I was invited to speak at an SSSUK Symposium last September and I chose to speak about South Sudan’s mental health challenge. Here’s the transcript.
There are four subjects concerning South Sudan that are close to my heart. These are (and in no particular order): the economy; girl-child education; the environment; and mental health.
I’m pleased today to be given the opportunity to share what I have learned about the significant mental health challenge that my country faces.
It’s worth noting at this point, that I am a layperson. I have no qualifications in psychology, psychiatry or counselling. Although I’m seriously considering enrolling in some sort of counselling training. This is a struggling service in South Sudan, that’s sorely in need of whatever support it can get.
Now, few in the UK, certainly of my generation, have needed to deal with the tragic consequences of chronic or acute post-traumatic stress disorder – either as sufferers or as persons close to a sufferer.
So imagine if you will, a profound traumatic experience that’s become indelibly stamped on your consciousness.
A word, an object, even a situation, may serve as a trigger to reliving that traumatic experience. Your heart races. You begin to sweat. You’re seized by frightening thoughts and unbearable tension. Bad dreams disturb your sleep at night. And your everyday routine is disrupted.
Therapists will call this re-experiencing symptoms.
You keep away from places, objects, people and situations that would remind you of your traumatic experience. You try to avoid thoughts and feelings related to the event. You withdraw from those close to you, who try a little too hard to understand “the why”.
Therapists will call this avoidance symptoms.
You’re easily distracted. You’re tense and on edge. You keep losing your appetite. It’s difficult for you to get a good night’s sleep. You become irritable and prone to angry and even violent outbursts.
Therapists will call this arousal and reactivity symptoms.
You think poorly of yourself. Perhaps because of a profound sense of guilt. Or perhaps because you blame yourself for something you did, or did not do. And yet, strangely, you have trouble remembering key features of your traumatic event. You find yourself losing interest in activities you’d once enjoyed.
Therapists will call this cognition and mood symptoms.
I hope I’ve given you a sense of what post-traumatic stress disorder could mean for those who suffer from it, and a sense of the disruption it often causes for those who live with sufferers.
The Legacy of Conflict
Now think on the countless opportunities for traumatic events and experiences created by over half a century’s worth of sustained conflict, exposing many millions of my countrymen and women to mental illness. And it is widely acknowledged that South Sudan is a country disproportionately afflicted with mental illness.
And it’s not just violent experiences we need to be worried about. Contextual stress, before and after specific conflict situations will also lead to mental illness. Economic hardship and the change in living conditions for internally displaced persons or for the women of households whose main bread winner has left to become a combatant, often causes substantial psychological and social suffering in the short term. If not addressed, this suffering can lead to long-term mental health and psychosocial problems.
For those South Sudanese here today, you’ll no doubt recognise the phrase – “I think too much”. It is a common idiom whose study has gained traction among ethno-psychologists. “What’s wrong with so and so?” you ask, “Oh, she thinks too much” is the response.
The implications for our society of the rarely discussed mental health epidemic are alarming. Our social mores and taboos aside, we truly are a fragile nation. Of course, the ongoing civil war, and its destructive ferocity, threatens to make matters even worse.
What’s the impact on civilians?
The World Health Organisation has estimated that rates of common mental disorders are likely to double within the context of humanitarian emergencies.
A study conducted in Juba, before the civil war, found that 36% of respondents met the criteria for post-traumatic stress disorder and 50% for depression. These figures are significantly higher than global averages of 15% for PTSD and 17% for depression. Just take a moment to think about the implications of this particular study if applied nationally.
2 out of every 5 South Sudanese are likely to be suffering from post-traumatic stress disorder
A larger study conducted by the South Sudan Law Society in conjunction with the UN Development Programme concluded that 41% of their respondents, across six of the former states plus Abyei, exhibited symptoms of PTSD.
A similar study conducted in Malakal concluded that 53% of respondents were likely suffering from PTSD.
This is a staggering number. To put it into context, if the United Kingdom was facing a challenge of the same scale, then 26 million Britons would be suffering from PTSD. That’s more than double the populations of Scotland, Wales and Northern Ireland combined.
And what of combatants and ex-combatants?
Bishop Emeritus Paride Taban, has always emphasised the role of trauma in South Sudanese society. He remained in South Sudan throughout the liberation war. He recollected one particular SPLA officer in his diocese who was prone to violent and uncontrolled outbursts. The officer took care to warn the Bishop, “Please, please don’t approach my while I’m angry. I may kill you and then later profoundly regret it.”
