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The ceiling fan is frozen for lack of electricity, but a breeze rushes through the window, refreshing the small consultation room with pastel green walls. Doctor Atong Ayuel has not yet had time to swallow her breakfast, ” leggemat » – small donuts sold on the street – wrapped in a plastic bag and placed on his desk. The South Sudanese psychiatrist does not hide her exhaustion: between two consultations, she rests her head on her crossed arms and closes her eyes.
On this Friday in October, a very busy week is coming to an end for the specialist, who is fighting at different levels to develop the mental health sector in her country. Trained in Khartoum, Sudan, Atong Ayuel, 40 and mother of three, has headed the psychiatry department of the teaching hospital in Juba, the South Sudanese capital, since 2014 as well as the mental health department of the Ministry of health, since its creation in 2015. As such, it has developed and has just had the various players in the sector amend its “ strategic plan “. This aims, in five years and at a cost estimated at some 18 million dollars, ” to ensure that 80% of rural South Sudanese have access to basic mental health care “.
This type of care is indeed almost non-existent in South Sudan, despite the trauma caused by a succession of civil wars for decades. A study carried out in 2009 on a sample of the population of the city of Juba had “provided evidence of high levels of mental distress”, estimating that 36% of people suffered from post-traumatic stress and 50% “met criteria for symptoms of depression”.
According to the WHO, in 2019, the country knew the 4e highest suicide rate in Africa (and the 13e in the world). But the domain remains globally underfunded ” and the lack of data prevents precise measurement of the phenomenon – it is only in 2021 that a “ systematic mental health data collection was undertaken in five of the country’s ten regional states.
The only one to practice at the public hospital
While NGOs provide psychosocial support and some even offer specialized psychiatric care, there are only three South Sudanese psychiatrists in the whole country for some 12 million inhabitants. And Atong Ayuel is the only one of them to practice in the public hospital.
” The needs are immense! », loose the one who chose this path against and against the criticism of her peers and her family. ” I was second in my promotion in medical school, people told me that directing me towards psychiatry was a waste”, she remembers. Initially drawn to pediatrics, it was during her practical internship in a hospital in Western Bahr-El-Ghazal, her region of origin located west of what is now South Sudan (the country became independent from Sudan in 2011), that she changed her mind.
” Faced with patients with psychiatric disorders, I realized my powerlessness, she remembers. We had no other solution than to put them in prison. I felt like I was useless and that motivated me to specialize in psychiatry. She is doing her master’s degree at the Sudan Medical Specialization Board and takes over the reins of the psychiatry department of the Juba university hospital as soon as she finishes her studies.
At the time, “there were no patient files, no qualified psychologists, and the service only operated for a few hours a day”, she remembers. The team now includes eight psychologists, nurses and doctors who provide care without interruption. For their psychotic disorders, depression or even mood disorders, patients have access to treatments provided by partner NGOs.
A capacity of twelve beds
” Currently, the most common pathologies are those related to the abuse of substances such as alcohol and cannabis, which can cause psychoses “, explains Atong Ayuel, seated at the large table in the infirmary where several files of admitted patients are arranged. Behaviors that indicate the presence of partly intergenerational trauma and attempts to heal oneself “, she continues.
Located on the edge of the Juba University Hospital complex, isolated by a fence and with its own access from the street, the psychiatry department – the “ ward 11 – includes a building with a capacity of twelve beds, as well as a small annex dedicated to outpatient consultations. It’s dark. Faded walls and iron-barred windows add to the gloomy atmosphere.
In the corridor, an internee is sleeping with a chain around his ankle. ” We gave him a sedative “, explains Atong Ayuel, while minimizing the racket that another patient creates by drumming on his window. “We are thinking of taking him to the central prison in Juba, because we do not have the capacity to deal with violent people”, she explains. For lack of a suitable structure, a section is dedicated to very agitated patients within the penitentiary establishment of the South Sudanese capital.
Because, despite the progress made to improve the service, the difficulties persist. ” We are the least well-funded department in the hospital, we have no money to renovate our premises and our employees are poorly motivated due to low salaries. explains the director, whose salary is only 5,600 South Sudanese pounds per month (about 10 euros), “and he doesn’t even get paid regularly”. She derives most of her income from her activity in her private clinic. And thus provides for the needs of her children while continuing to devote herself to, she says, ” building the nation of south sudanese “.
No less than 64 ethnic groups
Bari, Nuer, Dinka, Acholi, Luo… Atong Ayuel also boasts of having acquired sufficient vocabulary to make diagnoses in a number of South Sudanese languages. ” I am rarely wrong! “, she says, strong from her repeated missions inside the country. She was able to measure the challenges of disseminating tools such as the Diagnostic and Statistical Manual of Mental Health Disorders (DSM) of the American Psychiatric Association (APA), for the classification of mental disorders using standard criteria.
” We studied it in English,” she insists on recalling. With a multiplicity of languages and cultures – there are no less than 64 ethnic groups in South Sudan –, “ I realized that it was necessary to contextualize, taking the time to discuss with the communities to translate the symptoms and the diseases, which they often think are not “.
Then you have to ” convince them to try my method, make a pact with them “. She gladly recounts her experience with a healer in Warrap State in 2016. This traditional doctor had been keeping more than thirteen patients with signs of mental illness chained to trees in a remote place for years. They spent their time screaming. Putting its reputation and credibility at stake, “Doctor Atong” managed to persuade him to let her take these people to the hospital. ” Since then, calm has returned and this place has closed for good. “, she underlines.
Summary of our series “Africa in therapy”