'We built this from nothing': A country's bid for homegrown mental-health care

Adrienne Surprenant/Collectif Item
Dr. Sylvain Gomossa, one of only two practicing psychologists in the Central African Republic, takes psychology students on a tour of the country’s only psychiatric hospital on the first day of their internship.
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Dr. Sylvain Gomossa is one of just two psychologists still permanently based in the Central African Republic, a country of 4.5 million. Seven years of ongoing conflict, meanwhile, have left most families touched by violence – and often trauma.

But today, Dr. Gomossa is teaching interns in the University of Bangui’s newly reinstated psychology program. When the first class graduates later this year, they will more than quintuple the ranks of Central African psychologists.

Why We Wrote This

Central African trainees hope to make mental-health care more sustainable and culturally sensitive. Some are familiar with patients' challenges – and say treating others helps heal their own wounds, too.

Many are working through trauma themselves. But in a country where the little mental-health care that exists has been dominated by nongovernmental organizations, and often foreign doctors, they hope their own experiences can help support others’ healing – and foster a more sustainable system of care.

Tatiana Moussoua, a student who is now working on her thesis, barely survived a militia attack in 2016. “We were studying post-traumatic stress,” she says, remembering her classes at the time. “And I was living it.” But as she started to apply her coursework to her own life, her son’s, and at camps for internally displaced people, she says she started to feel capable again.

Dr. Sylvain Gomossa looks at the three students in front of him, curious how they’ll react to what he is about to say.

“We used to tie people up with big, heavy chains. Even right here in my office.”

The young men remain impassive. Dr. Gomossa looks disappointed.

Why We Wrote This

Central African trainees hope to make mental-health care more sustainable and culturally sensitive. Some are familiar with patients' challenges – and say treating others helps heal their own wounds, too.

“Anyway, it’s out of fashion now – we don’t do that anymore,” he says. “Shall we continue the tour?”

The students quietly trail the psychologist, jotting down notes in battered notebooks as he leads them through this ramshackle collection of buildings: the only specialized psychiatric and mental-health ward in the Central African Republic.

Covered in cracked and peeling paint, the men’s and women’s sections contain little more than rows of sagging beds and drooping mosquito nets. The main office is piled with stacks and stacks of yellowing, dusty files. Patients’ relatives fill the hospital: Some sit together on blankets spread in the shade; others tend small fires where they cook for their hospitalized family members. Generators hum, and a man chops down weeds with a machete.

The students take it all in with wide eyes.

They will spend the next few weeks interning here, at this specialized ward in Bangui’s General Hospital, as part of a newly reinstated psychology program – and, their professors hope, the beginning of a more sustainable solution to the mental-health crisis across this country in conflict.

When the first class graduates later this year, they will more than quintuple the ranks of Central African psychologists. Dr. Gomossa is one of just two permanently based in a country of roughly 4.5 million people, many of whom have experienced war at close range – including students in the program.

Most psychologists here are foreigners brought in by nongovernmental organizations, crucial support for a system demolished by war. But these psychologists-in-training hope to apply their intimate understanding of the conflict’s effects on their communities, and themselves, to build more homegrown care.

“After what my country has gone through, I just wanted to help my brothers and sisters,” says Wilfrid Odilon Guimendego, one of the student interns touring the hospital. “I want to use my studies to help traumatized family members reintegrate into society.”

‘We were studying post-traumatic stress, and I was living it’

The Central African Republic has been mired in insecurity and violence for decades, but today’s crisis emerged in 2012: the year the Séléka, a coalition of rebels from the marginalized northeast, began a long march on the capital, Bangui, and left havoc in their wake. In 2013, after the Séléka toppled the government, rival militia groups called the Anti-balaka started to organize, and a bloody struggle broke out. Though the conflict was about power and resources, not religion, the fact that the Séléka are predominantly Muslim and the Anti-balaka fighters mostly Christians and animists has led to vicious interreligious violence.

The Séléka gave up power in 2014, and the country elected former prime minister Faustin-Archange Touadéra as president in 2016. In recent years, the U.N. peacekeeping presence has kept the capital relatively calm. But fighting continues in the rest of the country, which is controlled by a complex web of armed factions, many of whom consistently target civilians. Thousands have died, and a fourth of the population has been uprooted from their homes. An eighth peace deal was inked in February, but one of the signing groups has already walked away.

Even before the crisis, the mental-health ward was understaffed and underfunded, employees say. Since then, the number of patients has nearly doubled, to about 1,500 per year, Dr. Gomossa estimates. Most of them, or their loved ones, have experienced trauma.

