FREETOWN, Sierra Leone — For centuries, they called the foreboding building on a hill above this capital city the Kissy Lunatic Asylum. It was built in the early 1800s by the British colonial administration, and behind the high walls, patients were kept in chains. People here say the stench seeped from the brick walls, and the screams of patients, whose psychosis and trauma were untreated by medication or therapy, echoed out the narrow, barred windows.
Today a small wooden sign hangs over the front desk in the outpatient department: “Sierra Leone Psychiatric Teaching Hospital: Chain-free since 2018.” The sunny corridors of the newly renovated facility flash with the fuchsia uniforms of psychiatric nursing students. The shelves of the pharmacy are lined with the latest antipsychotics and antidepressants. Children bounce on a trampoline at a cheerful clinic just for them. And six residents are on their way to being the first psychiatrists ever trained in this country.
The transformation at Kissy is part of an extraordinary effort to build a mental health care system from scratch in one of the poorest countries in the world. The residents work the wards and see patients in the packed outpatient clinic, under the supervision of three consulting psychiatrists. They are the only three in the country’s entire health system — a staggering ratio, but a threefold increase from decades when there was just one, who paid the patients at Kissy a weekly visit.
Around the globe, the Covid-19 pandemic has brought a surge in mental health problems — and has drawn attention to the severe limits on resources to help. There are often long waiting lists for appointments with therapists in high-income countries, but the shortage in the developing world is something else all together.
“You could have situations with one psychiatrist per million people, and no psychiatric nurses whatsoever,” Mark van Ommeren, who heads the World Health Organization’s mental health unit, said in an interview from Geneva.
The absence of personnel to study and diagnose mental illness makes the actual scope of the burden of disease in developing countries something of a mystery. Dr. George Eze, the head of the new teaching program, surveyed the noisy line that spilled from the clinic into the courtyard on a recent steamy morning and declared it both a tragedy and a wonderful thing. Sierra Leone is a vivid example of human resilience — anyone over the age of 30 today has lived through a civil war and displacement, an Ebola epidemic, devastating mudslides and now the lockdowns and disruptions of Covid. Most people, he said, have absorbed the traumas and carried on. But not everyone.
“There is PTSD, depression, all the psychopathology that goes with disaster,” Dr. Eze said. “We see 100 outpatients per day. The wards are full. Now I extrapolate to the entire population. If you pass through any market, you’ll pass many people with depression, phobic states, personality disorders. This is just the tip of the iceberg.”
Families once dreaded handing over their loved ones at the Kissy gates, Dr. Eze said; they brought them only when they felt they could not care for them at home, when paranoia or psychosis made their behavior violent or strange. “People used to bring their family here with their hands tied and say, ‘Take this man’ — a last resort,” he said.
These days, when he arrives at work, he notices that patients and caregivers park motorbikes or cars out front, unashamed to be seen. “Now they come for help,” he said.
Sierra Leone lacks more than just psychiatrists; there are only three physicians for every 100,000 people, the W.H.O. says (compared to 278 per 100,000 in the United States). But efforts to build the health system in the country are focused on physical health and primary care, as they are in many countries in the global south. Mental health care is often seen as an impossible luxury.
The curriculum in medical schools and nursing colleges in developing countries rarely includes even a passing mention of mental health, Mr. van Ommeren said. Graduates primed on infectious disease and obstetrics are never taught to diagnose or treat postpartum depression, schizophrenia or post-traumatic stress.
Sierra Leone has been pouring money, including funds from the World Bank and international donors, into rebuilding its health system since the end of a brutal civil war in 2001. The country is making gains against chronic problems such as malaria and maternal mortality.
But it took serendipity, and some significant outside help, to take Kissy, named for the neighborhood where it is located, from asylum to teaching hospital.
In 2014, the Boston-based humanitarian medical organization Partners in Health teamed up with the Sierra Leone health ministry to rehabilitate the hospital. The walls were lowered, the bars removed. Workers installed plumbing and electrical wiring, and a giant suite of generators, to make up for the failings of the rickety municipal power service. Patients were given bedsteads and fresh bedding, in lieu of torn and filthy mats on the floor.
“And on the 18th of August, 2018, we unchained the patients,” said Anneiruh Braimah, the head of nursing. “It was epic.”
Mr. Braimah, a wiry man who is known at Kissy as the Matron, has worked at the hospital since 1998. Drawn for reasons he can’t explain to psychiatric nursing, he studied in Nigeria and then turned down a job offer there to come home and offer his services at the health ministry, which dispatched him to “the asylum.”
At Kissy for decades, he was both nurse and doctor, he said, sometimes prescribing medications, when he could get them, and supervising a shifting roster of people who came briefly to work there. The standard of care involved physically restraining patients — with the chains — and injecting them with heavy sedatives, when they could be obtained.
