In September 2015, I attended the Mental Health in Complex Emergencies (MHCE) training in Debre Zeit, an hour’s drive from Addis Ababa, the capital of Ethiopia. The training was organized by the Institute of International Humanitarian Affairs (IIHA) at Fordham University in collaboration with HealthNet TPO, UNHCR, and International Medical Corps (IMC).
I arrived to Ethiopia with my colleague Boniface Duku from South Sudan. He is the Mental Health Advisor for South Sudan’s programmes and at the time, I was the Coordinator for a Psychosocial Project we ran across four counties.
I had been to Addis Ababa before very briefly during a period of leave from South Sudan. However, this was my first time outside of the capital, and my first time to see the wonderfully serene surroundings of Lake Bishoftu where we were staying for the duration. Prior to the training, I had very few expectations due to the fact that I was so immersed in and consumed by my work in South Sudan that I hadn’t given myself the space to fully read up about the content of the course. All I knew is that it would be a prime opportunity to delve into challenges and opportunities of implementing mental health programmes in complex humanitarian emergencies worldwide. In all honesty, I hadn’t even researched the facilitators, who it turns out were renowned and highly experienced members of the mental health and humanitarian professional communities. Once I arrived and took some time to read the articles, look over the agenda and do a quick google of the facilitators I felt pretty sure that I’d lucked out on a potentially life-changing experience from which I would take away a vast amount of knowledge, experience and opportunities. I wasn’t wrong.
While working in South Sudan, I was also undertaking a distance MSc in International Humanitarian Psychosocial Intervention through the University of East London in the UK. Previously, I studied BSc Psychology, with a Professional Placement in a Psychiatric Hospital where I worked with people with severe mental health issues and those who needed additional support in the community. In my role as Psychosocial Project Coordinator in South Sudan, I was able to use some of these academic and practical skills to support people who have experienced trauma and high stress during the period of conflict, as well as during the displacement that ensued. I had never had comprehensive training or academic studies combining the two areas – the support of people with mental health issues within the context of humanitarian emergencies. The MHCE training was the perfect fit for me, and it provided me with information from a variety of sources, contexts and experts to supplement my academic background and work experience. Previously, I mentioned feeling privileged that I was put forward for this training by my organisation, HealthNet TPO. I stand by that and reiterate the fact, because the training did not only enhance my understanding in the short-term or specific context of South Sudan, it also provided me with lasting lessons and friendships with like-minded people.
During the training, the focus was primarily on clinical mental health service provision such as diagnosis and treatment of severe mental health disorders in fragile states, or disaster or conflict settings. This was extremely interesting for me as I hadn’t actually seen this up-close in South Sudan. There are limited clinical mental health services available in South Sudan as it is one of the most underdeveloped countries in the world. It has extremely limited infrastructure, very few resources and the personnel are few and far between, and when they are there they are barely trained, and when they are trained they are whipped up by better paying non-governmental organisations (NGOs) because they are often underpaid in government positions. This is extremely common, and desperately sad for the country, because it means the sustainability of any programming that requires government backing, continued resource supply or long-term supervision and follow-up from training is unlikely to withstand the restrictions mentioned. I also run a Psychosocial project, which although psychosocial issues and mental health issues are on a sliding scale, we aren’t able (given the context) to do very much in the way of clinical support. It was inspiring to hear the variety of challenging circumstances and experiences faced by the facilitators, in humanitarian emergencies across the world, spanning decades, and the innovative and varied ways they overcame and learnt from these situations. It gave me hope that even in the most dire of circumstances, in the least established countries, there are still opportunities where professional communities such as ours can at least initiate the conversation, create an evidence-base and forge the beginnings of quality and impactful work in relation to mental health service provision. Although, in terms of the situation in South Sudan, I fear these goals are still a long way off.
