In countries affected by conflict and political volatility, mental health problems are often serious and complex but poorly supported by public health services. Take Somalia. Here trauma is common, and illnesses such as depression — often caused or exacerbated by poverty — are widespread after decades of civil war, instability and (more recently) terrorism. The WHO estimates that 1-in-3 Somalis have been affected by a mental illness at some point in their lives.
War and poverty have decimated the country’s health sector. Services and research in mental health fare even worse: Somalia has only a handful of trained psychiatrists.
In this interview, we speak to Djibril Handuleh, a Somali doctor and mental health researcher working in Somaliland, a self-declared state in northwest Somalia, and member of the King’s Centre for Global Health in the United Kingdom.
Handuleh is active in using information and communications technologies (ICTs) as a cheap, effective way of training health workers in an impoverished nation where medical infrastructure is weak and opportunities for postgraduate training almost non-existent. He explains how training programmes can use technology to draw on regional and global expertise and develop robust, evidence-based systems of care.
What kind of mental health issues do people tend to be affected by in Somalia, and what is the capacity in terms of mental health support?
The main issues people in Somaliland face are those like post-traumatic stress disorder and substance misuse, as well as others that are closer to issues experienced in the rest of Somalia: depression, psychosis and so on.
“I think Somalia is a typical example of a failed state and shows how to establish a health system again in a fragile state.”
Djibril Handuleh
The basic reality in this country is that the institutions are now building up after 25 years of conflict. The capacity [we have] now is just to train nurses and medical doctors. Postgraduate training is not yet established: those who want to study [mental health] have to go elsewhere and specialise in their respective fields.
Could you tell us more about your research on the training of mental health workers in Somalia?
Currently my research looks at the use of ICTs in mental health education.
Because of poor access to mental health services, we need to train general healthcare workers to treat patients. Using local broadband internet, it’s possible to connect a supervisor to a practising physician or nurse based elsewhere, and then the supervisor can teach the nurse how to assess the patient, run a management plan and so on. The people doing the training can be in the country, in the region — wherever they work. This system has been used in other fragile states like Palestine and Sierra Leone.
What ICTs are used in mental health training? And how do you go about getting ICT training programmes up and running?
It’s usually text-based teaching like PowerPoint presentations and a Facebook-like chatting system for teaching, where colleagues can have training sessions. We cannot do video-based teaching because of the low capacity of the internet at the Somaliland end.
My approach [to getting them up and running] would be very simple. First, I would start with the local government in the local town, then regional government and then the national ministry of health.
To give you an example: I developed an idea for training and then presented it to a medical school in Amoud in Borama, Somaliland. We then had to send a project proposal to a British NGO based in Somaliland, the Tropical Health & Education Trust, and applied for a UK Department for International Development grant to help establish mental health services in Borama. We had to present the idea at Somaliland’s ministry of health and get its endorsement.
The project had many facets: we planned to work in prisons, schools, the community. We had to write to Somaliland’s ministries of education and justice to get their approval for us to do the study. If you’re working in a country like Somalia, you need to get everyone on board: the societies, women’s associations, police, religious groups. Getting everyone on board is very important in any healthcare intervention.
You mentioned religious groups. Is religion something that comes into your work a lot?
It comes into it quite a lot, particularly when we are setting up mental health services for the first time. I would invite women’s associations, religious community leaders, the elders of the community, young people, civil society groups, artists. As a big group they then can contribute to persuading decision-makers about the importance of mental health services for the public, and to explaining what everybody wanted.
For instance, in Borama, the idea was to convince people that we didn’t need to put mental health separately — which would have just increased the stigma — but instead establish the mental health ward within the hospital in the town. To convince them, I had to present all the literature from elsewhere, whether from the WHO or case studies from other countries. And people then said: “Other countries are doing the same. We can do the same.” After all the meetings, they were able to say: “Now it’s our responsibility and we’re going to build our own ward.” And this is how the community themselves had crucial leadership in the set-up of their own services.
It’s all about how we sell ideas to communities and get their trust. The communities usually listen and are willing to improve their own healthcare systems.
What about the different ways that people in different countries conceptualise and articulate mental health issues — does this come into your work often?
Yes, it comes into my work from the social cultural perspective and public health perspective. I think mental health systems in fragile states can be well addressed if there’s the right commitment and the right people in place to work with the community and establish what is culturally feasible and realistic.
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Overall, the idea was to develop culturally sensitive course modules addressing Somali mental health perspectives — because we cannot put the core aspects of psychiatry into practice without cultural, religious and social understanding of the local context.
Have you found any kind of resistance to engaging with the idea of mental health treatment altogether, because it might be seen as showing weakness or being somehow culturally inappropriate?
Yes, in my experience in the first one or two years it has been quite difficult to get the message across about how mental health presents in communities that have not been accustomed to mental health services. But when we had extensive community-based awareness and community work, we came to [see] that the people were very cooperative. And in the last project I was working on, the community had a bigger say in the design phase of the implementation of what they wanted, how the services would be established — things like that. This is a very positive note from the Somaliland community.
Do you think these findings are transferable to other countries?
Absolutely. I think Somalia is a typical example of a failed state and shows how to establish a health system again in a fragile state. And this could be used in other countries that have had similar experiences. There is room for improvement, and let us all be optimistic for a better world.
Q&As are edited for length and clarity. This Spotlight article features a researcher from INASP’s AuthorAID programme.