It was hard to feel good about the work they were doing, Mr. Braimah said, but they didn’t have options. “We just weathered the storm,” he said. “Even basic care, you couldn’t do it.”
With the Partners in Health investment, two things changed: The unchained patients no longer raged and hurled the contents of their chamber pots, and students — just one or two at first — expressed interest in doing proper training rounds at Kissy.
Regina Conteh, a nursing student, said her parents had barraged her with warnings before her first day at Kissy. But on her first day in the women’s ward, she found that patients were not threatening her with violence. In fact, some sought out her care.
On a recent day, a young patient named Aminatta brandished a bottle of orange nail varnish and offered to do Ms. Conteh’s nails. Aminatta had come to Kissy from a crowded low-income neighborhood in the city, mute and immobile with a depression that had never been treated. After a couple of months at the hospital, on regular antidepressants, she smiled and held her own hands out for Ms. Conteh to do the polishing. “You can do things for people,” the student nurse said as she painted.
In the airy ward behind them, some patients lay unresponsive in their beds, while others did their laundry at a standpipe and tried to engage trainee nurses in boisterous conversation on topics including lunch, visitors and the possible return of the messiah.
Partners in Health does not usually work in the field of psychiatric care, or in capital cities; it focuses on delivering services in the most underserved parts of the countries where it works. But in 2016, Dr. Bailor Barrie, now the organization’s country director in Sierra Leone, and a few colleagues happened to pay a brief visit to Kissy.
“From the moment we walked in, it was so miserable, so sorrowful, that it was clear that we had a moral imperative to be involved,” Dr. Bailor said.
The organization and the health ministry agreed to work together on rehabilitating Kissy. The effort involved not just physical renovations but a significant shift in perception of mental illness as a public health problem like any other.
The ministry hired Dr. Eze from Nigeria and another psychiatrist, a Sierra Leonean who had recently returned from years in the United States, to be the faculty for a handful of medical students who were newly willing to consider stints at the transformed clinic.
Partners in Health has spent $2.5 million at Kissy over four years on renovations, drugs and a laboratory and on earning accreditation as a teaching hospital. The complex now includes a soccer field, an occupational therapy center where patients play board games and gather for group therapy, and a playground for the children’s clinic.
The Kissy hospital project became a favorite of Dr. Paul Farmer, the organization’s co-founder, who died recently. In a conversation with a reporter shortly before his death, he called it “just the most fantastic story,” evidence of what was possible not just in Sierra Leone but across the global south.
When Mattia Jusu qualified as a doctor and was given his assignment by the health ministry in 2019, he was horrified to learn that he had been posted to Kissy. “I was expecting a very short stay,” he said with a laugh. “But a few months into coming, I started to change my mind.”
Some patients were calmer and more engaged with each passing day, and he began to see the power that mental health care could offer people who had been trapped in treatable but untreated illness for years. He is on track to be certified as the first domestically trained psychiatrist in two more years.
Across the continent from Sierra Leone, in Ethiopia, there is a clue to both what the residency program may one day produce and a reminder of how long it may take. There, for the past 18 years, Addis Ababa University has run a program to train psychiatrists. The first group graduated in 2006 — seven of them, for a country of 115 million people. The program has grown steadily since then, so that there are now psychiatrists in most of Ethiopia’s major hospitals, a once-unthinkable level of coverage, said Dr. Dawit Wondimagegn, a professor of psychiatry who until recently served as director of the university’s college of health sciences. Still, that is one psychiatrist per million people.
“Our fundamental challenge is that psychiatric disorders, and the need for access to mental health care in general, really is not a priority for health policy, in Ethiopia or anywhere in Africa,” Dr. Wondimagegn said. Stigma is pernicious, and it feeds the idea that there is nothing to be done to help a patient who suffers from psychosis or depression.
Ethiopia’s model includes psychiatric education for nurses and community health workers who will be the main points of interaction with the health system in rural areas. The W.H.O. advocates for building mental health into primary care, rather than training specialists and building dedicated clinics.
The newest construction project at Kissy is a rehabilitation center, which will bring addiction treatment to Sierra Leone for the first time.
“We have such high rates of substance abuse — have we ever asked ourselves why it’s happening?” mused Dr. Elizabeth Allieu, the resident who set up the children’s clinic. “All the child soldiers from the war, they have children now. These untreated people, traumatized and not healed, having children. What do you think will happen?”
Kissy once turned children away. Now Dr. Allieu’s clinic has helped put programming about mental health in children on radio shows, and a team is starting school outreach.
“We can do a lot here,” Dr. Allieu said. “A lot.”