Special Report: Rebuilding Northern Uganda

Northern Ugandans Bear Mental Scars

Experts say more specialist care is needed for psychological trauma caused by war.

By Caroline Ayugi in Gulu and Bill Oketch in Lira (AR No. 184, 27-Aug-08)

Specialists in northern Uganda are struggling to treat thousands of patients with mental health conditions thought to have been caused by the long-running conflict with the Lord's Resistance Army, LRA.

Experts say that 20 years of war with LRA rebels have devastated the north of Uganda, and left thousands of its residents with mental health problems.

Dr Tom Otim, the medical superintendent at Gulu regional referral hospital, said limited resources and staff shortages at hospitals have left overstretched nurses and doctors struggling to treat large numbers of patients.

“It is very common to get just two nurses attending to a crowded ward in the hospital, because the clients are too many [and] the hospital now serves people from [neighbouring] South Sudan,” said Otim.

He added that services were even more limited in rural areas.

“Drugs to treat mental illness are so expensive, yet our target should be to extend services to the villages,” he said.

Mental health problems are rife in the war-torn north, to which peace is now returning.

At the mental health unit of the Gulu district hospital, 9,600 cases of mental illness were reported in 2006 and 2007, and more than 4,400 cases were reported in the past four months, according to officials. The conditions include post-traumatic stress disorder or PSTD, depression, epilepsy, alcohol abuse, acute psychotic disorders, and chronic psychosis.

According to the New Vision newspaper of Kampala, a recent survey conducted by a team of British and Uganda psychiatrists concluded that the rate of PTSD was higher in northern Uganda than in most other places in the world. For example, out of 1,200 adults assessed by mental health doctors in Amuru and Gulu districts in 2006, 54 per cent were suffering from PSTD. Researchers also found that 67 per cent of the respondents had depression.

At the African Centre for Rehabilitation of Torture Victims in Gulu, 1,507 cases of mental illness were registered in 2007, and 206 cases have been recorded so far in 2008.

According to Kizito Wamala, a clinical psychiatrist at the unit’s trauma centre, most patients are scared, suffer from nightmares, and frequently relive past horrors related to the war. These people tend to avoid socialising, suffer from sleeplessness, and are easily angered.

Dr Thomas Oyok, regional psychiatrist at the Gulu Mental Health Unit, agreed that many of the mental health problems experienced by people in the region have been triggered by the violence committed by LRA rebels.

Post-traumatic stress disorders often develop after experiencing or witnessing life threatening events such as killing, rape and fatal accidents, he said.

Oyok said that the lack of available treatment during the war had compounded the problems. During the insurgency, treatment for physical and mental problems was scarce, and many patients used alternative medicines or went without treatment altogether.

“Few medical staff and limited drugs for the patients made most people resort to other means like traditional herbs, which are not the best alternative for most illnesses,” said Oyok.

Oyok said that while PTSD was a treatable condition, many sufferers had tried to rid themselves of symptoms by turning to drugs.

“Most people are resorting to drastic steps, like abusing drugs, to help them to forget, but that only renders temporary therapy,” he said. He added that drug abuse had instead increased the rate of mental health cases in the region.

Experts say children in the north have been particularly affected by war-related trauma. Approximately, 50,000 people have been abducted during the war, which began in 1986, and the vast majority of them were children, studies indicate.

According to a report published by the African Journal Psychiatry in November last year, many youngsters abducted during the war have been deeply affected psychologically.

“70.7 per cent of war-abducted children have been affected compared to 45.7 per cent of [children who were not abducted],” according to the report.

School teachers confirmed that their pupils are often very disturbed.

“They recall what they witnessed in the course of the LRA war,” said Geoffrey Ocere, a teacher at Abella primary school about 50 kilometres from Lira. “These memories preoccupy them so much that they cannot perform well in class.”

“I cannot forget about my lost brothers,” said a 13-year-old Leo Bua. “I cry each and every moment I think about them.”

Dr James Okello, a psychiatrist at Gulu University’s faculty of medicine, said the current methods of dealing with psychosocial problems and reintegration among war-affected children were inadequate.

“The formal health sector alone is not sufficient to meet [their] needs,” said Okello.

“Mental disorders, for example, developmental disabilities, are risk factors for [poor] learning, underachievement, and school drop-out,” he said.

“Vulnerable children [orphans, former child soldiers and street children] have increased rates of mental illness and educational failure.”

One aid group recently organised a news media visit to a refugee camp, where photographers took pictures of weeping children. Talking to IWPR under condition of anonymity, aid workers said the children were confused by the long-lens cameras and thought they were guns, the source said.

The children thought the photographers were LRA who had come to kill them.

“Photographers had created the very fear they thought they were simply recording,” the source said.

Experts say that nearly all youngsters who have experienced catastrophic situations display symptoms of psychological distress, including flashbacks, nightmares, withdrawal, and inability to concentrate.

While some children bounce back quickly from traumatic experiences, others need treatment

“Most children and adolescents will regain normal functioning once basic survival needs are met, safety and security have returned and development opportunities are restored, within the social, family and community context,” said Joyce Opon Acak of the Lira Women Peace Initiatives group.

“Some children will require more specialised interventions to address their suffering and help restore their flow of development,” she continued.

She said that it can be beneficial for children to talk about painful experiences and feelings, or express them by other means such as physical and artistic expression, particularly if this is facilitated by people the children know and trust.

However, experts say that neither children nor adults in northern Uganda with mental health problems are receiving the specialist help they need.

"There has been understaffing, under-funding and non-prioritisation in the [Ugandan] mental health sector,” said Dr Sheila Ndiamarangi, Uganda’s coordinator for mental health.

“Many NGOs flocked to northern Uganda with the agenda of giving solutions to the increasing cases of mental sicknesses, but they ended up giving social support without psycho-social support.”

Emmanuel Otala, the Ugandan minister of state for health, acknowledged that addressing psychiatric issues had not been a priority while the war was ongoing.

He said it was important to address the problem now by helping people take advantage of treatment on offer.

“[During the conflict] people were traumatised at varying degrees… They should be guided to make good use of the services available at the mental health unit.”

Otala called for mental health services to be extended throughout rural areas, where he said there is the greatest need for treatment.

“To solve mental problems, there should be a special attention and provision of services, because [it is] not only the [internally displaced who] are affected, but the entire community in the northern region.”

Caroline Ayugi and Bill Oketch are IWPR-trained reporters in Uganda.