Adri Kotze and Eromo Egbejule
Lay counsellors are being trained to assist a handful of psychiatrists to deal with the minds of Nigerians racked by Boko Haram terror.
Bulus Apollos is sitting in the small courtyard of a compound in Gomari Gana, an area with dusty streets in Maiduguri, Nigeria. His hands, gnarled from years of onion farming, shake as he lifts faded yellow trousers to reveal swollen feet.
Apollos (47) was held captive for over a year by Boko Haram fighters, the Islamist insurgents who have waged a bloody terror campaign in northeastern Nigeria for seven years. He says his feet are still aching from being shackled for the 15 months he was detained.
“Every Friday each of us would be paraded in front of a special court and ordered to convert to Islam,” Apollos explains, a vein throbbing in his right temple. “We refused … and they would beat us and take us back to detention.”
Boko Haram enforces its own, radical version of Islam that forbids Western education and seeks to destroy the secular Nigerian state. Its campaign has been marked by sexual violence against girls and women, including rape and forced marriage.
“I still have nightmares of those who starved to death,” Apollos says. “And of those who were beheaded.”
No money for mental health services
Apollos doesn’t know if he is suffering from depression or post-traumatic stress disorder. He doesn’t have money to seek professional help and has not been diagnosed with a mental illness.
Rescued from captivity by Nigerian military forces in October last year, Apollos is among the hundreds of thousands who have sought the relative safety of Maiduguri, the capital of Borno state and birthplace of Boko Haram, to wait out an end to the bloody conflict.
More than 20 000 people have been killed since the start of Boko Haram’s campaign to establish a caliphate, according to the United Nation’s Office for the Co-ordination of Humanitarian Affairs, and in Nigeria alone 1.8 million people have fled their homes.
As vast swaths of farmland and entire villages in the underdeveloped and poor northeastern provinces of Nigeria were destroyed, Maiduguri, once a regional trading centre, saw its population double from one million to two million people with the influx of villagers from across the region since 2009, UN figures show.
The 16 government-managed camps set up for the displaced here have simply not been able to accommodate the huge numbers. Makeshift shelters cram open spaces and families have moved into schools and half-built government buildings. Many of Maiduguri’s residents have opened their homes to refugees, but the city is overcrowded and battling to provide basic services. Long lines quickly form when there is news of aid handouts.
Apollos found temporary sanctuary when a member of his church took him in. Abducted in 2015 along with more than 1 000 other men from his village of Kerenuwa, near the border of Cameroon, Apollos was held in a detention camp just outside Maiduguri.
Northeast Nigeria has only one mental health hospital
At the Federal Neuropsychiatric Hospital in Maiduguri — the only psychiatric facility in all of northeast Nigeria — there is not a single empty seat in the waiting room. Orderlies in pink and nurses in white rush back and forth.
Doctors here estimate they have treated at least 60 000 patients since the start of the conflict.
Nobody has escaped the trauma of the conflict, says Abba Shuwa, a doctor at the hospital. “Everyone has been affected: nursing mothers, teenage girls, ageing elderly men.”
Over the past year, President Muhammadu Buhari and the military have repeatedly claimed victory over Boko Haram as government forces have pushed back the insurgents.
Although Nigerian soldiers have regained territory and freed many captives like Apollos from the militants, the army too has reportedly been accused of abuse and brutality by civilians. As suicide bomb attacks continue — increasingly by women and even children – distrust of suspected Boko Haram supporters among the refugees grows.
“If you are hungry, your mental health becomes a secondary issue”
One woman recently brought to the Federal Neuropsychiatric Hospital was mute, says Ibrahim Wakawa Abdu, the chief medical director. “She’s from Gulak in Adamawa state but she was rescued by the soldiers on one of their operations within Borno state here. They thought she was a spy, one of the insurgents.”
The woman did not respond to anyone, but would sob when left alone for more than a few minutes. They did not learn what horrors she had experienced, but diagnosed her with post-traumatic stress syndrome.
It was weeks before she could talk and even then could only say where she was from. A staff member helped reunite her with her family, but she had no money to pay for ongoing treatment.
