Reflections On Mental Health In Somaliland

In this blog, Dr. Peter Hughes, Consultant Psychiatrist, looks back at his involvement in the Kings, THET, Somaliland Project and the impact it’s had on mental health care in Somaliland.

I’m writing this piece on World Mental Health Day, which seems an ideal time to reflect on the progress of the Kings, THET, Somaliland Project (KTPS) and its impact on mental health care in Somaliland.

I came across KTSP by chance. An acquaintance, I can’t remember who but I’m grateful for their prompting, knew of my work in Malawi and Ghana and suggested that I get in touch with KTSP. This sparked an association with the project that started in 2008 and continues today.

I was lucky to be on the first mental health training trips to Somaliland and, since then, I’ve been on seven more. In this time, I’ve been able to see the changes and the great deal that’s been achieved in mental health care, achievements that KTSP and our Somaliland colleagues can be proud of.

I barely knew anything about this self-proclaimed independent state when I set off on my first volunteering experience. The combination of a war that ravaged the country and extreme poverty meant there was barely any health infrastructure, and mental health was not on the map at all before 2008.

When I arrived in the capital of Somaliland, Hargeisa, it was hot and dusty, the streets crowded and markets bustling. Somalilanders walked tall and erect; all women wore traditional Somali hijab; goats were seen everywhere and Qat, the local amphetamine based drug, sold on stalls on every street corner. The place is exotic and exciting.

On my first trip, I took on the role of teaching the graduate doctors. I’ve had quite a bit of experience with international teaching so was able to put my skills into practice. I taught six interns who had no previous training and got them up to speed on mental health. I’ve seen them many times on my trips to Somaliland and have followed up their progress with interest.  I’m proud of their continuing aptitude for the mental health aspects of clinical care. One of the interns is now working on the mental health ward in Hargeisa. 

Since that initial trip, it has been a process of fine-tuning the teaching programmes. We have added areas such as ethics, developed a culturally appropriate bank of Somali cases, and more recently introduced the WHO mental health curriculum.

The training in nursing and other specialities has similarly developed over the years with KTSP. I did training for nurse tutors during one trip and it is immensely satisfying to hear from my former students now working and teaching themselves. I hear from them regularly on Skype and they tell me about cases they see now and how they are now teaching.

During my time in Somaliland I have seen cases of autism that were never diagnosed previously, depression, mania, and somatic problems. What is most difficult are when the problems are born out of poverty or gender inequality. If you leave the main towns of Hargeisa, Boroma, Berbera or Burao there are absolutely no provisions for the mentally ill.

There was a lot to learn along the way about Somaliland culture. Everything is prismed through religion. Religion is a hugely important psychosocial aspect of all mental health and we learned ways over the years as to how our students would address this. Gender is a huge issue too and women have a very different and challenging life in Somaliland. Qat, or Khat, use in Somaliland also badly affects Somaliland society in terms of economic, mental health and family life. 

When I first arrived at the Hargeisa Group Hospital there was one mental health ward. The conditions were horrible and all staff there recognised this. The care was not good and clear violations of human rights; most of the male patients in the male ward were chained up.  Now five years later there is hardly any chaining and there is professional nursing and medical input on the ward. We’ve been able to use this experience as a base for our teaching of medical students.

In my most recent teaching programme, in May 2012, I went with a core trainee, Lauren Gavaghan. It is so important for trainees to get this experience and bring a new energy and freshness to the project. We had two Somaliland graduates who were our co-lecturers. These co-lecturers directly delivered 40% of the teaching to the undergraduate group and indirectly facilitated role-plays, clinical sessions and all other aspects of the teaching.

One can’t talk about the KTSP experience without talking about Edna Aden and her hospital. Edna has created this maternity hospital out of nothing and it really is a place of excellence. The hospital also provides support including mental health support to their nurse trainees and midwives. Edna is a hugely inspirational character in Somaliland in advocating for the health of women and is very accepting of the need for good mental health.

Mental health is now very much on the map in Somaliland thanks to KTSP and the doctors and nurses who have gone through our teachings.  We have invested in young, professional Somalilanders to support them with their future careers; we have Dr. Jibriil in Boroma and Dr. Abdirizak in Hargeisa who are now local leaders and providers of mental health care; mental health is now delivered in hospital, community, maternity settings and prison; supervision is embedded from UK to undergraduate and postgraduate doctors and nurses. There is a lot to be positive about. We have come a long way from August 2008 and long may it continue and prosper further.