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An Appreciation:

Pa Ngobeh (RIP) and the City of Rest

September 27, 2016 By Dr. Lansana Gberie

In October last year, while on assignment for Open Society Institute for West Africa, I visited City of Rest, a rehabilitation centre for people suffering from acute depression or mental health problems and drug use disorder. It was a salubrious, well-secured three-acre gated compound at Grafton, a quiet village down the mountain slope of Freetown, Sierra Leone. There I met a wiry man with kindly whiskers who walked ramrod straight, his smart safari shirt suggesting seriousness and attention to detail. He was Pastor Morie Sakeima Ngobeh, the founding-manager of the centre. His humility and austere concern with results, rather than mere optics, has ensured that you might not have heard about him. He didn’t wear his religion on his sleeves or collar; and he didn’t want to talk about it. His great calling, his founding and running of this centre for the despised and abandoned – offering practical therapeutic rather than wholly ‘faith-based’ treatment – made him one of the most transcendent and humane persons I have ever encountered.

Mr. Ngobeh walked me around the compound, where I saw several dozen people – men and women – some in conversation, others walking around languidly, and a few reading. He was, I reckon, about 70, but –slightly built – was sprightly, walking me around the compound briskly and purposefully. Mr. Ngobeh then took me to a spacious hall in the main building of the centre and, seated straight up on a wooden chair, he told me how the idea had come to him to found the City of Rest. He looked to me then to be imperishable; and now I recall the moment with a sense of profound loss because I learnt this evening, on 23 September 2016, that Mr. Ngobeh has died. His great work must endure.

City of Rest

He had registered the City of Rest in 1985 as a Christian charity. The idea had come to him, he told me, in a dream. Mr. Ngobeh was not a very religious man, and he wasn’t a Christian at the time. He had been born a Muslim, in Kailahun. His conversion was remarkable in itself. He had been an employee of a German company importing Volkswagen cars into Sierra Leone, earning a good salary. On his way to work every other day, he would meet homeless people, many in their prime, often in rags and often hungry and harassed, wondering about aimlessly. Onlookers, judging their dereliction as self-inflicted, considered them as something of a menace: they were mad people and had been dumped on the streets because they were ‘drug addicts’ – ‘bad people’. Mr. Ngobeh confessed to holding this opinion himself at some point, but one night he had a dream – of God commanding him to provide shelter and comfort for the ‘vagrants’ and ‘delinquents’, as they are cruelly called in Freetown.

A week later, Mr. Ngobeh quit his job. He was then living on Fort Street in Central Freetown. Without much money himself, he simply decided to share the small compound he had rented with the homeless ‘vagrants’, picking up the younger ones at first. He thought, but he didn’t make clear why, that the God he saw in his dream was the Christian God; and so Mr. Ngobeh converted to that religion and he named his enlarged family a Christian Ministry. That turned out to be an astute decision: Christian charity for his kind of calling is more available in Freetown than an Islamic one. It wasn’t easy, however; but Mr. Ngobeh persisted, raising support from friends and relatives at first, and then from churches in Freetown.

City of Rest moved to its current premises in 2013.The Government of Sierra Leone donated the three acres of land; and churches, as well as the embassies of United States and Germany, provided funding support for the construction of the buildings. City of Rest has 70 rooms. There were 43 patients at the centre, all between the ages of 15-45, in October 2015 when this writer visited. Each patient spends three months at the City of Rest; and social workers monitor the released patient while at home for another three months. Rehabilitated patients are then given a certificate celebrating their success.

Though registered as a Christian charity, City of Rest’s ecumenical spirit embraces people of other religious faith (there are several Muslims patients brought there by their relatives) as well as those who profess to no religion. I saw patients from Liberia, Guinea and elsewhere there. Patients who are Christian daily participate in group-prayers, but no one is apparently forced to do so. Dr. Edward Nahim, Sierra Leone’s only psychiatrist (retired) is on contract, providing medical treatment for patients, and nurses (also on contract with the City of Rest) provide therapeutic care; patients are regularly provided medication. The resources of the City of Rest are so modest, however, that often it has had to turn down patients. Its limited success is a reminder of the yawning gap in mental health capacity in Sierra Leone: over 30 percent of the patients admitted at the City of Rest suffer from depression or other forms of mental illness. A woman I saw there had been suddenly struck by the condition after a man he was waiting in church to wed to failed to show up. There were several suffering from drug use disorder, including an educated man I had long known who was flown back by his middle class family to Sierra Leone from the United States because of his condition. He told me he was faring much better now.