The majority of patients are brought to the hospital by aid organisations such as the UN International Organisation for Migration (IOM), Shuwa explains. With many battling to survive here, mental illness is hardly a priority.
Shuwa says: “Most of them are battling just to feed themselves so they take their [mental] health as a secondary issue until it becomes life threatening. It is then that they present to the hospital.”
Most health centres have been destroyed
Shuwa and the other doctors here have often pooled whatever money they have to help the victims.
There are severe food shortages in northeastern Nigeria as farmers have been unable to return to their fields for a third year in a row. Crops have been destroyed and livestock stolen or slaughtered.
In Borno, 75% of water and sanitation infrastructure has been destroyed or damaged, according to a statement by Unicef executive director Anthony Lake. Since the conflict started, 72% of health centres have been damaged or destroyed in Yobe state and 60% in Borno, figures from the World Health Organisation show.
With these pressing difficulties in an already impoverished region, psychiatrists at the Federal Neuropsychiatric Hospital say the mental health crisis reaches far beyond what they can manage.
The hospital couldn’t even deal with its normal workload before the insurgency, explains Fatima Akilu, a psychologist and executive director of the Neem Foundation. The nonprofit group offers trauma counselling and psychological support to victims of the insurgency in Borno state.
“The mental health services here are completely inadequate. We are talking tens and tens of thousands of people who need help,” Akilu says.
One psychiatrist for every one million people
More than 2.7 million conflict-affected children alone in the region need psychosocial support, Unicef reports. But only 3.3% of Nigeria’s health budget goes towards mental health, a 2016 study published in BioMed Central points out. In the whole of Nigeria, with its population of 180 million, there are less than 200 psychiatrists — or just one for every one million people, the same study states.
Although not everyone with mental health problems needs to see a psychiatrist, there is also a lack of other professionals: at the Federal Neuropsychiatric Hospital there are only four psychologists, Akilu says. “My foundation also has four psychologists. That means there are only eight in the whole of Borno state. We need hundreds and hundreds.”
Apollos, like many others here, has turned to the church for spiritual healing and mental health assistance. His treatment here consists of prayer, fasting and counselling by church elders.
“The prayers have helped me sleep better,” he softly says.
Many Nigerians still believe there are supernatural or preternatural causes for mental illness, a 2008 study in the African Journal of Psychiatry found, and they often turn to spiritual healers who attribute mental illness to witchcraft, the use of cannabis or believe it is punishment for sins. Curses and punishment from gods and ancestors are also cited as causes for mental illness. Treatment may involve fasting, drinking of holy water, prayer, beating, bathing and sacrifice, according to the study.
The lack of understanding of mental health issues has left aid workers overwhelmed, Akilu says. The IOM and Unicef have also been providing psychosocial support, but many areas are still inaccessible with no access to any form of counselling.
She says: “We need to use lay counsellors — it is the only solution.”
The Neem Foundation has opened a psychology training centre, where lay counsellors undergo an intensive nine-month training programme. This covers all aspects of psychological counselling, Akilu explains, including assessment and diagnosis. They specialise in trauma treatment, working with victims of gender violence as well as child trauma. Here social workers, preachers and teachers also get trained to give psychosocial support to children and the foundation has opened a centre dedicated to child trauma.
In June last year, Neem started a project called Counselling on Wheels to bring trauma care to the doorstep of victims of violence. Twelve mobile units travel in small, three-wheeled tuk-tuks to different locations in Maiduguri. They visit four communities at a time.
“We do individual assessments and then we sort [people] into groups and do group therapy for each group for a month at a time,” Akilu explains. Those in need of greater psychological services are seen individually.
“Every month we see 1 000 people. With the limitations we have in funding, our target is to reach 12 000 people a year, providing comprehensive psychological services.”
Akilu says people often queue for more than eight hours in the blazing northern sun to get to see the counsellors.
“The impact has been incredible. For many the symptoms have decreased and they have built resilience. We have reports of people being able to sleep for the first time in months.”- Mail & Guardian