“My cousin was forced to watch as rebels burned someone alive. Then, they made him stay by the body,” says Mr. Guimendego, the student intern. “My cousin used to be gentle, but that experience turned him aggressive. He’d slam doors. He’d yell. He’d threaten people with knives and sticks. He had nightmares.”

Mr. Guimendego was already studying psychology, and brought his cousin to the mental-health ward for treatment. He himself is working through trauma, he says – struggling to trust people, and jumping when he hears a car backfire, for fear it is gunshot. 

Adrienne Surprenant/Collectif Item
The eight final-year psychology students listen attentively to a lecture on neuroscience given by the director of the Hôpital de l'Amitié in Bangui, the capital of the Central African Republic.

He’s far from the only one. Tatiana Mossoua is now working on her thesis on children’s anxiety and trauma. On Sept. 25, 2016, she was at home with her niece in Bangui when they heard a burst of gunfire. Within seconds, members of a local militia were breaking down the door.

“I couldn’t reach my husband, so I called a colleague,” she remembers. “I told him, ‘You might be the last person to hear me alive.’”

Miraculously, she says, one of the militants recognized her and escorted them to safety. But the neighbors were killed, and her home was burnt to the ground.

In the following weeks, she would lie awake at night, reliving the attack.

“We were studying post-traumatic stress,” she says. “And I was living it.”

Ms. Mossoua began to apply counseling coursework to her own life, and her son’s. The 9-year-old was asking repeatedly about their pet cat, who had disappeared in the attack. Gradually, she started to feel capable in the face of her loss.

“I asked myself, ‘Why am I focusing on my experience when other people need help?’” she said. “I started going to IDP [internally displaced people] camps to counsel people. That helped me a lot.”

‘You need to believe in yourself’

In 2015, when the University of Bangui resurrected its defunct psychology program, Barthelemy Doui was appointed head of the department.

“Everyone – and I mean everyone – in the Central African Republic has been traumatized,” says Professor Doui, a sociologist by training. He holds up three fingers: the number of times someone held a gun to his head during the initial phase of the crisis, when fighting was commonplace in the streets of Bangui.

“I am proud because we built this from nothing,” Professor Doui says of the program, which now has 33 students. “But we still lack material and proper facilities. Our students are like nomads, going from campus to campus.”

Students have little access to computers, and copy down notes from cracked chalkboards. Before the program, many had little concrete knowledge about mental health, despite what they’ve witnessed. Across the Central African Republic, many communities associate mental-health issues with possession and witchcraft. And it was not so long ago that “treatment” involved chaining up patients.

But these students have something invaluable to offer – culturally specific understanding and treatment.

Up to 58 percent of health facilities in the Central African Republic are supported by NGOs, many of them international, according to a 2017 report. Most have brought in their own staff, who typically consult patients in French, a second language to many Central Africans, or through translators. Other NGOs run short courses to give Central African health and community workers basic mental-health training. Recently, some organizations have created internships for students in the program, which allows their clinics to provide counseling in Sangho, the country’s primary language.

Psychology student Gilbert Nguerepayo is interning today at Voix de Coeur, a shelter for street children. A former teacher and father of five, Mr. Nguerepayo took to the work immediately. Several days in, he is already conducting entry interviews in a pale green office. A tall man squeezed into a dress shirt, he sits opposite 12-year-old Caleb, who seems lost in his plastic chair.

The boy explains that he lost his father first, in a car accident, and then his mother died shortly thereafter “of sadness.” He moved in with his grandmother, but “she beat me, so I ran away,” he explains, pulling up his pant leg to show a long scar. He bends his head forward to show another, slicing across his brow.

Mr. Nguerepayo listens, studying the boy. He knows that street children come and go from the center, often disappearing and returning to the red dirt streets of Bangui.

“Caleb, I have some advice to give you,” Mr. Nguerepayo says, sounding gruff but caring. “This is painful and sad. I know it was hard for me when my own mother died.

“But we can’t stop death. It happens to everyone. So don’t focus on the loss of your parents. Your life will go on. You need to believe in yourself,” he continues. “Here, you’ll meet other orphans. They all go to school, they play, they live their lives. So, tell me, what do you want to do with your life?”

“I want to be president or minister,” says the small boy.

Mr. Nguerepayo smiles, breaking the lines across his face.

“Ah! When you are big, I will vote for you.”

He laughs as Caleb’s face lights up. “President Caleb – President of the Republic. Don’t you ever, ever forget that. Now, go on, that’s enough for today. Go and join the others.”

Still smiling, the boy slips out the door.

This story was reported with support from the International Women’s Media Foundation.

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