A ticking time bomb

It is Friday evening, a little before five o'clock, when the first ever psycho-education group in Somalia meets at a well secured factory complex close to Mogadishu's airport. Sixteen men and women sit on colourful cushions and rugs in a large circle on the ground, with tea in paper cups and chocolate cake on napkins between them. They have removed their shoes, their phones are in flight mode, all their attention is focused on a woman in their midst giving instructions in a calm voice. "Write down your biggest worries on a piece of paper," says course instructor Rowda Olad. "What has caused you the most stress recently?"

Most in the group are about 30 years old. They work for the government or international organisations, are fashionably dressed, the men in jeans and shirt, the women in long dresses and colourful headscarves. They are here to learn something about themselves. Psycho-education imparts information for coping with mental illness. "You can talk about your problems here without anyone judging you," Olad tells the group. When she collects the slips and asks for the anonymised responses to be read out, they reveal the inner depths of the human mind.

A few years ago, the World Health Organisation (WHO) estimated that the prevalence of mental health illness in Somalia is amongst the highest in the world. Psychoses, schizophrenia, bipolar disorders, paranoia, depression and post-traumatic stress disorders (PSTD) are the most frequent diagnoses listed in the WHO report, with one in three persons affected. The causes range from poverty, unemployment and drug abuse to war, terror and living in constant fear. "These massive psychological problems are going to leave their mark on our society for decades to come," says Rowda Olad.

A few years ago, the World Health Organisation (WHO) estimated that the prevalence of mental health illness in Somalia is amongst the highest in the world. Psychoses, schizophrenia, bipolar disorders, paranoia, depression and post-traumatic stress disorders (PSTD) are the most frequent diagnoses listed in the WHO report, with one in three persons affected. The causes range from poverty, unemployment and drug abuse to war, terror and living in constant fear. "These massive psychological problems are going to leave their mark on our society for decades to come," says Rowda Olad.

Dr Habeeb shares her view. His real name is Abdirahman Ali Awale. He has built Somalia's biggest network of mental healthcare facilities from scratch and has trained countless professionals in the field. "Mental health issues have far-reaching consequences for our society," he says. Life for most people in Mogadishu has improved significantly in recent years, but for reconstruction to be successful, more specialists, treatment options and discussion groups more money for mental health services across the country is needed. When asked about support for his centres from the government or international organisations, the doctor just laughs. "Zero," he then replies. "Precisely zero point zero zero zero."

Investments in the mental health of Somalis, in fact, are in stark contrast to the severity of the problem. According to the WHO, there were just five mental health hospitals and three trained psychiatrists in the entire country in 2017. "Mental health is not a priority for either the government or foreign donors," says Rowda Olad. She is convinced that should peace finally return to Somalia, the repressed wounds of its society will really start coming to the surface. "We are sitting on a time bomb. And most of us here haven't even noticed that."

The utter inadequacy of mental health services in Somalia is an extreme example reflecting a wider malaise. Mental disorders such as psychoses, depression or traumas have severe negative implications for public health in all regions of the world. A team of experts of the Lancet Commission on mental health calculated in 2018 that mental disorders will cause losses amounting to about USD 16.1 trillion to the global economy between 2011 and 2031. In low-income countries, mental illnesses play a greater role in aggravating other illnesses, exacerbating poverty or reducing the life expectancy of affected persons and their children. "One in four people experience a mental health episode in their lifetime," stated UN Secretary-General António Guterres in a speech in 2018. "But the issue remains largely neglected."

Erika Placella, deputy head of the SDC's Global Programme Health echoes this view. "Global investments in mental health are in no way commensurate with its significance," she says, placing this neglect in the broader context of non-communicable diseases (NCD). Apart from mental illness, NCDs include diabetes, cardiovascular diseases, cancer and chronic respiratory diseases. Each year they account for 40.5 million or almost 70% of all deaths worldwide.

Because these diseases can be caused by unhealthy lifestyle choices, such as consumption of tobacco and alcohol and physical inactivity, it was assumed for a long time that NCDs were "diseases of affluence" and primarily an issue for rich countries. But according to the WHO, in fact over three fourths of all NCD-related deaths occur in developing countries. Yet, just 2% of all development aid in the health sector is directed towards combating them.

This disconnect can be attributed to several factors according to Luke Allen, health policy researcher at the University of Oxford. In an article for the Journal of Global Health Perspectives he writes that NCDs have less emotional appeal than other diseases and are largely perceived to be non-infectious and even self-inflicted. It is also difficult to demonstrate the costs of non-intervention, while it tends to take a long time for the results of intervention to show. Moreover, the causes of NCDs are often so complex that their treatment requires a holistic approach possibly spanning several medical disciplines. The example of Irbid in northern Jordan illustrates what this means in concrete terms.

Jordan is a stable country in the midst of a region beset by conflict. Syria and Iraq are located in the north and east respectively, while the occupied Palestinian territory and Israel lie to the west. This constellation has led to hundreds and thousands of refugees from neighbouring countries seeking refuge in Jordan in the last decades. The northern city of Irbid, just 20km from the Syrian border, became the focal point for persons fleeing from Syria soon after the war began. The NGO Médecins Sans Frontières (MSF) therefore set up a clinic here in 2014 for Syrian refugees suffering from non-communicable diseases.

