Studying Mental Health in Zanzibar.

Most patients go to Kidongo Chekundu Mental Hospital in Zanzibar City as a last resort.

“Many people go to traditional or spiritual healers first, and these healers may treat severe disorders like schizophrenia with traditional herbs and special prayers,” says MPH student Damilola Iyiola, who spent her summer researching perceptions of mental illness in Zanzibar. “This delayed treatment has negative consequences for the individual, their families, the community, and the health system. It has led to worsened health status, incarceration, and other preventable outcomes.”

Although most Zanzibaris view mental illness as a “spiritual attack” rather than a health issue, that perception is not the main barrier to care, says Iyiola.

Instead, it is access.

Kidongo Chekundu is the only psychiatric hospital in Zanzibar, a semi-autonomous group of islands off the coast of Tanzania with a population of 1.3 million people. Interviewing psychiatric hospital workers and patients, as well as other Zanzibaris, in their native Kiswahili—thanks to a Foreign Language Area Studies (FLAS) fellowship from the Boston University African Studies Center—Iyiola learned of the difficulties reaching the hospital. Paying for transport, spending a day traveling, and missing work all keep patients and their families from seeking care at Kidongo Chekundu, even if they know that psychiatric care will be more effective than a traditional or spiritual healer.

“Many people would prefer more community-based services so they don’t have to leave their communities to get care,” Iyiola says. Integrating mental health services into primary, community-based care is becoming a central goal in the global mental health field, she adds, by training non-specialist healthcare workers to deliver mental health care. That work has already begun with Health Improvement Project Zanzibar (HIPZ), a UK-based organization that has incorporated mental health into two primary care clinics.

“This is a great shift in the right direction,” Iyiola says, though she is quick to point out that three facilities are still far too few for all of Zanzibar.

Integrated services can also address the issue of stigma, she says, because patients could receive care in the same way they would for any other illness. Community health workers can also become advocates and educators around mental illness.

“Changing perception about mental illness could be a slow process, but it can be done in tandem with scaling up services,” Iyiola says.

Iyiola began studying Kiswahili through the BU African Studies Center, including taking a special course focused on health topics and language designed and taught by African Studies faculty on the Medical Campus. Two to four SPH students have received FLAS fellowships from the African Studies Center each year for the last six years, reflecting the close relationship between SPH and the Center. MPH student Kaylee Kim also went to Zanzibar this past summer, where both students took daily Kiswahili classes at the State University of Zanzibar. Suegatha Kai-Rennie, a dual-degree student at SPH and the Frederick S. Pardee School of Global Studies, was the third SPH fellow, and spent her summer in Uganda.

Iyiola, who is Nigerian and a native speaker of English and Yoruba, studied Kiswahili at BU for two semesters before going to Zanzibar: “I’ve also always been fascinated by language and how much more information you can get when you cross a language barrier.”

Her studies paid off. “In Zanzibar, many people speak English because they’ve learned it in school, but many people either haven’t received that education or do not speak English comfortably,” she says. “Because I was able to speak Kiswahili, I was able to speak to people along the range of educational statuses in order to get different perspectives. I’m grateful for the knowledge I had, because I was able to speak with a diverse range of people who I might have not otherwise been able to communicate with.”

Iyiola is currently finishing a report of her findings for Kidongo Chekundu Mental Hospital, and says she hopes it will be useful in future advocacy for mental health care in Zanzibar.

“I’m hopeful, because there is some recognition of mental health needs and there is a feasible way of reaching those needs—but this still loops back to perceptions of mental illness” and of who should care about it, she says. Iyiola’s host family and other Zanzibaris she explained her project to would inevitably ask her if she had a mental illness.

“It was usually meant as an innocent question, but it reinforced the insidious perception that those who suffer from mental illness and their families are the only ones who need to care about these issues,” she says. “It’s a false and costly perception.”

—Michelle Samuels