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In South Sudan, stigma and underfunding plague mental health care

Juba, South Sudan – On the side of a road a man stands by a wall ready to fight. He picks up a piece of broken glass to defend himself.  The white cloth around him falls off and he is now bare-chested, facing five policemen. They are wearing medical gloves.  “I don’t want to go.…

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In South Sudan, stigma and underfunding plague mental health care

Juba, South Sudan – On the side of a road a man stands by a wall ready to fight. He picks up a piece of broken glass to defend himself. 

The white cloth around him falls off and he is now bare-chested, facing five policemen. They are wearing medical gloves. 

“I don’t want to go. Leave me alone,” the man yells.

Dr Atong Ayuel, one of only three practising South Sudanese psychiatrists in the country, watches the scene unfold.

Since 2015, she has led a project supporting mentally ill homeless people, providing baths, fresh clothes, a medical check and long lasting anti-psychotics if necessary.

“It’s okay. Leave him alone. We don’t force anyone to come,” Dr Atong* tells the police and then boards a bus.

As part of the initiative, Atong, with a group of psychologists and policemen, hop onto a Juba’s Teaching Hospital bus three days a month and look out for people to help.

Dr Atong Ayuel makes sure a homeless man who refuses to partake in her project is left alone, since participation is voluntary [Jasmin Bauomy/Al Jazeera]

They treat 20 to 30 homeless patients with mental conditions a month. Over time, many have become willing participants, with some returning to families and jobs, but that’s not always the case. 

After being treated at hospital, they are usually returned to where they were picked up.

“We don’t have the infrastructure to keep them,” Atong says. There are only 12 beds and two nurses in the mental health ward at the hospital she works at.

Aside from overseeing the GEMS (Goats, Education, Medicine and Sustainability) – funded project, Atong, 40, treats hospital patients and people around the country, and heads the government’s mental health department.

The two other practicing psychiatrists are Dr George Nazario and Dr Richard Wani.

George treats patients at Juba’s main prison and the outpatient clinic. Richard works at the hospital and University of Juba.

After reaching the hospital, the homeless get a haircut, a shave, the opportunity for a bath, fresh clothes, a medical check and long-lasting anti-psychotics if needed [Jasmin Bauomy/Al Jazeera]

As the director of the mental health department, Atong develops policies for the country’s 12.5 million people, many of whom are trying to recover from the trauma caused by decades of conflict and displacement.

South Sudan suffered two civil wars before it won independence from Sudan in 2011, and is only now regaining its footing from its own civil war that lasted from 2013 until 2018. The country’s three practicing psychiatrists and 29 psychologists are all in Juba.

After independence, the South Sudanese government had to create a healthcare system from scratch. Thirteen years later, Atong and her colleagues are still struggling to provide mental healthcare. 

The Juba Teaching Hospital is the only public medical facility that provides psychiatric care; the availability of psychotropic drugs is inconsistent and limited. 

If the 12-bed ward is full, or if a patient is not eligible to take a bed, the mentally ill are often detained in Juba’s Central Prison.

One of the psychologists sits in the bus with the homeless to conduct preliminary medical interviews and assesses their mental health [Jasmin Bauomy/Al Jazeera]

Others are transferred to prison from medical facilities or taken to the detention centre directly by family members. 

In May 2016, according to rights group Amnesty, the prison held 66 male and 16 female mentally ill patients. 

While those numbers have dipped, Atong expects them to rise once again given the lack of resources.

Outside of Juba, psychiatrist Jairam Ramakrishnan, a New Zealand doctor who works for Doctors Without Borders (MSF), has been based at a clinic at a Protection of Civilians (PoC) site in Malakal, in Upper Nile State, a highly contested area, for more than a year.

“On a monthly basis we get anywhere between 30 to 40 new patients,” he tells Al Jazeera. 

Including follow-up consultations and first visits, there are about 250 mental health cases a month. 

The site is home to about 25,000 displaced people. When the United Nations force in South Sudan (UNMISS) established the camp after an outbreak of violence in 2014, improving living conditions wasn’t a priority.

Psychologists and policemen drive through Juba three times a month to pick up and care for mentally ill homeless people [Jasmin Bauomy/Al Jazeera]

To recover, Ramakrishnan says, patients need “basics like food, housing, safety, security, education transfer and employment. […] So, even though a person may have a good chance of recovery from an acute severe mental illness”, it is difficult to provide a setting where this is possible. 

