If you go to Mesalemiya, near Africa’s largest open air market Merkato, you likely find yourself dodging cars, pedestrians, donkeys and carts struggling to reach their destinations. And adjacent to this world where traders and buyers barter loudly all day and grain is unloaded from dusk till dawn; you will also come upon the entrance gate for Ethiopia’s only public mental hospital, Amanuel Specialized Hospital.
Established in 1938, it is the sole mental institution responsible for providing services to an estimated 90 million people. Although the neighbourhood was in a better condition when the hospital first opened doors, the street it sits on is filled with dirt and trash now. The buildings of the hospital are old and run down. Chairs inside are broken and the grounds of the compound are congested. There are long lines of people waiting to receive treatment and patients milling around the center of the compound, sometimes wearing restraints. At the center of all this chaos is the office of Medical Director Kibrom Haile, a young psychiatrist running the institution that cares for three hundred inpatients and twelve thousand outpatients a month.
“Being the lone mental hospital, we are burdened with handling almost all the Nation’s mental health issues,” said the very busy Director.
He seemed to be constantly ‘putting out fires’, as our conversation was repeatedly interrupted by his secretary, for many things that required his immediate attention.
“A shortage of facilities and well trained professionals has always been a challenge for our institution,” he said. This statement is indicative of the state of mental health in Ethiopia, which is in crisis due to years of neglect.
Everyone experiences issues with their thinking, behavior or emotions but when a person experiences mental illness their behavior or thoughts stop them from functioning in society as they have trouble maintaining jobs, relationships or taking care of themselves. This of course varies depending on the person so Psychiatrists developed the Diagnostic and Statistical Manual of Mental Disorders, now it its fifth edition, which helps classify mental illness.
A person is said to have a major mental illness if they have clinical depression, schizophrenia or bi-polar disorder.
Depression is a feeling of hopelessness that lasts for a long time. The person may eat and sleep too much or too little, has difficulty functioning at work or isolate themselves from relationships. If left untreated they may have thoughts of harming themselves that they eventually act on.
When a person has Bi-Polar disorder they experience frequent mood swings. One day they may feel like they are invincible and another they may feel very depressed. When they feel ‘on top of the world,’ they may do things like spend all their money on something they don’t need or they may engage in unsafe promiscuous sexual behavior. If left untreated they may become paranoid or stop taking care of themselves. In general, a person with Schizophrenia will see things that other people don’t see or hear things that other people don’t hear. They often will have false beliefs and lose touch with reality.
Mental illness in Ethiopia is commonly caused by drugs, trauma, losing loved ones, imprisonment, sex or other physical abuse and ill treatment in foreign, especially Arab Countries, according to the Mental Illness Strategy (MIS); the first legislative strategy document the country adopted in 2012.
In mostly rural areas of the country, 11 percent of the population is estimated to have some form of mental Illness, with Schizophrenia, the most common. Incidents of depression are also high. Along with depression, Schizophrenia is included in the top ten most burdensome conditions and out ranks HIV/AIDS.
In Ethiopia, about 17 to 23 pct of children are affected by mental illness, according to MIS. Around 38 pct of people infected with HIV and 64 pct of people infected with TB experience severe depression. Epilepsy, a mental disorder characterized by seizures, affects one percent of the population and dementia, a non-specific syndrome that attacks memory, language and other cognitive abilities of the brain, affects 65 pct of those living above the age of 65.
One in ten pregnant women and one in 20 post-natal women suffer from undetected depression. Moreover, even though demographic data from all Ethiopian prisons is not available, a survey on Federal Prison of Addis Abeba, Kality, has found out that more than 61 pct of prisoners are dealing with high levels of mental distress. Substance abuse makes up 43 pct of the psychiatric inpatients in the country, with Khat, alcohol and cannabis leading the pack, according to United Nations Office on Drugs and Crime.
Most people with mental illness are harmless but sometimes when people are experiencing hallucinations or delusions and they are not taking medication they can become confused and engage in socially inappropriate behaviors like walking naked in public, verbally insulting people or at times, attacking people because they have the mistaken belief that they are under threat. When there is a lack of treatment for people who have mental illness or when they do not have their basic needs met such as shelter and food or when they begin using alcohol or other drugs to cope with their illness; social problems increase as pedestrians, who are not trained in communicating with people who are psychotic can get into dangerous situations.
“Some time ago a mentally ill man squeezed my neck so hard that I was not able get him off of me until a passerby came to my assistance,” said Bethlehem Leul, a second year student of Economics at Gondar University. “Since that incident, which almost took my life, I never walk on the same side of the road if I see a person with mental illness.”
Often though the severity of the mental health problem is overlooked as many families are forced to take care of their loved ones who have this problem and they lack resources, training or understanding of the struggle they are facing.
“My sister suffers from Bi-Polar disorder she goes from being able to go to school and take her medication to sometimes standing in front of the mirror for hours, throwing her food out the window, accusing us of poisoning her. One time we needed to get her help because she was going around the city sleeping with random strangers and not taking care of herself. To get her into a private facility would cost us ETB 6,000 for a weekend and involved a struggle with our entire family. She even went to the police and accused us of mistreating her and they did not know how to handle the situation or try to take her somewhere she could get help,” said Selam Belay a working professional with a loved one who is mentally ill.
