In South Sudan, decades of civil war have resulted in widespread trauma, and the chronically underdeveloped nation is struggling to provide facilities, staff and treatment for those in need of mental healthcare.
After a 2005 peace deal with Khartoum, aid agencies poured into southern Sudan to provide the bulk of health and education services. Since the area gained independence in 2011, the fledgling government has been attempting to build a state from scratch, leaving health services largely provisional and mental health programmes all but non-existent.
"The situation is very rudimentary in terms of mental health, but there are so many people suffering because of post-war trauma and because of frustrations that some people may find themselves in and also because of some people that take drugs," said Deputy Minister of Health Yatta Yori Lugor.
The South Sudan Medical Journal reports that depression, post-traumatic stress disorder (PTSD), anxiety and substance abuse are major mental health issues affecting the country. The only recent prevalence data derive from a 2007 survey of 1,242 adults in Juba, which found that 36 percent of respondents met symptom criteria for PTSD and half met symptom criteria for depression
No psychiatrists or drugs
"There are so many people who are affected by mental health problems, and if you go about in [the capital] Juba, you will see a lot of them roaming the streets," Lugor said.
He says the lack of understanding about mental health in a country with 27 percent adult literacy, poor communications infrastructure and very few roads means that mental, emotional and behavioural disorders are often reported to traditional healers or the police rather than health clinics.
George Wani is in charge of Juba Teaching Hospital, the only public medical facility in the country that treats mental illness. Its mental health ward has just 12 beds. He says South Sudan has had no psychiatrists since the only one left to work in Tanzania.
Although it treats the severest cases, the ward has only a handful of nurses with the barest of training. It has no psychiatric drugs, and even sedatives are hard to come by.
"In all of the medical emergency kits, you'll find one or two tranquilizers. So we have to remove these and use them in the department of psychiatry. But the drugs for psychiatry are not there," he says.
Records show that patients are given regular doses of diazepam, a sedative and anti-anxiety drug.
Some, like Mathew, whose mother brought in him for treatment, have been handcuffed to their beds.
"Look at me; I am bound down, bound down," he said, dragging his wire-frame bed into the corridor. Weary staff say they cannot cover the large open wound on his wrist as they have no gauze or cotton.
Sedation or prison
Wani explains that it's either this or prison for patients the hospital cannot control.
"The sanatorium of Juba is inside the prison. We have no alternative," he said. "In an open space, the patient would be very destructive, very harmful to others, very violent, aggressive, and people on the outside cannot right that."
In June Human Rights Watch denounced South Sudan's "harsh, unacceptable prison conditions" and unlawful detention, and found that scores of inmates were incarcerated "solely because they appear to have mental disabilities."
Wani, who regularly visits the prison, acknowledges that that situation is very bad, with patients almost permanently shackled to the floor. But he says the 50 or so mentally ill patients currently inside the capital's prison have nowhere else to go.
"The only solution is to build a sanatorium outside the prison... because the hospital does not have the capacity to take all the mentally sick," he said.
An overwhelming problem
Meanwhile, violence continues to take its toll on the population's mental health. Disputes over cattle raiding recently turned into a massive ethnic conflict affecting over 140,000 people. Mental health services are extremely hard to come by in the country's camps for refugees and internally displaced people.
"It's that daily frustration coupled with past trauma that generates more trauma" and violence, said a senior international aid worker who asked not to be named.
"I think there needs to be a shift in how aid organizations address health issues in South Sudan. Mental health issues crop up in normal health programmes and are simply undetected or health structures address [only] the physical manifestations."
But the government says there is no funding for mental health services.
"Resources are the issue. They are spread over all of what is needed and, you know, much of it is used on emergencies," said Lugor of the health ministry.
Soldiers in the national Sudan People's Liberation Army (SPLA), who were at the frontline of the country's long war, are badly affected by the health system's incapacity to handle mental health issues. The director of Juba's military hospital, Peter Ajak Bullen, says that the problem in the army is overwhelming.
"The number of soldiers that have been traumatized - there's so many. And you cannot just neglect them because the SPLA form a formidable part of the country," he said.
The SPLA has an estimated 140,000 soldiers, according to the research group Small Arms Survey.
Despite having better facilities than other hospitals, the military hospital only has three staff members trained in psychology who carry out basic counselling.
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"We don't have a mental health hospital, we don't even have a well-established mental department, neither in Juba military hospital nor in Juba Teaching Hospital," Bullen said.
William survived an aerial bombardment as troops advanced towards the disputed area of Heglig during Sudan and South Sudan's brief clash over oil and land in April. He is now at the Juba military hospital.
"He was confused. He lost consciousness a bit, but when he came here he regained a bit of it. He did not sustain any injury, but he was confused," Bullen said as William stared into space.
After being sedated for four days, William could sit up, eat and talk. "But later on, he relapsed.We put him on the same tranquilizers, the same sedatives. We don't have more than this. These are basic mental health medicines we have, plus the counselling."
Difficult cases are referred to the public hospital, and if that doesn't work, they are sent on to Uganda.
If all else fails, Bullen says that patients like William, who has a wife and five children, are kept on the payroll and transferred to the "wounded heroes" programme for disabled veterans to learn new skills.
Perpetuating the cycle of violence
Violence borne of mental illness must also be addressed.
"We haven't the statistics but we have heard of people taking their own lives," said Lugor, citing a recent example of a husband killing his wife and then turning the gun on himself.
"These things happen, and they happen everywhere in South Sudan. It's not only for the military, it's all over the place," he continued.
Officials say soldiers are taking their own or others' lives on a weekly basis. "Shooting civilians is common, being violent towards civilians is also common," said Bullen.
"I'm a general surgeon. I'm not a psychiatrist, but we do see cases of schizophrenia - very few, maybe one or two a year. But most of them are depressive patients," he said.
In an effort to address the severe shortage of mental health professionals, one programme - a collaboration among the University of Oslo, the Norwegian NGO SINTEF Health, South Sudan's University of Bahr El Ghazal and Khartoum's Ahfad University for Women - is training students and medical professionals in mental health issues.
"There is a huge gap between the need and the health services available, and a very poor knowledge and understanding of mental health issues," said Lisbet Grut, senior scientist with SINTEF Health.
"We are trying to get to a point where health workers can recognize the symptoms of mental health problems, correctly diagnose them and refer them to specialists who can provide treatment."
The programme, which has been running since 2007, has so far enrolled nine bachelors-, masters- and doctorate-level students in mental health programmes at the University of Bahr El Ghazal and has provided short-term training in mental health to 72 health workers.
The government also plans to develop a mental health strategy "that will include advocacy, legislation and human rights, planning, financing and organization of services, quality, the use of psychotropic medicines".
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This article was produced by IRIN News while it was part of the United Nations Office for the Coordination of Humanitarian Affairs. Please send queries on copyright or liability to the UN. For more information: https://shop.un.org/rights-permissions