Survivors of traumatic experiences and others in need of support in Sierra Leone are being failed by the severe lack of available mental health services years after the country's brutal civil war and devastating Ebola epidemic, Amnesty International warned in a new report published today.
In 'They Are Forgetting About Us': The long-term mental health impact of war and Ebola in Sierra Leone, survivors reveal how they continue to struggle with a range of symptoms of distress, including lasting grief.
However, mental health services in the country fall far short of meeting people's needs, due to multiple significant barriers. These include a lack of government spending, insufficient donor support, a shortage of skilled mental health professionals, and the few available services being concentrated primarily in cities.
"In Sierra Leone, people have endured horrific traumas in recent decades and the country is now also dealing with the aftermath of the COVID-19 pandemic," said Rawya Rageh, Amnesty International's Senior Crisis Advisor.
"Financial constraints and the challenges of a weakened health system face Sierra Leone, like many other countries - but mental health is not a luxury, it is a fundamental human right.
"The Sierra Leone government must now translate its policy commitments into tangible action by investing in improving mental health services. Working alongside national actors, donor governments and agencies should provide the assistance desperately needed to prioritize these much-needed systems of care."
Amnesty International is also calling on the government to expedite the process of passing new mental health legislation to replace the discriminatory colonial-era 'Lunacy Act' of 1902, in order to bring national law into line with international human rights obligations.
Repeated exposure to trauma in conflict makes people more prone to developing mental health conditions. Many civil war survivors told Amnesty International they witnessed their homes and villages razed by rebel forces. Many watched their loved ones shot dead, or discovered their bodies as they ran for their lives.
Many people were left with permanent physical injuries and disabilities, after being shot or hit by shrapnel. Five interviewees were subjected to crude amputations by rebel forces, one of the war's signature atrocities. They described pleading for their lives, as fighters cut off one or both of their hands or arms.
Marie* told Amnesty International that her village was attacked in the late 1990s by rebel forces who cut off her left hand. She said: "I begged them, I said, 'Please spare me in the name of God'... They said, 'We are God here, we decide whether you live or you die'." Marie said the fighters left her to die, and she had to finish severing her left hand herself in order to save her life.
Ebola survivors told Amnesty International of the immense psychological toll they experienced from the illness and its aftermath. Many described being so sick they did not know whether they would survive. They said the confusion, lack of information and overall poor government handling of the crisis at the time contributed to their distress.
The majority of Ebola survivors interviewed said they were profoundly impacted by the stigma and discrimination they faced even after their recovery. Several said community members blamed them for bringing Ebola to their areas.
Several survivors said the virus took the lives of multiple family members. Kaday* described sharing a hospital room with four siblings after they all contracted the virus in 2014. She said: "They died, and I was the only one to cover them up. Even though I was on a drip, I had to crawl on the floor to cover their faces."
The majority of Ebola survivors interviewed continue to deal with various health complications, including muscle pain and weakness, eye problems, irregular blood pressure, and forgetfulness. Several Ebola survivors said COVID-19 had brought back distressing memories and revived their persistent fear of death.
Social stigma and lack of support
In Sierra Leone, there remains major stigma around mental health conditions, with common myths attributing them to supernatural causes. People with psychological distress and mental health conditions frequently face abuse, yet there is insufficient effort by the government to combat this through public awareness and information campaigns.
Despite the clear immense need, mental health care provision is scarce. With a population of seven million people, Sierra Leone has only around 20 mental health nurses and three psychiatrists.
The very small number of mental health nurses placed in general hospitals around the country receive entirely insufficient support, enduring difficult working conditions and lacking formal transport provisions for home visits.
Of the 25 war and Ebola survivors interviewed by Amnesty International, 15 said they did not know about any current psychological counselling services on offer, either through government health facilities or NGOs. Overall, the formal mental health services that are available remain extremely centralized; there is a distinct shortage of community-based care.
Amina*, a war survivor, told Amnesty International: "We need that kind of support in our community and that kind of counselling services, so that people who have [had] traumatic experiences and people who are going through all this kind of stress will be able to understand that life should go on, [that] there is a life and they need to live it."
Many survivors instead rely on peer support networks which, although important, are not a sufficient substitute for professional mental health services.
Poverty is an additional factor seriously affecting mental health. Many survivors said broken promises of social protection and reduced livelihood opportunities have further undermined their wellbeing, and that they felt abandoned by both the government and international organizations that once provided aid.
Mariatu*, an Ebola survivor, said: "In so many ways, they are forgetting about us."
While emergency humanitarian programming helped deliver temporary mental health support, much of it ended in the aftermath of the immediate respective crises. The report shows long-term investment in government services is needed to provide sustainable and effective care.
"Not only is mental health a human right, it is a public good. The Sierra Leone government must now sufficiently prioritise mental health and request specific allocations from donors to properly expand its mental health and psychosocial services," said Rawya Rageh.
"We are also calling on international donors to further support campaigns aimed at combatting the stigma that persists around mental health. This crisis cannot continue any longer."
Between November 2020 and May 2021, Amnesty International conducted research and interviewed 55 people, including 25 Sierra Leoneans across five districts who were directly exposed to violence during the war or contracted the Ebola virus. The ages of the survivors interviewed - 16 women and nine men - ranged between 28 and 73.
Amnesty International also interviewed, among others, Sierra Leonean mental health professionals; government officials; members of civil society organizations, including the Mental Health Coalition - Sierra Leone; and public health specialists and mental health experts.
Between March 1991 and January 2002, Sierra Leone experienced an armed conflict during which tens of thousands of civilians were killed, and more than two million people were displaced.
In 2014, as Sierra Leone was still struggling to rebuild after the war, an Ebola outbreak affected West Africa. According to the World Health Organization, between May 2014 and March 2016, an estimated 14,124 cases were recorded in the country, including 3,956 deaths.