After decades of civil war, Somalia is awash in mental illness and without a single trained psychiatrist. That the folk cure for PTSD involves being locked in a room with a hyena isn't helping.
MOGADISHU — Mohamed Abdulla Hersi reclines on a foam mattress in the Habeb Rehabilitation Treatment Center's crowded mental ward. His eyes are glazed over from antipsychotic drugs, probably some combination of chlorpromazine and haloperidol, but we can't be sure. His medical files, in a bundle in the facility's office, do not list his drug regimen. Hersi doesn't even bother to swat away the flies gathering on his face and body. Loose-fitting combat fatigues, emblazoned with the light blue and white-star emblem of Somalia's tattered army, expose his chest and two bullet-sized scars -- evidence of the battlefield violence he has suffered since joining one of the country's myriad militia groups as a boy.
That was back in 1991, when the toppling of dictator Mohamed Siad Barre plunged Somalia into more than two decades of chaos. Subsequent fighting under clan warlords and Muslim hard-liners drew in the United States, Ethiopia, U.N. blue helmets, and a coalition of African forces. Now that African Union troops have dislodged al-Shabab militants from most major cities and a new government is shining a dim ray of hope over parts of the country, the battle-scarred Hersi serves as a reminder to the many challenges Somalia has yet to overcome.
"Where is my M-16? My Kalashnikov?" he murmurs, seemingly unaware that he is miles from the front lines, where his fellow soldiers fight an enemy with links to al Qaeda and ambitions to overthrow the U.N.-backed government. Hersi speaks in a muddled stream of consciousness about gunfights, explosions, and mangled comrades from his years serving under various militia leaders, generals, and presidents. He mumbles about a car-bomb blast he survived in Kismayo, about Osama bin Laden, and about his father, who apparently died in Minneapolis.
"I was 7 when I joined the soldiers. My life has been for fighting only," he says. "I fought for all the warlords. In Jubaland, Puntland, Mogadishu. I grew up with the war. I joined Somalia's national forces. I killed al-Shabab, but I do not know how many."
The 29-year-old calls himself a general -- though his fatigues suggest he is an ordinary foot soldier -- and yearns to exit the locked compound and return to his comrades in arms. "I have more experience at the bad things," he says.
Somalia has among the highest rates of mental illness globally, affecting at least one-third of its estimated 10 million people, according to the World Health Organization (WHO). Rates are higher in Mogadishu and the turbulent south, where civilians have endured harsher stresses of war, drought, and instability. Many witnesses of bloodshed and atrocities face post-traumatic stress disorder (PTSD). Without treatment, sufferers can experience depression and maniacal, violent fits, and they are more prone to substance abuse -- often of the khat plant that sends chewers' minds and pulses racing. A psychosis, such as schizophrenia, can follow, though the number of Somalis who have been formally diagnosed pales in comparison with the number who are afflicted.
After decades of civil war, Somalia has virtually no capacity to cope with widespread mental illness. The country's only trained psychiatrist died last year in a car crash; the better-trained staff members at mental health clinics like the Habeb Rehabilitation Treatment Center have only three-month diplomas in basic psychiatry from the WHO. Most are untrained volunteers.
Abdirahman Ali Awale, who founded Mogadishu's first mental clinic in 2005, has been working feverishly over the years to improve and expand care. The energetic father of nine, known locally as Dr. Habeb -- despite his lack of formal medical training -- is now one of Somalia's main mental health-care providers, running half a dozen centers across the country. Relying on paying relatives, private donations, and drugs from the WHO, he has provided care to some 14,000 patients over the last eight years.
"War and conflict is the biggest problem causing mental disorder," says Habeb, his vocal chords straining from the combination of a birth defect and near-constant yelling. "Nobody supports the mental ill people in Somalia."
At the Mogadishu facility where Hersi lies, vacantly staring into space, mattresses are strewn across floors, squeezed into storerooms and onto porches. Patients while away the hours in idle gossip and argument, hunkered down under flimsy steel roofs. A few years back, many patients were chained to their beds, but they have since been freed after WHO officials intervened.
"I speak English in many different dialects, but I'd rather speak Latin," says a young male patient, who claims to have lived in London but whose actual identity remains unclear. "Latin is a general word for English. A word for Latinos. Now the World Cup is Latin. Brazil is hosting the World Cup next year. And I wish you all the best," he says, wandering out of the overcrowded ward.
