“It is a lonely space”

Twenty-year old chef Amina (not real name) is as beautiful as they come. She speaks with melodic intonations and when she smiles, she bears the look of a happy girl. Behind that, however, is a life of emotional ruptures that, until recently, often resulted in self-inflicted injuries and suicidal thoughts under the cover of dark solitary nights.

Having lost her mother at the age of three and father at five, she was picked up by one of her late father’s friends. He was rich and he enrolled her in one of Kampala’s high-end primary schools. She was, however, to endure an abusive childhood which included physical and mental torture as she changed from one family to another, and from one school to another.

In 2017, at just 16, while she lived and studied in a town in western Uganda, she was one evening thrown out of the house by her auntie and dumped at the roadside bus stop. Darkness fell. Stranded, with no idea where to go, she later fell asleep. In the middle of the night, three men subdued her into forced intercourse.

“It is a whole ball of emotions from then to now. It is like ‘does my life make sense? It doesn’t. Does it make sense? It doesn’t make sense’. That is where I am. Sometimes I am OK, sometimes I am not. Sometimes I don’t know what is right or what is wrong. I am just there”, she tells me during a lengthy conversations. At one moment, as she narrates her story, she breakdown in tears.

Amina was able to complete Senior Four a few months after that fateful night. She was supported by an uncle through a catering institute and she was able to get a job at a posh restaurant in Kampala but all through that time, she was struggling mentally. Those around her could hardly understand it. If they did, none of them bothered about it.

“From 2018 to 2019 my mental health was at another level. I was crumbling down in my own thoughts. It was getting worse every day. I became so reckless; I had wounds everywhere, self-inflicted. Then the drinking began.”

In March 2020, a COVID-19 induced lockdown took her to one of the worst levels of her mental problems.

“Things got terrible. People were laid off. I wasn’t but then my salary was cut. We came from 14 chefs to three in a very busy kitchen. I was doing work of, like, six people. I had issues with the head chef and I nearly stubbed him. My mental health was degenerating every day.” Eventually, in August, she resigned her job. But that led to a new lifestyle which included smoking, massive drinking and sleeping with men for money.

In March 2021, Amina’s new employer noticed that she had a mental problem and hired a therapist for her. She completed her therapy at the beginning of October and she says she is now in a much better mental shape.

“It has been a whole journey since March. It could be worthless if you don’t put in the effort. I wanted to stop the crying, the self-pity, I was always feeling worthless because of the rape. I wanted all that to stop. During this period, I have met people, a few good people. They have made me appreciate the person that I am. Every single morning is about praying and trying to be better. I am still on medication because I have sleeping problems, I have illusions, panic attacks – though I have not had a panic attack in two month. Other than that I have learned to manage the situations in a good way. Back then I would just get drunk, smoke it out, go home, drawn in self pity and hate the world for my problems,” she says.

The ignored killer

Mental illness is one of the most ignored, if not least understood illnesses in Uganda. Mild and moderate levels are hardly noticed as illnesses. At extreme levels, it is surrounded by deeply rooted cultural myths – with most people seeing it as social-cultural phenomenon other than a health issue.

Amina is among the very few who get professional attention in a country where up to 40 percent of the population is estimated to suffer a mental disorder.

“Our society has a lot of stigma and I think this is because mental health has not been prioritized in terms of human resource and funding. Fifteen years ago when I told people that I wanted to become a psychiatrist they said ‘you will become mad’. Even now it is the same perception,” says Marjorie Mukisa, a medical doctor and passionate mental health advocate. Mukisa works with the NGO Servir Foundation and she is the Central Region representative of Uganda’s national youth coalition for Sustainable Development Goals (SDGs).

“We have a lot of misconceptions about mental health. People don’t know that mental health has a spectrum. There are people that are mentally healthy. Then mild, moderate, and other people may have severely mental illness. Many of us are on that spectrum but we don’t even know,” she adds.

Uganda’s delivery of mental health services has been described as inadequate. An estimated 90 percent of the mentally ill in Uganda do not receive treatment. Only one percent of Uganda’s expenditure on health goes towards mental health. And in a country of over 42 million people, there are only 50 psychiatrists with most of them based in Kampala, at the country’s only mental health national referral hospital, Butabika.

Access to treatment is more in urban centres than the rural, and it is mainly for a few who are in elite settings and also have the financial ability. Butabika handles far beyond its capacity, up to 1000 inpatients for a 550-bed capacity facility.

Private psychologists or therapists are extremely expensive. “They charge between UGX 80,000 (USD 22.5) and 100,000 (USD27.8) per hour. That is a lot of money. Patients can only do one visit and they don’t return,” says Moses Ssemakula, Executive Director, Mental Health Focus Uganda.