Mental Health in Sierra Leone

I had met Dr. Nahim before visiting the City of Rest; he told me about its good work. Dr. Nahim has been the only psychiatrist in Sierra Leone since 1976 when he returned to the country after his training abroad. He was head of the Kissy Mental Home in Freetown. His picture of the mental health situation in the country was grim. He is now a key member of the National Drug Law Enforcement Agency (NDLEA), and his long collaboration with the United Nations Office for Drugs and Crime (UNODC) clearly colour his views on the causes of mental health problems. However, he said his opinion is based on his decades of observation and treatment of patients at the Kissy Mental Hospital. He said that 80 percent of the patients at the hospital suffer from drug use disorder and have become psychotic as a result. Cannabis is the drug of choice for most of the patients, Dr. Nahim said, though some have used cocaine, ‘brown brown’ and heroin. From this he has sought to establish a correlation between narcotic drug use and mental illness.

Not finding this entirely convincing, I visited Kissy Mental Hospital the following day. The British established the hospital in 1823, mainly to confine traumatised freed slaves that had been repatriated to Sierra Leone. It is West Africa’s first, and for many decades only, Western-style mental hospital; and it remains Sierra Leone’s only psychiatric hospital.  There were a total 104 patients – or ‘inmates’, as some refer to them – housed at the hospital, of which 75 were men. Most of them are under age 40. That was in October 2015. Patients – more accurately victims – lived in deplorable conditions; I saw several of them chained, in other words forcibly confined.

I was horrified but not surprised. I had long read Leland V. Bell’s Mental and Social Disorder in Sub-Saharan Africa: The Case of Sierra Leone, 1787-1990 (1991). The author is an American academic who did his research before the civil war added a new element to the mental health problem in the country; he acknowledges Dr. Nahim for providing a facilitating ambiance for his study. Bell writes that from the start, Kissy Mental Hospital (‘Craise Yard’) hardly provided therapeutic care; it functioned largely as “a custodial facility – a place for the demented and dangerous people who were burdens and created trouble for family and society.”

Of course, the guiding principle for the hospital was strongly rooted in old European tradition, as Michel Foucault demonstrated in The History of Madness (a book from which Bell draws.) Mental hospitals in Europe in those far off years, Foucault writes, were houses of confinement, a place where ‘deviants’ were shut away from the world. They were not medical establishments; they were places were the very poor, the vagrants, beggars, were kept away from respectable society, as lepers were in the middle ages.

Visiting the City of Rest taught me in a practical way that a far more humane method is not only possible but produces far better result, even in Sierra Leone. It adds an extra weight to Mr. Ngobeh’s magnificent achievement.

Narcotic Drugs and Mental Health

Dr. Nahim drew my attention to a study he had participated in, of mental health and substance abuse in post-conflict Sierra Leone in 2002 by Dr. SoerenBuus Jensen for the World Health Organisation. Dr. Jensen’s report estimated that 400,000 people in Sierra Leone were suffering from mental health disorders like depression and post-traumatic stress disorder; only about one percent of the population of about 6 million received any treatment. This was shortly after the end of the country’s brutal civil war (1991-2002).

The study noted that though the “frequency of severe traditional mental health problems in Sierra Leone is similar to most other countries,” many people in the country “were exposed to severe potentially traumatic events” which exacerbated the problem of mental health in the country.The report also noted that in Sierra Leone “there is a high frequency of people who never drink alcohol (85% of the random sample and 97% among secondary school students). Even less have tried or abused drugs” [my emphasis]. Still, the “frequency of drug-induced psychoses in the mental hospital is very high (60% of the patients with drug-induced psychosis)”, noting that this problem necessitates the establishment of “a comprehensive mental health system.” The report described the Kissy Mental Hospital as particularly unfit for the purpose, since it was squalid, with a quarter of its patients in heavy iron chains, lacked basic drugs, and many of the staff lacked adequate mental health training. The report also deplored the country’s lack of community based mental health care.