“Social aspects play a big role for mental illness and social support systems are very weak in a protracted conflict.” 

As well as battling for more resources, the few psychiatrists in charge also have to tackle misconceptions.

“Mental illness is a huge problem in South Sudan,” Atong says. “We have over 60 tribes in South Sudan with different beliefs.” 

Most communities believe in supernatural possession or punishment by higher powers, as opposed to accepting a mental illness diagnosis, Atong says.

A policeman is on the lookout for possible new patients. He is one of a handful of security forces that help Dr Atong find patients on the streets of Juba [Jasmin Bauomy/Al Jazeera]

Paradise Agaak Henry, one of Atong’s patients in Juba, has been diagnosed with schizophrenia. 

She is in her 20s, loves fashion and beauty products, and is a keen student enrolled in paediatrics at the University of Upper Nile. 

“What makes me sad is to see what my former schoolmates are doing now. Some of them have finished their universities and I’m still in my first year,” she says, mourning the time she spent taking care of her mental health. “The devil attacked me and I tried to die. I didn’t eat or drink for four days.”

Her neighbours took her to church where believers tried to rid her of what they thought was an evil spirit. 

“They just prayed and cried. They beat me.” 

Her family later brought her to hospital, where she spent two months in Atong’s ward.

“It’s a stigma to be diagnosed as mentally ill,” Atong says, “people believe that it runs in the family. So when a family member is diagnosed, it could be harder for other family members to get married for example.” 

People would rather be known to be possessed than have a treatable mental illness, she explains. 

Paradise is improving. Asked whether faith or the psychiatrist helped, she says: “First of all Jesus, and then Dr Atong.”

This is my country. It’s the country I have. We’ve had a bad start, but we’re committed to create a better South Sudan for all.
Atong Ayuel, psychiatrist

Stigma is not limited to patients.

Medical professionals who choose psychiatry are looked down on by their peers, Atong explains, and their salaries often don’t match their colleagues.

Atong had earlier chosen paediatrics, but changed track when she encountered a mentally ill patient, who ended up being sent to prison. 

Her colleagues were shocked to see her “waste her talent” after she graduated second-best in her year from the University of Bahr Al Ghazal College. 

There is also a lack of accessible training, but over the last two years Atong has managed to include psychiatry as part of the curriculum at the universities of Bahr el Ghazal, Juba and Upper Nile. 

In 2017, to help doctors at least identify mental illnesses, the World Health Organization (WHO) committed to supporting the country’s health ministry in training supervisors and healthcare workers across the country.

“However, due to limited financial resources to support procurement of medication, supervision of health workers and procurement of other materials, largely not much could be done until the fourth quarter of 2018,” Dr Joseph Mogga of the WHO told Al Jazeera, adding the organisation would offer further support this year.

Atong welcomes WHO’s support. She knows the lack of funds makes it hard to move the needle. 

The country’s 2017-18 budget allocated two percent to the health sector – or about $2.7m. None of that is currently allocated for mental health.

Atong is well aware of underinvestment in healthcare but small victories keep her going. 

“Since the current minister of health [Dr Riek Gai Kok] came into power, he put mental health as a priority,” she says. He established the department of mental health within his ministry. 

In 2014 South Sudan commemorated mental health day for the first time. 

“Even in Western countries, mental healthcare always lacks [lags] behind a little compared to general healthcare.” 

In a country where general healthcare isn’t easy to come by, “you can imagine how difficult it is to establish a mental healthcare system”, says Jairam of MSF. 

But there are promising plans for 2019. 

India’s Central Public Works Department (CPWD) has taken on the challenge of building a new psychiatric hospital in Juba, next to the current psychiatric ward.

Atong plans to create a mental health policy within the national general health policy. 

“This is my country. It’s the country I have… We’ve had a bad start, but we’re committed to create a better South Sudan for all,” she says before rushing off to see another patient. 

