, there was enough fear in me. But now, I don't know, like, for now, I don't. There are no need for me to fear them. We need to come closer. These are our brothers, they are our sisters.

Jon Lascher: It wasn’t just the hospital itself that had changed.  Staff have found themselves transformed, too. And it’s inspired some--like Alpha--to follow new dreams. 

Alpha Sesay:  You know, in the future, I really want to do, uh, I really want to study psychiatric, because I do have passion for it. Because I know, like, some of these guys, if they were healthy, we know- we know, we can't tell their future. Maybe tomorrow they might be the one that will be, you know, helping me, or helping the nation. 

Jon Lascher: Over the course of nearly four decades, Julianna says her patients have helped shape and support her, too.

Julianna Showers: Okay. I started working here, I was so tiny. Yeah. I started working at the age of 19 years. You know, when I started working here, I was so impatient but when I started working here with the mental patients, it, it makes me go lovely for the patients. Yes, I love them. I love them and I have some patients in my community. I always go there and talk to them and counsel them. I love the job because the psychotic job is good. You learn a lot. You learn a lot from the patients, yes, and practical you learn a lot.

Jon Lascher: Transformation at the hospital has been both structural and personal. And fear has shifted to love, understanding, and loyalty.

But what about for those beyond the walls of the hospital? Those living in communities where fear, stigma and shame around mental health is widespread? How many lives can one hospital truly touch? 

Join us next week for our final episode, where we’ll meet a former patient and a psychiatrist finding ways to break the chains of stigma surrounding mental health care--in Sierra Leone, and around the world.

*Aminata: It is quite different now from what it used to be, but the, the, the, the, the, the notion is still very prevalent in the minds of people, that this is a place for mad people, anybody you see here is a mad person. So I, I struggle with that. How will I face my world? How can I go from here? Where do I go from here?

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 Facebook, and DM us your comments or questions.

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

 

* Some names have been changed.