When I moved to Ethiopia as a Peace Corps Volunteer, one of the first people to befriend me was Dinkinesh, or Dink. We came to know each other in a remote village of less than 1000 people in the Amhara District. The village was 2 kilometers up a mountain from the nearest road, 15 Kilometer from the nearest city, Dessie, and 415 kilometers from Addis Ababa, the capital of Ethiopia, and the nearest and only mental health hospital in the country.
Dink was about 11 years old and lived with an undiagnosed developmental disability. I met her when I left my home and ventured into my new community for the first time. It was particularly hot that day, so I was pushed out of my home in order to find something cold to drink. I used my basic language skills to ask where to find a cold drink and was brought to the only shop with a refrigerator in town. I bought myself a cold orange flavored Mirinda and sat down in the shade nearby to enjoy my drink. It did not take long before Dink wandered over and pointed at my Mirinda and made grasping motions. She sat down next to me and waited impatiently, continuing to communicate her request. I sipped a bit more of my cold Mirinda and handed the remaining drink to Dink. This became our tradition.
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The prevalence of mental health disorders has been rising globally due to demographic, environmental, and sociopolitical transitions (2). In the last 30 years mental health disorders have risen from the 13th leading cause of disability-adjusted life years (DALYs) to the 7th leading cause (3). Risk factors associated with common mental disorders, including discrimination, history of abuse, and higher rates of interpersonal stressors, create disparities between the sexes (4).
Projections indicate an increased burden of mental diseases will continue, and the greatest impact will be in low- and middle-income countries (LMICs) (6). While there is an increase in mental illness prevalence, many LMICs are simultaneously experiencing a gap in human resources for health care, particularly for mental health (6). There is an estimated 1.2-million-person gap needed to provide mental health services, and nearly 90% of people living with mental illness have not seen medical professionals in LMICs (7).
In Ethiopia with a population of approximately 100 million people, there are only 60 psychiatrists and one mental health specialty hospital. This means that for every psychiatrist, there are about 1.7 million Ethiopians. The prevalence of mental health disorders in Ethiopia is conservatively estimated at 18% for adults and 15% for children, 6 translating to 16.5 million people suffering from mental illness. If all of those suffering in Ethiopia sought care, the patient load for one psychiatrist would be 275,000 patients. For Dink, there are two specialists in Autism Spectrum Disorder, both of whom live and practice in Addis Ababa.
While there have been advances in the development of evidence-based practices for treating and preventing common mental diseases, the uptake has been especially slow in LMICs (2). This could be attributed to the vast shortage in human resources, the continued growth in the burden of disease, and the high levels of stigma towards and discrimination against those suffering from mental illness and their families. These barriers to care often lead to cases of human rights violations that disproportionately impact women as victims.
In Ethiopia, persons living with mental illness may be imprisoned in their homes, sent to religious encampments where deprivation of food is common, or sent to the streets to survive as they can. For women, these outcomes are particularly dangerous. Dink was lucky in regards to these norms. She was not in school or out playing with other children, but her parents had not imprisoned her in the home. During holidays, children and family members whom I had never seen were suddenly in public fields at dawn on Eid Mubarak Praying East to Mecca or were in the Orthodox Church for Easter to atone and receive forgiveness. Those family members were stashed away to prevent the public from seeing their conditions due to discrimination against people living with mental illness and their family members.
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Dink became a companion, and when I left for hikes around the lake or up the mountain she came along, and we shared our cold Mirinda when we made it back home. On market days, she would sit with me at breakfast and eat bread that she dipped in her sugar-laden tea. This went on for the first 8 months of my 2 year stay.
Then I stopped seeing Dink.
She was no longer my breakfast companion. She didn’t appear when I stopped by the shop for a cold Mirinda. She wasn’t even there at Timket, an Orthodox celebration, when all other Christians attended the ceremony. I asked around to try and find her, but the topic was avoided. One day, while visiting friends in the nearest city, Dessie, I spotted Dink. She was barely clothed, dirty, and living on the street.
After some digging I found out that the family had been ostracized for Dink’s illness. Her mother was no longer getting jobs cleaning peoples’ homes, and no one was coming to their family compound to buy Tela, a traditional drink that the family sold. Their livelihood was disappearing as Dink became more of a fixture in the village. Her family was facing an impossible decision: their livelihood or Dink. The best option from the family’s perspective was to leave Dink on the streets to fend for herself so that they could avoid starvation.
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While I never again saw Dink after that day in Dessie, I know that there is no happy ending to her story. Dink’s story is not unique in Ethiopia or any other country in the world. Resources for mental health are scarce, and stigma is high in many countries, including the United States. The ongoing COVID-19 crisis has only worsened the situation. With already scarce resources being reallocated to fight the virus, mental health services will continue to be inaccessible for countless individuals around the globe, and without a concerted effort to address this problem, the impact on global mental health will be immeasurable.
References
Puffer E, Drabkin A, Stashko A, Broverman S, Ogwang-Odhiambo R, Sikkema K. Orphan status, HIV risk behavior, and mental health among adolescents in Rural Kenya. Journal of Pediatric Psychology. 2012;9(1).
Patel V, Saxena S, Lund C, et al. The Lancet Commission on Global Mental Health and Sustainable Development. Harvard; 2018.
Institute for Health Metrics and Evaluation (IHME). Seattle, WA: IHME, University of Washington, 2018. Available from http://www.healthdata.org/. (Accessed May 2020).
Puffer E, Drabkin A, Stashko A, Broverman S, Ogwang-Odhiambo R, Sikkema K. Orphan status, HIV risk behavior, and mental health among adolescents in Rural Kenya. Journal of Pediatric Psychology. 2012;9(1).
WHO, ed. Mental Health Atlas 2017. World Health Organization; 2018.
Engidaw N, Abdu Z, Chinani I. Prevalence and associated factors of common mental health disorders among residents of Illu Ababore zone, Southwest Ethiopia: a cross-sectional study. International Journal of Mental Health Systems. Published online 2020. doi: 10.1186/s13033-020-00394-3.
Hailemariam M, Fekadu A, Prince M, Hanlon C. Engaging and staying engaged: a phenomenological study of barriers to equitable access to mental healthcare for people with severe mental disorders in a rural African setting. International Journal for Equity in Health. 2017;16(1).
Patel V. Global Mental Health: From Science to Action. Harvard Review of Psychiatry. 2012;20(1).