Most extreme cases of mental illness, if not ignored and left to loiter on the streets and in villages, are taken to traditional healers or churches for spiritual rituals.

“Urban people can easily access Butabika, the few who can, but of course its capacity is limited. The urban people also understand mental health better. When you go to the rural areas it is tragic. You still have people being tied up, being locked in rooms, people being beaten to death because they believe they are demon possessed – that is still there in urban areas but it is worse in the rural settings,” Mukisa says.

Uganda in 2018 repealed the colonial Mental Treatment Act to now the Mental Health Act 2018. The act among others provides for mental health treatment at primary healthcare centres. When the provision of other health services is inadequate, as it is, however, mental health will certainly not go above the prevailing standards.

Covid-19 and mental health in Uganda

The onset of COVID-19 in early 2020 came with new challenges. First of all, in April 2020, the Ministry of Health directed 14 regional referral hospitals to convert their mental health units into Covid-19 Treatment Units (CTUs). While ministry was responding to a crisis, its directive could be interpreted as low prioritisation of mental health.

Indeed, as reported by the local media, there was confusion in a hospital in northern Uganda with mental health patients forcing their way back to their former place and mixing up with COVID-19 admissions. Another hospital in the same region, according to the press report, did not heed the ministry’s directive as it has for long been battling with a lot of mental health issues as a result of the Lord’s Resistance Army (LRA) conflict.

Secondly, a number of the mentally ill already undergoing treatment also contracted COVID-19. They had to be isolated from the rest, yet they could not be taken to CTUs. Space constraints are enormous even at the national referral hospital.

Thirdly, COVID-19 and measures to control its spread including extended lockdowns since March 2020 have thrown more people into mental health problems. Many have lost jobs, businesses have collapsed, gender-based violence has increased, schools remained closed and more young girls are getting pregnant. At the same time, more youth are getting involved in drug and alcohol abuse as a result of staying out of school.

There is no report on the impact of COVID-19 on mental health in Uganda as yet – the last survey on the prevalence of mental health in Uganda was done 20 years ago – but mental health practitioners fear mental health illnesses have gone to unprecedented levels.

“All age groups have been affected by COVID-19, apart from may be those who are three years and below because those ones are yet to get to realities of life. From the school going age to the very aged there are so many cases. The youth are the most affected – many are not working and they are not studying. They indulge in drug and alcohol abuse. I normally go to Butabika and I can tell you most of the cases that are coming in now are as a result of Covid-19,” Ssemakula says. “The government has put in a lot of effort to handle physical wounds of individuals. But when it comes to mental health, with all the budgets that were passed for Covid, mental health was not given priority. Many people have committed suicide because they don’t see any future ahead of them. There is nothing to give them hope”

Mental Health and SDGs

Mukisa has another way to stress the impact of COVID-19 on mental health in Uganda, and it is through the SDGs.

“Among the SDGs we have Zero Hunger, No Poverty, Gender Equality, Quality Education, and Good Health and Wellbeing: Learners are not going to school. Their parents are not working; many of them have lost their jobs, their income. Girls are getting pregnant at 15 and below, that is before they are physically or mentally ready to bear children. There is no money. People are frustrated. There’s a lot of gender based violence going on right now in our society and it is more against the women. A woman who is being abused is not okay, mentally, and she’s raising children in that abusive home. There is a whole generation of mental health problems that are coming on top of the ones that already exist. All these issues – the education, the unemployment, the poverty, the hunger – go to mental health in the long run, if you look at it.”

It’s a lonely space

Mental health in Uganda is highly stigmatised and this is not only against the victims but also those seeking to give them help. While many families may treat mental health problems, especially severe and genetic ones, as a curse, it is common for the public to scorn those who fail to cope with daily life pressures and eventually fall to mental illness.

Scarcity of reports and statistics on mental health in Uganda indicates that this is an area which is under-researched. “It is still a virgin area for research. That means it is not being prioritized in terms of funding, so there’s no research, and therefore there’s no information to appropriately inform policy,” Mukisa says.

“As an individual in the mental health space in Uganda, you get drained. It’s a lonely space. You find that there are so many people you have to reach but you have very little time or even the funding is not there,” she adds. “I think, all this goes back to lack of information, stigma, and bias which might go hand in hand with stigma.”

There is hope

The government’s review in 2018 of the mental health law means that there is recognition of the country’s mental health challenges. The number of NGOs involved in mental health is increasing, so there is increased awareness about mental health, as well as increased support to victims. But, until there is enough investment in public awareness about mental health, most cases of mental health in Uganda will still go untreated.

William Odinga Balikuddembe is a science journalist based in Kampala, Uganda
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