Since the MHCE training, I have been able to integrate some of the elements into my daily work, and I was able to facilitate conversations regarding coordination of mental health and psychosocial support mechanisms within South Sudan. I have referred information to other interested partners, and referred back to it on many occasions as I continued my project through December 2015. I also earmarked many of the readings and research articles in relation to my Masters. There was a wealth of information and knowledge imparted that was invaluable to me and my career development. I can’t fault the content or the delivery of the training as it was varied and engaging throughout. Upon my return to South Sudan, I felt I didn’t fully have time to absorb the content and the lessons learnt because I jumped straight back into work as soon as the training had finished. I am now taking the time to immerse myself in the training again and go through it with fresh eyes to really take on some of the wisdom I may have missed first time around.
At the beginning of December I was fortunate enough to be able to attend another IMC event, this time a workshop in Juba, South Sudan. It was a presentation of the current delivery of mental health services in the country, drawing on experiences from other countries, and the disparity between them. It became very clear from the presentations that the current level of the health systems within the country would be an unfertile ground for consistent, quality mental health service delivery. This, combined with the previous ten-day training in Ethiopia were starting to bring together a formation of ideas for me to present to the coordination mechanisms in country, as well as discussions about how we can document this. From the MHCE training it was abundantly clear that we need to step up our game as an international community in terms of creating and sustaining an evidence base to support our work. It’s not good enough to share ideas once a year at trainings such as this; we need to have a systematic way of recording our experiences, both positive and negative, to inform future project implementation.
Stepping back from the technical side: the lack of systems, infrastructure, resources, funding and personnel, the poor attitudes and awareness of mental health in the communities, is really devastating. It is truly heart-breaking to hear about individual cases of people who are systematically uncared for because there is just no support available, or lack of knowledge or understanding. People with severe disorders are often chained to trees in order to ‘limit their aggressive behaviour’. A common misconception, or an immediate knee-jerk reaction to people expressing symptoms of mental health issues, is that violence will ensue. Sometimes, it does, but is usually related to the negative response from the community and the lack of effective treatment.
Much of the mental health and psychosocial work carried out in South Sudan currently is focused on internally displaced people (IDP) settlements or camps, because the needs are extremely high. Many of these people have experienced extreme levels of trauma. Some of these people are just children, infants, who have lost members of their families or even seen them killed in front of them whilst fleeing violence consuming their homes and communities. The needs are usually imminent and acute, and require some follow-up but can ultimately, often, be dealt with by mobilising community support systems and resources that the person or family already has. Often whole communities flee together, so their social structures are still around them, it’s just a case of reiterating this and encouraging them to utilise them. The issue for the rest of the country is that it’s in a state of chronic emergency. It’s no longer a humanitarian emergency because the threat or risk of violence is lower in some areas. It’s not, however, in a development stage because as I’ve mentioned, the infrastructure is not there to build upon. Therefore, there is a vast majority of the country that doesn’t fall in this ‘emergency’ phase, requiring only the immediate psychosocial support. People living with mental health issues are at the back of the queue as they don’t fall in the ‘emergency relief’ beneficiary category, nor are they provided for by the services already in place.
The needs are clear. The solutions, however, are not. However, the kinds of trainings provided by the IIHA at Fordham University and IMC bring the mental health and psychosocial support (MHPSS) community within the NGO sector a step closer to understanding what it is that can be done. It helps us to direct the conversation at the ground level, at the national and international level and then to express the needs (and potential solutions) to the donors. The training in Ethiopia has really given me the direction I need both within my work in psychosocial programming, and also at the country level. I am able to feed into the coordination mechanisms and reference the training and experiences of experts in the field, in order to guide the discussion and suggest options for improving the provision of services. This is something that will take time. South Sudan and its mental health services is like a metaphorical Rome; it won’t be built in a day, but with experiences such as the one I had in Ethiopia, I do think with time and passion and imparting of knowledge, we can edge closer to supporting countries such as South Sudan to provide basic mental health services to their people.
Read the recap of the MHCE 11 course and read more about Caitlin’s experience on MHCE participant Sujen Man Maharjan’s blog. The next MHCE course will take place in October 2016 in Geneva, Switzerland. Learn more on the IIHA website.