Doctors* are usually referred to by their first name in South Sudan

This report was made possible through a reporting fellowship from the International Women’s Media Foundation (IWMF) and local journalist Samir Bol

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Why the Women’s Tennis Association rallied for Peng Shuai

A prominent Chinese citizen associated with a major international organisation disappears, then a letter is sent stating all is well. The organisation appears to accept the letter at face value although questions remain before the citizen emerges months later under duress. The circumstances are different but there is a similar thread to the disappearance of…

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Why the Women’s Tennis Association rallied for Peng Shuai

A prominent Chinese citizen associated with a major international organisation disappears, then a letter is sent stating all is well. The organisation appears to accept the letter at face value although questions remain before the citizen emerges months later under duress.
The circumstances are different but there is a similar thread to the disappearance of Chinese tennis player Peng Shuai, who last month accused former Vice Premier Zhang Gaoli of sexual misconduct, and Meng Hongwei, the former head of Interpol, who disappeared on a trip to China in 2018 and 18 months later pleaded guilty to corruption. He was sentenced to 13 years in prison.
Following Meng’s disappearance, Interpol largely appeared to accept his resignation letter and Secretary-General Jurgen Stock told the Associated Press news agency that the international police body was forbidden by internal rules to investigate.
Things could have turned out the same for Peng, a world-class athlete and Olympian, after a social media post about her ordeal with Zhang was deleted, except that the Women’s Tennis Association (WTA) immediately began to push back. Prominent tennis players also followed suit, including Naomi Osaka and Serena Williams.
The WTA has also continued to raise questions even after Chinese state broadcaster CGTN shared an email on Twitter – purportedly from Peng – saying that she was “not missing” or “unsafe” and that reports of her allegations were “not true”. She reemerged in public a few days later and spoke to the International Olympic Committee over a now heavily-criticised video call.
“[It] remains unclear if she is free and able to make decisions and take actions on her own, without coercion or external interference,” WTA Chairman and CEO Steve Simon said afterwards, stressing that the organisation remained concerned about her wellbeing.
The alleged email from Peng Shuai to Steve Simon that was aired on state broadcaster CGTN last month [CGTN/Twitter via Reuters]After the WTA’s repeated expressions of concern about Peng Shuai’s wellbeing, the IOC said it had held a video call with the player and released a still photo from the call [IOC via EPA]Late on Wednesday, the WTA announced the “immediate suspension” of all tournaments in China and Hong Kong. China hosted nine WTA events in 2019 and a year earlier signed a 10-year deal to host the WTA finals in Shenzhen, according to Reuters news agency.
“It’s really crazy that the Women’s Tennis Association has more credibility right now than Interpol in pushing back on China’s gross human rights abuses, abduction of members of its organisation, and poking holes in what is just thinly-veiled coercive statements and propaganda,” said Michael Caster, co-founder of the human rights watchdog Safeguard Defenders, which monitors disappearances in China.
‘Not acceptable’
China’s foreign ministry has accused critics and media of “malicious hyping” and politicising Peng’s disappearance from public view.
Meanwhile, Zhang, the high-ranking party member at the centre of Peng’s allegations, has not been seen in public in several weeks, according to Caster.
He described Peng’s situation as part of the same “playbook” used by the Chinese government when concerns are raised about the wellbeing of a citizen or foreigner living in China – from human rights lawyer Wang Yu to Swedish human rights activist Peter Dahlin who went on to become one of the founders of Safeguard Defenders.
“These farcical public presentations from Peng Shuai are clearly scripted as part of a propaganda effort and we say that because we’ve seen this movie before,” Caster told Al Jazeera.
In announcing the suspension of tournaments, the WTA’s Simon stressed that China’s handling of Peng’s case was not acceptable and should not be allowed to become acceptable.
“If powerful people can suppress the voices of women and sweep sexual assault under the rug then the basis on which the WTA was founded – equality for women – would suffer an immense setback,” Simon said in a statement. “I will not and cannot let that happen to the WTA and its players.”

Game, set, and match to the @WTA in the grand slam for sports and human rights in #China! Steve Simon announces WTA’s decision to suspend tournaments in China… via @WTA https://t.co/LlZ7yW86BQ @hrw @MinkysHighjinks @hrw
— Sophie Richardson (@SophieHRW) December 1, 2021