Just two years later, a separate department for mental healthcare was added. "We realised very quickly that there was need for psychological and psychiatric support among our patients," says Ali Abu Saqer, who heads the nursing team at the MSF clinic. "We therefore now offer comprehensive treatment services." In practice, this will enable patients who come to the clinic with NCDs, such as cardiac ailments or diabetes, to be referred to the department for mental healthcare depending on their needs. There they receive psychosocial support in a confidential setting through individual or group consultations.

"The symptoms are often inextricably linked," says Saqer. His colleague Ahmed Bani Mufarij, who conducts consultations with patients at the MSF clinic, notes that hypertension, for instance, is often caused by anxiety. "The cause is psychological, not physical," he says. During consultations, he discusses with patients how they can talk about their problems and deal with them. If a psychiatric evaluation is needed, the patients are referred to a partner institution.

Albeit on a different scale to Somalia, in Jordan too there is a disconnect between demand and supply. One fourth of the population needs psychosocial support, but there are barely 2 psychiatrists and 0.27 psychologists per 100,000 population. In and around Irbid, the third largest city in the country, there is just one government psychiatrist seeing patients. "There are also private doctors," adds MSF staffer Mufarij. "But due to the high cost they are not an option for our patients." Many of the local residents cannot afford expensive treatment, so the MSF clinic also treats Jordanians from vulnerable communities.

A large part of the development aid that is invested in mental health flows into the humanitarian sector and to conflict countries. However, the problem equally affects poor countries with no conflict and those that have overcome conflict. In concrete terms, it is not just refugees from Syria who grapple with mental health issues, but also people in Jordan who have never experienced a war. "Naturally, for people from Syria there are additional stress factors, such as the war or acute financial difficulties," says Mufarij. "But as far as their problems are concerned, there is not much difference between both population groups."

Similarly, there are hardly any differences as regards stigma. "Mental illnesses are stigmatised in all societies, even ours," says Saqer. In rural areas, especially, persons with severe mental disorders are often considered to be mad. That makes life difficult not just for the affected person but also for their families. "If people think I'm crazy no one will want to marry my daughter," says the head of the nursing team. This perception results in affected persons being apprehensive about seeking treatment.

At least in Jordan's urban areas this stigma has reduced, explains Saqer. And he discerns a change in attitude even among patients. "People who are very sceptical during the first session, completely open up by the second or third session," he says. "Once our patients understand that we can help them, their friends and relatives also get to know about it."

Erika Placella of SDC's Global Programme Health also finds that despite all the criticism, much positive progress has been made looking back at the last ten years. At a societal level, the stigma of mental illness has reduced and acceptance has grown in many countries. Great strides have been made on the medical front. Biological causes and risk factors are now better understood and treatment methods have been further developed. Even at a global policy level, there have been many achievements. "One could say that mental health has made it onto the international community's agenda," says Placella.

The WHO, for example, has identified mental health as a priority and intends to ensure universal health coverage for mental illnesses in 12 priority countries by 2023 through a special initiative. Switzerland is also contributing to this initiative. A pilot project of the SDC demonstrates how this could be done.

Prior to the war, Bosnia and Herzegovina did not have a single mental health centre today the country has 72. This development is the result of a reform process in the field of mental health initiated in 1996, which has been supported by Switzerland for almost ten years. The cantons of Bern, Jura, Geneva and Fribourg lent their expertise to support this reform for a period of eight years.

The stigmatisation of mentally ill persons was reduced, primary healthcare services were expanded and decentralised. It became easier for people to access help that was close at hand. The new system is not funded by external donors, it is sustainably financed through the national budget. Of course, not everything is perfect, but in the space of two decades Bosnia and Herzegovina has transformed from a developing country in terms of mental health into a role model. How did that happen?

"There is no simple answer to that question," says Maja Zaric, who was closely associated with the process as programme manager and adviser on development policy at the Swiss embassy in Sarajevo. Firstly, the programme was not initiated by external donors but by the country itself. From the outset, the authorities had a strong interest in the reform succeeding. This was closely linked to the second success factor: the external environment. When the reforms were introduced, Bosnia and Herzegovina had just emerged from a devastating war. There were numerous mentally impacted war veterans, families that had been torn apart and post-war trauma. "The authorities realised that the existing healthcare system would not be able to cope with this challenge," says Zaric. This resulted in the goal to reduce the hospitalisation of people with mental health issues, and to replace large psychiatric institutes with smaller, community-based centres.

Zaric feels the third success factor was bringing together foreign expertise with existing capacities within the country. The reforms were evolved jointly, not just implemented by external actors and then handed over. From the very beginning, an attempt was made to develop integrated services for a variety of mental health disorders. Multidisciplinary teams comprising psychiatrists, psychologists, nursing staff and social workers provide high quality treatment and conduct awareness campaigns in the community.

The final factor contributing to the success of the reform, according to Zaric, was that it was legally enshrined. While developing new schemes, care was always taken that these were also covered by relevant amendments to the laws. Consequently, patient rights, government funding, cost coverage through health insurance etc. are all enshrined in legislation. And even persons without insurance have the right to be treated at mental healthcare centres. "Persons with mental disorders now need not spend weeks or months in a psychiatric clinic," says Zaric. Prospects of recovery have improved and mental healthcare costs have fallen. "Naturally, there is scope for further improvement," says Zaric. The country has made huge strides and the reforms are viewed as a model case far beyond its borders. It shows what it is possible to achieve in promoting mental health.

Article by Christian Zeier, published in One World 02/2020