Newly qualified doctors in Sudan are more likely to specialise in higher paying areas of medicine, rather than mental health.

Mental illness has been in the news again with the story of Germanwings Flight 9525 which is thought to have been intentionally crashed in the French Alps by its co-pilot Andreas Lubitz. Lubitz appears to have had a history of suffering from mental health problems. This comes a few months after the passing of comedian Robin Williams who committed suicide after struggling with depression.

Mental illness should not simply be seen as a product of the rich or “˜westernised’ world; it can affect all ages, ethnicities, nationalities and socioeconomic classes. According to the World Health Organzation, approximately 450 million people worldwide suffer from a mental or behavioural disorder. The United Nations recognises mental health as a human right essential for wellbeing and social development yet there are millions of people, particularly in developing countries, who lack access to basic mental health services.

Sudan was one of the first African countries to have practicing psychiatrists. For example, Dr Tigani Al-Mahi founded a psychiatry clinic in Khartoum as early as 1949. However, to this day, mental health services in the country remain poorly developed and under-resourced. Although Sudan’s mental health policy was re-formulated in 2008, mental health continues to receive very little attention from the government and is not high on the list of priorities for policy-makers.

Mental health facilities are scarce even in the major cities. There is a chronic shortage of psychiatric doctors, nurses and other trained mental health professionals. Newly qualified doctors are often swayed by higher paying medical specialities with many experienced psychiatrists and mental health professionals opting to leave the country in search of better pay and working conditions abroad.

Since gaining independence in 1956, Sudan has suffered from political instability, armed conflicts and poverty resulting in high rates of illiteracy, unemployment and economic inequality. The gulf between rich and poor is widening and many Sudanese struggle to cope with soaring prices, a weakening currency and rising costs of health and education. Even in the big cities, there are high rates of unemployment particularly amongst young people. Other socioeconomic factors such as social discrimination and poor housing conditions are also recognised as being contributors to poor mental health.

Moreover, mental health is on the rise amongst the upper middle class and high earners. The stresses of life and battle to be successful, makes this group susceptible to anxiety and depression as well as drug and alcohol abuse.

Like many other African countries, a large proportion of the population still depends on alternative or “˜traditional’ medicine as their first port of call when ill. In a country without a proper social insurance scheme, the poor cannot afford the doctors’ fees and even when diagnosed they struggle to pay for the expensive medicines. The rich who can afford both often tend to ignore or deny their symptoms because of the stigma attached to mental illness.

Sudanese society, like many around the world, has stereotyped views about mental illness and how it can affect people. This often leads to discrimination and social isolation of affected individuals. For example, a person with schizophrenia suffering from hallucinations or delusions may be labeled as majnoon (Arabic for “˜crazy person’) or as someone who is possessed by a Jin or evil spirit. A person with depression may not receive any support or empathy from their employer and can easily lose their job if they cannot cope. A child with a mental health problem may be beaten by school teachers, bullied by classmates and shunned by society.

The situation is worsened by religious concepts, cultural practices and popular beliefs. Depression is dismissed by many as over-worry or lack of Iman (Arabic for faith). Another common belief is that insomnia is a consequence of an accumulation of sin.

Belief in supreme beings, sacred objects, supernatural phenomena, magic and witchcraft are widely accepted by both illiterate and well-educated Sudanese people and influence all aspects of life for both groups. This explains the popularity of religious healers or Muslim clerics referred to as wali, fagir, faki or sheikh, who employ a variety of healing methods including ruqya (incantations), al-azima (spitting cure), bakhra (ritual incense burning), mihaya (quranic holy water), hijab (phylacteries) and huruz (amulets). In some areas, Zar remains a popular method of managing mental illness. Technically prohibited by Islam as a pagan practice, Zar is a trance ceremony that uses dancing and drum music to contact the possessing spirits. It is particularly popular amongst women. Many men find their own solace in another trance ritual, a Sufi religious ceremony known as zikr.

Women and children are particularly susceptible to mental illness in Sudan. Sudanese women enjoy more freedoms than many other Muslims countries but are equally affected by the sociocultural constraints and gender disparities associated with patriarchal societies. The problem is exacerbated by a high rate of illiteracy amongst women and increased pressure to play multiple roles in society. Indeed, in many regions in Sudan, women are expected to work and at the same time take care of children, do all the housework and often be the prime carer for parents, in-laws or both.

Sudan also has one of the highest global rates of female circumcision (also referred to as female genital mutilation), a traditional practice with dire medical and psychological consequences. Women are hence particularly susceptible to depression, anxiety-related disorders and the psychological effects of violence.

Domestic/sexual violence and emotional blackmail are not uncommon but often go unreported or are covered up to appease family members or out of fear of societal stigmatisation. Cultural norms compound an already complex situation as many women believe that it is acceptable for a husband to beat a disobedient wife. A study performed in Kasala in Eastern Sudan showed that a third of 1009 women surveyed reported current experience of physical violence. A large number of women reported sexual coercion, emotional violence and verbal insults as well as threats of divorce and second marriage. A high prevalence of domestic violence was strongly associated with illiteracy, polygamous marriage and the husband’s alcohol consumption.

Alcoholism is yet another elephant in the room – the fact that it is considered a substance abuse disorder is often overlooked. In Sudan alcohol is prohibited by sharia law (implemented by the Nimieri regime in 1983); anyone caught drinking or intoxicated can be sentenced to 40 lashes and a hefty fine. However, there is no shortage of illegal brewers of date-based alcoholic drinks. Even smuggled western-made beers and spirits are available to buy for those who can pay.

Underground alcohol sales and prosecution of public drinkers means that the stereotypical alcoholic who wakes up the neighbourhood with his stumbling and rowdiness is not as common as the “˜secret’ alcoholic. The latter group may be successful in their personal lives and careers but often hide their drinking problem from those around them. Secret alcoholics are therefore more prone to mental health disorders as they appear happy on the outside but are internally battling a demon, silently and alone.

Mental illness is also very common amongst war victims living in war zones like the Darfur region where there are elevated rates of post-traumatic stress disorder, anxiety, depression and social dysfunction. These problems are also common amongst internally displaced victims who are faced with unemployment, malnutrition, poor living conditions, lack of security in refugee camps and sexual violence (particularly against women). However, provision for mental health in war-torn areas remains limited or nonexistent.

Sudan is a country plagued by war, poverty and incompetent political leadership. Amidst these more obvious challenges the increasing burden of mental health should not be ignored.

Dr. Mohamed Shawgi @shawgimd is a radiologist and nuclear medicine physician based in the UK.