I draw attention to this report because it does not support the argument that correlates drug use with mental illness. This point is important because I suspect that part of the reason why successive governments have not prioritised mental health in Sierra Leone is because of the widely held view that mental ill patients brought the disease upon themselves. It becomes then a matter of moral choice: if you don’t take illicit drugs you won’t get mad. This is a profoundly unhelpful approach, and utterly cruel.

I had investigated the problem in Liberia before I got to Liberia. It, too, suffered a prolonged civil war; and there, too, the Chief Medical Officer in October 2015 stated that 400,000 people (of a population of about 4 million) in the country suffer from various kinds of mental illness. A survey of 1,600 households in 2008 revealed that about 43 percent of those surveyed meet the diagnostic criteria for serious depressive illness, major depressive disorder and post-traumatic stress disorder. Liberia, too, had only one psychiatrist, Dr. Benjamin Harris, who told a reporter that there is a growing problem of drug addiction linked to mental illness among young people in Liberia. He said that 27 percent of individuals surveyed had had “substance abuse related problems and substance abuse issues are a growing problem in Liberia.” He warned that unless “something is done pretty quickly to try to address this problem, it is bound to get worse.”

Liberia has only one psychiatric hospital, in Monrovia, the capital, and no rehabilitation centre for drug users. It is called Esther Grant Hospital, now part of the government-owned John F Kennedy Hospital in Monrovia. I visited the 80-bed hospital: it had 68 patients (48 male) in October 2015. Facilities were bare; and the atmosphere was one of sullen and brooding dereliction. Patients admitted at the hospital must show obvious signs of psychosis, and must be accompanied by their relatives. People with drug use disorders are not admitted, except if they are already psychotic and violent. When taken there, they are counseled and dismissed. There is no need to keep anyone in chains, in other words.

Leaving Sierra Leone, I decided to visit Ghana, which is now a middle-income country. A report by Human Rights Watch in 2012 estimated that 2.8 million people in Ghana have mental health problems, of which 650,000 were thought to have severe mental disabilities. This is comparable to both Sierra Leone and Liberia. The report cited Dr. Akwasi Osei, director of Accra Psychiatric Hospital, that drug-related psychosis affected 8-10 percent of mental patients; 20-30 percent of patients are diagnosed with schizophrenia, 20 percent with bipolar disorder, and 15-20 percent with major depression. Sadly, 97 out of 100 mental patients who require health care do not get it, the doctor was quoted as saying. Ghana has over a dozen psychiatrists and several mental hospitals.

I visited one – Pantang Psychiatric Hospital in Accra. I found the section for the treatment of drug use disorders far more salubrious and professionally managed than the government-run treatment centres in Sierra Leone and Liberia. It had 22 patients – it has a capacity for 30 – of which five were women; and each patient spends a minimum of six months (and a maximum of 18 months) before being released from the hospital. Each patient pays 1000 cedis – a prohibitive sum for many young people in the country – as admission fee at the hospital (which is then used to cover feeding), and patients buy their own medication. The hospital does not have the capacity for monitoring of patients after being released, however, and there have been countless cases of relapse.

Pa Ngobeh’s Legacy

Mr. Ngobeh, a very ordinary man, had an extraordinary vision, and he brought this vision to fruition. He showed that proper care of our most vulnerable citizens should be a concern for everyone; that mental disease is like most other diseases that afflict mankind: it can be cured, it is morally neutral, and must be seen as a concern for society as a whole. Our governments must take the lead in tackling this problem, and it must be tackled in a humane and, yes, civilised way. May Pa Ngobeh enjoy eternal peace: he was a true hero, he showed us a way to do it.