“Heaven, Hell and Earth”

"Bridging Approaches to Mental Illness in Sierra Leone," at NYTimes.com:

War leaves all manner of scars, and the dusty towns in eastern Sierra Leone still bear the marks of a decade of civil strife.

Cities like Koidu, in the diamond-rich Kono district, were the site of many of the atrocities carried out by rebels backed by former President Charles G. Taylor of Liberia, Sierra Leone’s southern neighbor. Unfathomable acts like amputations lend a particularly gruesome hue to the murder, rape and terror that characterized the conflict.

“The history of the war is everywhere,” said Nyani Quarmyne, a Ghanaian photographer who visited last year. “There are bombed-out buildings all over the place. There are people wandering around with both their hands hacked off.”

It’s this kind of trauma, shared on such a scale — an entire nation — that can drive a person to madness. “One has a sense that there are a number of damaged people wandering around,” Mr. Quarmyne said. “How could there not be?” And, despite some improvements in the quality of life of the people of Sierra Leone, it still lacks effective ways to address chronic and profound corruption, poverty, unemployment and substandard health care.

And, not least, mental health care.

Mr. Quarmyne had previously worked in his native Accra, Ghana, to document the toll of mental illness. There, he met a Prague-based writer named Catherine Cooper who told him about the Wellbody Alliance, a clinic run by Dr. Mohamed Bailor Barrie of Sierra Leone and Dr. Dan Kelly of the United States. Mr. Quarmyne and Ms. Cooper made a trip there together. With the cooperation of Wellbody staffers and the consent of the patients’ family members, who were often present, they set out to understand the patients at the clinic, which blends the services of faith healers and so-called witch doctors with medicine-based psychiatry.

In a country where mental illness is widely stigmatized, and certainly not viewed in medical terms, it’s a pragmatic way to draw in patients. When the afflicted believe they married witches, were cursed by devils or swallowed evil snakes, appeals to empirical reason can seem naïve. There, mental illness is framed spiritually.

Nyani Quarmyne
Isata, the mother of a patient named Mohammed, who lives in an abandoned taxi, received medication for her son from Ahmadu Jalloh, the manager of the mental health program at the Wellbody Alliance clinic.

According to Mr. Quarmyne, this mixed approach worked reasonably well with the faith healer. “He’s a lovely man,” he said. “He would refer patients to the clinic, and in that way they received a mix of medical treatment as well as spiritual treatment from the faith healer.”

Not so with the witch doctor. Motivated, perhaps, by his ego, he seemed eager to demonstrate his powers. “He had, shall we say, a very robust belief in his abilities,” Mr. Quarmyne said. “At the same time, he was afraid that what the doctors really wanted to do was find out his secrets and steal them.

“There was a great deal of distrust or suspicion in that relationship,” he said.

That distrust frustrates the doctors’ efforts as very real needs go unmet. There was one patient who thought it was 2003, a year after the civil war ended, and who heard voices, planes and helicopters when there was silence. Another case saddened Mr. Quarmyne because the patient struck him as full of promise. Samuel (Slide 11), fiercely intelligent, creative and “remarkably articulate,” Mr. Quarmyne said, “had made it as far as university, which in many ways is a really significant achievement considering the background he’d come from.” But Samuel believed that he was Haile Selassie, the former Ethiopian emperor, and that he had gotten married in the underworld. He spoke of a figure he’d drawn on his wall as his spiritual tutor.

What Mr. Quarmyne also found unsettling was Samuel’s use of drugs, particularly marijuana. He had seen a great deal of cannabis use among mentally ill Ghanaians as well, and it struck a personal chord. Mr. Quarmyne felt that what separated him from them was arbitrary, yet decisive. “Coming from a background of relative privilege, there are a number of things that I look out and think, ‘Whoa, were it not for an accident of birth, it could be me under these circumstances,’ ” he said.

But few others seem to care. Mr. Quarmyne’s work is largely unfinanced, and his traveling partner, Ms. Cooper, has yet to find a publisher for her essay about Dr. Barrie’s and Dr. Kelly’s efforts. Besides the cultural obstacles, the clinic faces enormous logistical problems — maintaining a reliable supply of medications, for example, or trying to integrate its services, and psychiatry and counseling in general, with the larger Sierra Leonean health care system. “The unfortunate fact of it is, it’s not a sexy topic anywhere,” Mr. Quarmyne said. “Much less in this part of the world, where nobody wants to have anything to do with the mentally ill.”

Mr. Quarmyne’s photo series and Ms. Cooper’s unpublished essay are titled “Heaven, Hell and Earth,” reflecting the varying versions of medicine, well-being and spirituality they encountered in the Kono district. There is no electricity or running water in Koidu, and virtually no paved roads. Mr. Quarmyne spent his days hearing about the dark world, demons, sickness and horror. Water was fetched from a well, and at night, it was pitch black. “Some nights you would hear people singing spiritual songs at the home of the faith healer,” he said. “Other nights you would hear drumming and chanting, and nobody could tell you what it was.”

And there is nothing like total darkness to invite people to explore their own mental recesses. “Both Catherine and I went in there with very clear views of real versus unreal, normal versus not normal, if it’s between reality, superstition, etc.,” Mr. Quarmyne said. “And that got shaken up pretty well on this trip.”