To hear Habeb tell it, curing mental illness is cheap and simple -- just a case of drugs, know-how, and some rest. Most patients stay for between a few days and several months, though some have been locked up for years. Once his patients are discharged, however, there is little follow-up to assess whether they relapse. Patient records are barely four pages long, and on many documents, most sections are left blank.
As limited as the care is for patients in Habeb's clinics, however, the situation for the majority of Somalis suffering from mental trauma is far worse. In much of the country, modern medicine is not the first approach to curing mental illness. Because conditions ranging from epilepsy to schizophrenia are widely believed to be the result of possession by spirits or djinns, cures are often sought in faith and folklore. Mullahs routinely tie sufferers to trees and flog them with branches in order to exorcise demons. In rural areas, according to WHO officials, the mentally ill are sometimes locked indoors with a hyena for three-day stretches. Local legend has it that the arched-back scavengers possess mystical powers and can eat the evil spirits that poison the mind. Uncontrollable victims of mental trauma have simply been beaten to death by villagers.
Even in downtown Mogadishu, it is clear that few of the city's wild-eyed denizens receive treatment. On one street, a dreadlocked woman pulls down her dress and exposes her breasts. Locals say her husband and seven children perished from disease. Elsewhere, a man grimaces by the roadside. In his hand is a bunch of khat, a socially accepted but addictive stimulant. Under a nearby bridge, unemployed homeless men with bloodshot eyes rest on flattened cardboard boxes after a night's leaf-chewing.
These sufferers roam free. Others are locked down, out of sight. Abubakar Mohamed Sheikhow, 23, was chained by his wrists and ankles in a metal shack in southwest Mogadishu for 12 months before one of Habeb's rescue teams located him last year. Neighbors had restrained him after he violently attacked his mother.
Dowlay Hassaney, a 27-year-old schizophrenic, was chained to a bush in Eel-Adde, some 55 miles southwest of Mogadishu, when health workers found her in 2011. Her husband had been apparently undeterred by her mental state: She gave birth three times during eight years spent shackled in the sun, according to Habeb. Mobile teams from Habeb's mental-health facilities have saved roughly 2,500 mentally ill Somalis from chains in the southern part of the country, but Habeb guesses that another 5,000 remain shackled by their families in Mogadishu alone.
Bethuel Isoe, a psychologist with the Italian charity Group for Transcultural Relations who has spent 25 years aiding Somalis in refugee camps in Kenya and Somaliland, says that PTSD and other mental disorders may be feeding back into the cycle of violence. Those bearing psychological scars are often willing volunteers for extremist militias, he says, providing the cannon fodder for attacks. The problem is compounded by the fact that a whole generation of young people has known nothing but turmoil since 1991.
"I wish the Somali government understood the importance of this," says Isoe. "The country cannot move forward, economically, politically, or even socially with such a large number of mentally ill patients. If nothing is done, security will remain a challenge."
For his part, Habeb says he struggles to get attention from Maryan Qasim, the minister for human development and public services, whose portfolio covers health, education, youth, sports, women, and labor -- or the global charities that have increased their presence in Mogadishu.
"International agencies are only interested in diarrhea, TB, HIV, and malaria," he says, echoing a widely held view among mental health workers that infectious diseases secure a disproportionate amount of global health funding. While mental illness accounts for 14 percent of medical problems, it receives less than 1 percent of health spending in poor countries.
Dr. Zeinab Ahmead Noor, head of Somalia's mental health unit, says officials support Habeb's work by sourcing drugs through the WHO, though she admits that the health ministry is more concerned with re-opening Mogadishu's Forlanini Hospital.
"We help him as much as we can but we are more focused on the opening of a public hospital," she said. "There [are] many people who suffer from mental health. Every family has some problem, and, because of 20 years of lack of resources, there is a lot of suffering in the country."
In his ward in Mogadishu, Habeb's telephone rings throughout the small hours as new patients are admitted -- some of them kicking, screaming, and violent. The morning brings a new arrival, the 28-year-old son of a parliamentarian, whose ankles and wrists were bound with television cable after he trashed the family home.
Habeb looks exhausted and stressed. His son, Mohamed Alrahman Ali, worries that his father is overworked, that his diabetes, weight loss, and quick temper are worsened by helping Somalia's mentally ill. "I cry seven or eight times a day. I don't have any support. I am alone," says Habeb, his left leg jittering restlessly in a manner that resembles many of his patients.
There is debate over what proportion of Somalia's population suffers from mental trauma. Many describe the WHO's estimate of one-third as conservative. Some believe it is closer to two-thirds. For Habeb, the answer is simple. "All," he says, not even bothering to exclude himself.