Sierra Leone: Remember those living atop the hill at Kissy Mental Hospital

Dr Mandy Garber is a Sierra Leonean psychiatrist living in Pittsburgh, Pennsylvania. She spent the month of April volunteering at the Kissy Psychiatric Hospital, and her experience was sobering. The only psychiatric hospital in the capital Freetown, is in a deplorable condition and needs resources to make significant improvements. The mentally ill represent a vulnerable population worldwide, and in Sierra Leone, they do not have an advocate. As such, the state of the hospital and its patients is not a priority. I spoke to Dr Garber, who provided an eye witness assessment of the facility with some pictures. She’s the only daughter of octogenarian educator, Mrs Cassandra Garber, former principal of Freetown Secondary School for Girls, where I taught in the 1980s, when Mrs Garber was principal. This assessment is from Dr Garber’s perspective.

April 2011, Freetown, Sierra Leone, there are garlands strewn on electric poles, young men on street corners are hawking memorabilia celebrating Sierra Leone’s 50 years of Independence. Numerous citizens are decked in clothes, hair ornaments, necklaces, and bracelets featuring green, white, and blue, the national colors. Atop a hill in Kissy, at the Sierra Leone Psychiatric Hospital, commonly referred to as Kissy Mental, a whole population exists marginally with little to get excited about; these are some of Sierra Leone’s mentally ill citizens. Some have lived there for decades. Most of them have been abandoned by their families who attribute their illness to witchcraft, a curse, or even attribution for past wrongs. Very few have much to smile about or to look forward to.

Life for the mentally ill in Sierra Leone is incredibly hard. Due to their illness, most of the mentally ill have minimal earning power; they cannot hold a job, people on the street mock and harass them, and at worst, they are physically and/or sexually abused by the so-called saner members of society. Life as a patient at Kissy Mental Hospital is equally hard, very hard. If they could, most of the hospitalised patients would leave. Some cannot leave because they have been chained; others simply have nowhere to go because family members no longer want them around. Very few patients come to Kissy Mental willingly.

Most report that family members either restrain them to bring them to the hospital or mislead them into believing they are headed elsewhere only to realise they are bound for the mental hospital. If they try to resist admission, they are held down and administered a tranquilizer. Then come the chains, which may stay on for days or months on end; a chain is wrapped around the individual’s foot, looped around the bed frame and secured with a padlock. Family members may never visit. A completely new reality is born and the patient must learn to survive within this harsh, new reality in the midst of his/her sadness, delusions, neuroses, and/or psychoses.

Services at the hospital are bare-bones. Patients receive 2–3 meals a day; many try to supplement their intake because the rations are small. The visitor is repeatedly accosted by patients asking for money to buy bread, foofoo en bittas, foofoo en whaite soup, ress en cassada leaf, binch… Don’t try arguing with the patient that nowhere around the hospital sells food because a cooking stall across the street beckons to them.

Effective medications are hard to come by at Kissy Mental hospital. The hospital’s medication formulary is scant. Most patients do not get effective medications that would give them a chance at a somewhat functional, semi-independent existence. This means some never leave the hospital; others are deranged and remain chained for extensive periods of time; others live in their own worlds wracked by their delusions and hallucinations; some curl up feeling very sorry for themselves and longing for respite. Still some of the long-timers make a life for themselves at the hospital. They leave intermittently, go into town and ‘earn’ a pittance which allows them to get by from day to day. Overall, for the majority of patients at Kissy Mental Hospital, the prognosis is very poor.

Utilities at Kissy Mental Hospital are in exceedingly poor condition. The perimeter wall and gates have been damaged in various parts rendering the premises insecure. As a result, both patients and outsiders have easy access to the facility making it relatively unsafe. In fact, instead of repairing the wall in order to prevent patients from absconding, they are chained to their beds. For many years the facility has not had any running water but must rely on a weekly supply of a bowser of water from the Guma Valley Water Company. Needless to say this supply is grossly inadequate and the kitchen is given a priority. As a result, maintaining personal hygiene is a challenge for the average patient.

Electric power is supplied by a fuel-powered generator; electricity when it is available is rationed to a few hours daily. For the patient chained to her bed, life can be quite dehumanising as she must conduct all activities of daily living in full view of the public. It is a hard life being mentally ill anywhere in the world but in Sierra Leone, it is especially hard.

Who is to blame? It would be easy to point fingers at the government, the Ministry of Health and the staff at the hospital. There is definitely enough blame to go around. Sierra Leone has been a welfare state for as long as I have been alive. The country has never been able to utilise its resources towards improving the lives of its citizens. Instead, decades of ongoing corruption has left and continues to leave the country’s coffers bankrupt. Assuming the status quo, it becomes clear that the Ministry of Health and the Freetown City Council have little means to create the change that is needed at Kissy Mental Hospital. Yet the needs are dire.

What is needed? Everything: Visionaries; Lobbyists; Managers; Skilled, ethical, and honest laborers; compassionate and concerned citizens; and finally resources. We need individuals who can envision an improved and clinically effective environment for Sierra Leone’s mentally ill citizens. Lobbyists are needed to encourage others to contribute and insist that the government pass laws which are sensitive to the welfare of the mentally ill. Managers – health care system managers are desperately needed to advise and design strategies for effectively running a hospital which depends exclusively on disbursements and donations for its survival. Skilled, ethical, and honest laborers are a must in order to provide clinical care in an empathetic manner to these vulnerable and marginalised individuals.

Compassionate and concerned citizens must donate of themselves, their time and resources. Very few families have never been affected by mental illness and when it does hit, it paralyses the family, leaves them helpless, not knowing how to cope or what to do. What to do is to make it possible for all mentally ill Sierra Leoneans to have a chance at getting access to good clinical care. Resources are needed to make it all a reality. So I ask and appeal to all of you to think carefully about how, and not if you can help.

‘For of those to whom much is given, much is required’. (Luke 12:48)

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* © Roland Bankole Marke, Mandy Garber, MD MPH MSc
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