“We estimate that only 10 percent of people with mental illness seek treatment,” says Kibrom.
“Many feel that this is a spiritual problem, that the patient is possessed by the devil and they seek treatment by holy water at places such as Entoto, others do not want to get help because they fear the stigma surrounding mental illness and they do not want other people to find out they have a problem but the sooner they receive treatment the better,” Kibrom added.
Solomon Sime, focal person for mental health at Ministry of Health (MoH), agrees with this. “We need to do more to create awareness about mental illness among the public.” Of course lack of proper facilities do also contribute.
Woldeyohannes Tesfasillassie is a 50 year old man who lives with his sister-in-law in Akaki Kality District. Despite struggling with his illness for the last 35 years, Woldeyohannes was taken to Amanuel Specialized Hospital only a couple of years ago.
There are some organizations trying to alleviate the problem and lessen the burden faced by people trying to care for those with mental illness.
Mental Health Society- Ethiopia (MHS), a nonprofit, has been advocating for mental health issues through newsletters and radio programs and provides treatment and drugs for those patients who are attending spiritual treatments at different churches, in collaboration with the psychiatry department of Addis Ababa University (AAU).
“The publications and radio programs try to change society’s wrong perception, but they are produced only when funds are available,” says Alehegn Ketema, project coordinator at the Society.
MIS stipulates all the rights of the mentally ill: to live in the community; to entertain equal recognition before the law; to an adequate standard of living and social protection; to vote or stand for election; to property; to education; to work; to health; to confidentiality; to freedom from torture or cruel treatment and inhumane or degrading treatment or punishment. Yet, until the public understands all the rights of mentally ill people and starts to respond accordingly, attitudes are unlikely to change.
The country had no organized response to the state of mental health until it adopted MIS in 2012. The strategy seemed to recognize the dire situation and put forward a general plan to improve mental health care in the country. The objective of the strategy stretches from availing medical treatment for the mentally ill at the health extension level to setting up an information management system to keep a record of all mental illness cases diagnosed. Availability of data on mental illness has been one of the challenges.
For a nation of more than 86 million people, a little more than 300 beds are available for the mentally ill. There are only 461 psychiatric nurses, with no accurate estimate as to how many of them are serving in mental health services. A mere 44 psychiatrists; 14 psychologists, none of whom have clinical training; three clinical social workers and no occupational therapists are present in the country, according to the MIS.
The government was not able to repeat the success it had in other segments of health care when it comes to mental health.
“Even though there are improvements compared to the situation ten and twenty years ago, we are still lagging behind in satisfying the general demand,” says Yonas Bahiretibeb, head of Psychiatry Department at AAU and board director at MHS.
The highly scrutinized nature of mental health medicines, which should be prescribed with caution, because some can become addictive or have harmful side effects, and the accessibility of treatment is another challenge. Currently, a mentally ill person in rural Ethiopia cannot get treatment at any of the health extensions. A patient can see a psychiatric nurse at a health station, who can only take the medical history of the patient to professionals at Zonal hospitals that are ill equiped to handle mental health cases.
Lately some changes are being seen albeit small. Psychologists are being trained in a three year postgraduate clinical program at Addis Ababa University, supported by the University of Toronto, Canada. Its first batch of students graduated in September, 2011 and the program receives 4 to 6 students every year. The University has also availed a PHD program in the same field which is being attended by 7 candidates. In 2009, in collaboration with Amanuel Specialized Hospital, The University of Gondar began its masters program in Integrated Clinical and Community Mental Health, which currently enrolls 50 candidates. The same program was launched in 2010 at Jimma University and currently enrolls 9 students. Mekelle University has also started a BSc in Psychiatric Nursing and it currently enrolls 33 students.
The Program for Improving Mental Health Care (PRIME), a UKAID funded initiative in five countries: Ethiopia, Uganda, South Africa, India and Nepal, was established in 2011 with the objective of integrating mental health in primary health care and developing human capacity for mental health care. The Mental Health Gap Action Program (MHGAP), where MoH has collaborated with World Health Organisation (WHO) to bridge the gap between the number of facilities and mental patients, is another program working to improve mental health services in Ethiopia. A pilot project has been extended in all the four regions of the nation which is expected to lead to tangible mental health treatment at the primary level.
A National Institute for Mental Health is also under construction at a cost of more than ETB 100 million by the Ethiopian government. The new mental health facility, which the Ministry expects to be operational in one year, will incorporate a general hospital with 250 beds and a research center for mental health and other diseases, according to Tedla Woldergiorgies, PhD, a mental health advisor to MoH.
Though there have been some recent changes for the better, mental illness is still a huge health problem and much has to be done to avert the crisis. Availing such services as crisis intervention centers, addiction rehabilitation centers and day care centers is still way ahead. Setting up psychiatry units at every general hospital also would help ease the current burden, Yonas, who also run a private mental health center, recommends.
The efforts made by the government in improving mental health services and human development lacks the involvement of the private sector. It goes without saying that private sector assistance would help speed up improvements.
Still, many question the government’s seriousness regarding the issue, citing the meager investment extended to solve the problem. Compared to the aggressiveness that the state has shown in addressing other social and economical ills, the attention given to mental health seems insignificant. And this is reflected in the infrastructures availed to the sector, with a lone, overcrowded, seventy five year old mental hospital without the proper facilities.