I applaud Steve Simon & the @WTA leadership for taking a strong stand on defending human rights in China & around the world. The WTA is on the right side of history in supporting our players.
This is another reason why women’s tennis is the leader in women’s sports. https://t.co/PHiU0S7Prw
— Billie Jean King (@BillieJeanKing) December 1, 2021
Other international sporting bodies have already been targeted by Beijing over positions taken by their players and officials.
China briefly stopped airing NBA games after Houston Rockets manager Daryl Morey tweeted his support for Hong Kong’s 2019 democracy protests and erased Premier League football player Mesut Ozil from the Chinese internet after he spoke out against China’s treatment of Muslim Uighurs.
More recently, games involving the NBA’s Boston Celtics have been pulled from broadcast in China as Enes Kanter, their centre, continues to make criticisms about President Xi Jinping and China’s treatment of Xinjiang, Hong Kong, and Tibet while also voicing support for Taiwan.
Moment of reckoning
The WTA, however, had political momentum and timing on its side allowing the organisation to take a calculated risk, says Simon Chadwick, a professor of international sports business at Emlyon Business School in France.
Peng’s case and allegations of sexual misconduct also come at a moment of reckoning in the sports world over #MeToo allegations and mental health following the public struggles of athletes like Osaka and American gymnast Simone Biles.
“Number one for the WTA is that women and girls are their core business. It’s what the organisation is founded upon and to not be seen as supporting someone who apparently has gone missing would undermine what the WTA does,” Chadwick said.
“My feeling is that the WTA probably made a calculation and decided that it stood to lose more globally by not saying anything, then it stood to lose by essentially standing up to China.”
Chadwick says that despite considerable investments in the Chinese tennis industry, women’s tennis has not taken off there as quickly as the WTA initially anticipated.
Its deal with China has also struggled as a result of the pandemic. So far, Shenzhen has hosted only one WTA finals event in 2019. The 2020 final was cancelled as a result of the coronavirus, and the 2021 event was moved to Mexico following another Covid-19 outbreak in China.
The NBA came under pressure in China after Houston Rockets manager Daryl Morey tweeted his support for the Hong Kong protesters in 2019 [File: Xihao Jiang/Reuters]That may give the WTA the kind of latitude unavailable to groups like the IOC, which is due to host the 2022 Winter Olympic Games in Beijing in February. That organisation has also suffered as a result of the pandemic with the Tokyo Olympics, pushed back a year and not attended by the usual number of spectators.
Following Peng’s disappearance, the IOC has said it would “continue our open dialogue on all levels with the Olympic movement in China” following questions about Peng, according to the Associated Press.
Emma Terho, the IOC Athletes Commission Chair, said on Twitter that the organisation prefers a policy of “quiet diplomacy”.
Based in the Republican state of Florida, the WTA may have also felt some political pressure beyond Beijing.
Washington is mulling a boycott of the Winter Games protest against human rights abuses in places like Xinjiang and Hong Kong, notes Chadwick.
“I wonder to what extent there may have been some political pressure from within the United States put on the WTA to respond in the way that it did. I think from the perspective of the WTA, they reacted very, very quickly… unusually quickly, within a matter of two or three days, he said. “And that is extremely unusual.”
On Wednesday, Simon expressed regret at having to suspend events in China, but he said he was “greatly concerned” at the risks players and staff could face if events were held in the country in 2022.
He once again urged Beijing to prove Peng was free, and able to speak “without interference or intimidation” and to fully investigate the allegations of assault.
“I remain hopeful that our pleas will be heard and the Chinese authorities will take steps to legitimately address this issue.”

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Mexico and US to launch plan to stem Central American migration

The vast majority of people heading to the US-Mexico border are from Honduras, Guatemala and El Salvador.Mexico’s foreign ministry has said the Mexican and US foreign development agencies will work together on a project to address the root causes of migration from Guatemala, Honduras and El Salvador. The “Planting Opportunities” project announced on Wednesday will…

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Mexico and US to launch plan to stem Central American migration

