Post traumatic stress disorder affects not only military personnel but thousands of innocent civilians every year. Some practitioners may find refugees or asylum seekers who have suffered in this way and need their services. In this article, which first appeared in The Supporter, published by the Medical Foundation for the Victims of Torture, Stephanie Strong describes work being carried out in Somaliland among people devastated by war
Chained to a wall in Burao, in the east of Somaliland, is Janwar, a 23-year-old Somalian who suffers from epileptic seizures. However, with proper medication and treatment Janwar would be able to lead a relatively normal life. 'Mental jails' are widespread in Somaliland and chaining people who suffer from psychological or emotional crisis is common practice. Those who find their way to hospitals are people who are abandoned, without families or any kind of infrastructure to support them. In the face of a widespread lack of health resources, jailing has become the most common response to mental illness in a country that has been devastated by over 30 years of war and poverty.
The Medical Foundation is committed to bringing issues surrounding health and human rights to greater prominence in places like Somaliland, through overseas projects. For over three years, the Foundation, with the financial aid of the UK Community Fund, has been supporting a locally run project in Somaliland, helping local people with mental health problems to receive proper medical care and treatment for their disorders.
Mental illnesses are on the rise in Somaliland as a traumatised population's way of coming to terms with the massive psychological scarring resulting from long-term war. The Medical Foundation project worker in Somaliland, Anwar Awad, explains: 'More than 65 per cent of those now affected by personal crisis are those who lost education and employment opportunities due to the civil war.
In order to minimise the explosion of personal crises into insanity, and prevent these vulnerable people being locked up in jails, we are working to provide basic mental health services for all. The beneficiaries who require these services are half the population of Somaliland, many thousands.'
On 18 May 1991, Somaliland proclaimed itself an 'independent republic', splitting from Somalia after almost 10 years of civil war. The 1980s had been a decade in which Siad Barre's government bombarded the cities to pursue the separatist rebels, rasing schools and making water and electricity inaccessible. This forced many hundreds of thousands of northerners to flee to neighbouring Ethiopia.
Anwar explained: 'After 1991, soldiers who fought in the civil war and people from refugee camps came back to find that cities were destroyed, roads and bridges had been blown up and the social structure and infrastructure had been completely wiped out.'
Today, there is a peace apparent in the capital city and countryside following the battles that raged here 20 years ago.
Ten years on from self-proclaimed independence, however, this small territory perched on the tip of the Horn of Africa has yet to receive international recognition. Despite holding every appearance of an independent republic, including a democratically elected government, a national army, a national flag and national anthem, Somaliland does not exist in the eyes of the international community of nation states. It cannot enter into any formal trading with other countries or receive any international aid. It dwells, at present, as the forgotten republic.
Currently, the democratic government of Somaliland lacks the infrastructure, institutional capacity and the financial resources needed to address the physical, social and economic needs of its population, a large percentage of whom live in extreme poverty, and the widespread psychological disturbances of the surviving population remain a distant item on the national and international agenda.
The Medical Foundation project in Somaliland started with the intervention of Anwar Awad. He returned to Somaliland to help during the late 1990s. He quickly identified eastern Somaliland as the most deprived and remote region, with a shortage of housing, roads and electricity.
Travelling to Burao, he founded a local voluntary organisation called SARAR, which was a feeding centre for mentally ill people. Using donations from local markets and merchants, it was providing two meals a day for about 500 people who were either roaming around the countryside with no-one to care for them or chained to the wall at home, unassisted and unfed.
Anwar told us of a typical encounter in the region where he works: There was a man sitting in front of a destroyed hotel near SARAR. He'd been sitting there for two days when a member of SARAR approached him and asked him what he was doing sitting there.
'He said he didn't know where to go. He was a nomad who'd been conscripted into the military army, the former Somalian national army, and taken to training camps in the south of the country
'He was involved in many fights for the government against his will. When the government fell, he had to walk for 1,800 miles back to his home. He'd been away for seven years.'
'When he came back to his own people, his wife had remarried and she denied his existence. His possessions were inherited by her and her new husband, and he was believed to be dead. He had to leave and wander about the country, traumatised by the war and by his own family's refusal. That's the kind of people who come to SARAR or end up locked away in the mental jails.'
It was clear to Anwar that organisations like SARAR needed to be linked to specialist assistance and funding in order to help treat the thousands of cases in need of similar assistance across the region. Anwar got in touch with the Medical Foundation. At first, assistance was provided with financial management, then a larger space was found where training and counselling work could be carried out and doctors could visit the patients.
Over a three-year period, local staff were gradually trained in mental health issues; patient history recording and analysis; personal and crisis intervention; patient's care handling; common causes for mental illnesses and the principles of modern psychiatry. At the end of this three year period, SARAR and the Medical Foundation had set up a model psychological service in Burao. Anwar now estimates that over 15,000 people have benefited from the Medical Foundation Somaliland programme with SARAR.
Today the Medical Foundation Somaliland programme is expanding beyond Burao to meet the widespread needs of the people in this desolate region. Work is being undertaken with the Somaliland Ministry of Health with the introduction of mental health legislation, with children's orphanages and child psychology, with psychiatric and community mental health schemes across Somaliland and with an early crisis intervention centre in Hargeisa, for the prevention of mental illnesses. In addition to this, the Medical Foundation Somaliland programme is working with other local organisations to create better employment prospects and social services for displaced groups and on issues of women's empowerment.
From one small programme to feed the hungry, this programme has come a long way in three years. However, much more work will need to be done before this neglected population benefits from decent standard of mental health. MHN
Anwar Awad trained and worked as a veterinary doctor in Somalia before escaping to Britain in the 1980's where he trained in social work. He went to Canada before returning to Somaliland in 1997. Medical Foundation 020 7813 7777.
Stephanie Strong is the major grants fundraiser at the Medical Foundation.
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