A study, this time of ex-combatants in South Sudan, found that 36% were likely to be suffering from PTSD, with 15% having thoughts of self-harm and suicide. PTSD prevents ex-combatants from re-integrating into civilian life. They often suffer from anxiety, depression, hostility and social withdrawal. Violence commitment by ex-combatants, be they fully demobilised or still in active service, on the civilian population is a major problem.
PTSD and depression both lead to high instances of substance abuse, including alcoholism and drug taking. These have a disruptive, and sometimes tragic, impact on family life, working life and on society in general.
In South Sudan, police officers are almost invariably demobilised ex-combatants. Ten days ago, a policemen in Namurnyang state, formerly Eastern Equatoria shot dead two civilians and injured four others whilst reportedly under the influence of alcohol. These cases happen with alarming regularity, and we’ve become almost desensitised to them. One can’t help but wonder if at the psychiatric factors at play.
In order to find solutions to this challenge requires us to reassess and reprioritise counselling as an essential component of any future disarmament, demobilisation and reintegration programmes.
Mental Health Services
Tabu Grace Laki, a local counsellor working for South Sudan Red Cross recently highlighted the issue of South Sudanese dismissive attitudes towards trauma and mental health as a contributing factor to high incidences of mental illness. Not enough people are being referred for treatment by their family, friends and neighbours. She blamed a lack of awareness.
But even if they were referred, they would find the provision of mental health services is woefully inadequate to the task at hand. Like other low income countries, mental illness takes a back seat in policy terms and priority is given to physical illness. Mental health and psychosocial support interventions are therefore limited in scope and reach.
A 2015 report by the Dutch Consortium for Rehabilitation noted that: “with only two psychiatrists and few (clinical) psychologists working in the capital Juba, specialized mental health care is disproportionately distributed across the country. In Jur River County (the specific area of research) … people mostly rely on … traditional healing practices and social support of community members.”
Is the inadequate response to the mental health challenge cultural or is it a consequence of limited resourcing? Would more South Sudanese be referred for treatment if there were more clinics and better communications leading to greater awareness? I’m not sure I can answer that.
As it stands, Juba Teaching Hospital is the only public medical facility in the country that treats mental illness. Hospital records show that treatment for patients is sporadic and rudimental. Patients are given regular doses of diazepam, a sedative and anti-anxiety drug.
Before the civil war, limited services had been available in Wau and in Malakal. Despite having better facilities than other hospitals, the military hospital in Juba only has a few staff members trained in psychology who carry out basic counselling.
Those at Juba Teaching Hospital are the lucky few. A large number of mental illness sufferers are locked up in prisons so as to keep them from harming themselves and others. They are almost permanently shackled to the floor and are largely forgotten.
Several NGOs have attempted to support public mental health provision in South Sudan, mostly through psychosocial support programmes delivered through health centres and clinics. These efforts have, unfortunately, largely been frustrated by the rising insecurity in the country. More success has been achieved in refugee centres in neighbouring countries.
What Way Forward?
It’s difficult to be optimistic about the future.
The current conflict will only lead to an increase in mental illness as more combatants and civilians are exposed to war time trauma. The political and economic crisis compounds the problem of under-investment by the South Sudanese government in authorities to address mental illness. Sadly, our capability to treat mental illness will decrease just as the number of cases increases.
The effects on South Sudanese society will be felt for a long time to come. Besides the personal anguish of the sufferers of mental illness, South Sudan will likely face increased disruption and violence, both at home and in the community, committed by civilians and security personnel. We are likely to see more substance abuse, especially alcoholism. And we are like to see more apathy and neglect of work by able bodied members of society.
A collective NGO proposal suggests that our government should:
- Support the implementation of basic mental health services as part of the Basic Package of Health & Nutrition Services;
- Make finance available for specialised training, equipment, drugs and personal to improve access to mental health services;
- Implement findings from the 2001 WHO20 World Health Report on mental health in South Sudan.
But where will the money come from, bearing in mind state of the nation’s finances. Assistance from Non-Governmental Organizations, international donors and the World Health Organization will be critical in the years to come. But it is highly unlikely that South Sudan will receive any sort of budgetary support in the short to medium term.
Thank you for taking the time to listen to me talking about mental health in South Sudan.
The Society for the Study of the Sudans UK (SSSUK) promotes learning and provides resources for anyone with an interest in South Sudan and/or Sudan. I urge you to visit their website and find out more about the society and its work.