The vast majority of people heading to the US-Mexico border are from Honduras, Guatemala and El Salvador.Mexico’s foreign ministry has said the Mexican and US foreign development agencies will work together on a project to address the root causes of migration from Guatemala, Honduras and El Salvador.
The “Planting Opportunities” project announced on Wednesday will bring together the Mexican Agency for International Development Cooperation (Amexcid) and the United States Agency for International Development (USAID) and target the three so-called Northern Triangle countries.
Migration from Guatemala, Honduras and El Salvador has fuelled record numbers of people being apprehended at the US-Mexico border, as asylum seekers have tried to enter the United States after fleeing poverty, violence and political instability.
The surge in arrivals has piled political pressure on the administration of US President Joe Biden, whose Republican rivals have accused him of causing “chaos” at the border.
Mexico’s National Guard has been dispatched along the country’s southern border with Guatemala and along main roads to stem the flow of migrants [File: Daniel Becerril/Reuters]During the last fiscal year, US authorities detained some 1.7 million people along the border.
The US has been increasingly reliant on Mexico to stem the flow of migrants, as it returns to Mexico the majority of people who arrive at the border under a Trump-era border restriction enacted due to the coronavirus pandemic.
The US is also in talks with the Mexican government to restart a programme that would force asylum seekers to wait in Mexico for their US immigration court hearings.
Both Biden and Mexico’s leftist President Andres Manuel Lopez Obrador have vowed to tackle what they call the “root causes” of migration.
They have pointed to poverty, lack of education and job opportunities, gang violence, political instability and corruption as some of the leading causes of migration, especially of young people.
The new US-Mexico collaboration will begin in Honduras, with an effort to teach job skills to more than 500,000 at-risk youth, the Mexican foreign ministry said on Wednesday.
The department did not provide details about the programme or how much funding would be allocated for the scheme.
The project will bring together the Mexican Agency for International Development Cooperation and the United States Agency for International Development [File: Jose Torres/Reuters]As a presidential candidate, Lopez Obrador had touted social programmes aimed at creating better lives for people in Central American countries, which he said would discourage people from leaving.
But those plans were shelved after former US President Donald Trump took office and made hardline, anti-immigration measures the main focus of his government.
In recent years, Mexico has blocked several caravans of people seeking to reach the US. It also has dispatched its National Guard to the country’s southern and northern borders to try to keep people away.

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Displaced Syrians face brutal winter exacerbated by economic collapse, charity warns

PARIS: French President Emmanuel Macron called on his Iranian counterpart, Ebrahim Raisi, to return to fulfilling Tehran’s obligations under the 2015 nuclear deal “without delay,” Macron’s office said, as negotiators seek to revive the accord through talks in Vienna.During telephone conversations on Monday, Macron urged Raisi to engage in a “constructive manner” with the talks,…

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Displaced Syrians face brutal winter exacerbated by economic collapse, charity warns

PARIS: French President Emmanuel Macron called on his Iranian counterpart, Ebrahim Raisi, to return to fulfilling Tehran’s obligations under the 2015 nuclear deal “without delay,” Macron’s office said, as negotiators seek to revive the accord through talks in Vienna.During telephone conversations on Monday, Macron urged Raisi to engage in a “constructive manner” with the talks, which resumed this week after a suspension of almost half a year following the election of the hardliner to the Iranian presidency.European powers are seeking to revive the nuclear deal, more formally known as the Joint Comprehensive Plan of Action. It has been moribund since the US withdrew from the agreement in 2018, prompting Tehran to ramp up nuclear activities as Washington reimposed sanctions.France’s objective is “to see Iran return to full respect for all of its commitments under the JCPOA and that the United States returns to the agreement,” the French presidency said.Macron also “underscored the need for Iran to engage constructively in this direction so that the exchanges allow a swift return to the agreement,” it added.“Iran must return without delay to compliance with all its commitments and obligations … and quickly resume cooperation that allows the (UN atomic energy) agency to fully carry out its mission,” it said.Iran’s top nuclear negotiator, Ali Bagheri, adopted a hard-line approach after just one day of the resumed talks, suggesting that everything discussed during previous rounds of diplomacy could be renegotiated.Speaking to Iranian state television, he described all that has been discussed so far as merely a “draft.”He added: “Drafts are subject to negotiation. Therefore nothing is agreed on unless everything has been agreed on.“On that basis, all discussions that took place in the (previous) six rounds (of talks) are summarized and are subject to negotiations. This was admitted by all parties in today’s meeting as well.”Bagheri’s remarks directly contradicted comments on Monday by EU diplomat Enrique Mora, who is leading the talks.“The Iranian delegation represents a new administration in Tehran with new, understandable political sensibilities, but they have accepted that the work done over the six first rounds is a good basis to build our work ahead, so no point in going back,” he said.Another state TV report highlighted Bagheri in Vienna saying that Iran demands a “guarantee by America not to impose new sanctions” or reimpose previously lifted sanctions.Mohammed Eslami, Iran’s civilian nuclear chief, reiterated this demand in comments to Iran’s official IRNA news agency.“The talks (in Vienna) are about the return of the US to the deal and they have to lift all sanctions and this should be in practice and verifiable,” he said.Raisi’s office said that he urged Macron “to strive with other parties in Vienna to conclude the negotiations and lift the sanctions against Iran.”Raisi said: “Sending a full team to the talks shows Iran’s serious will in these talks.”Referring to the US, he added: “Those who have started to violate the nuclear deal must gain the confidence of the other party for the negotiations to proceed in a real and fruitful manner.”

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