Habeb Mental hospital in Mogadishu, Somalia. “We are working in the most dangerous place around the world, Mogadishu!” shouts Dr Habeb who runs the only mental health clinics in Mogadishu, Somalia. The World Health Organisation (WHO) says 1 in 3 Somali’s suffer from some kind of mental illness. From the camps for Internally Displaced People dotted around the region to the bombed out streets of Mogadishu is a generation of Somalis who’ve only known war, famine, displacement, and loss. The most common response though is forcible restraint. The use of chains in homes – or as is more common in huts or under trees outside the home - to restrain a family member with a mental illness is widespread. WHO says that in the last decade 90% of the treated patients it surveyed were subjected at least once in their lifetime to chaining. Chaining patients is seen as an alternative medication, which not only leaves the patients stigmatized but also causes physical injuries on hands and legs. Some of the chained patients end up committing suicide. The person is usually chained not only during the ‘acute crisis’ but throughout his or her life. To say there is a skills shortage in mental health practitioners in Somalia would be an understatement. WHO say there are only 3 psychiatrists in the whole region and that their skill levels are insufficient. Photo Robin Hammond/Panos. May, June 2011, Somalia. © 2011 Robin Hammond

The Mental Ward at Hargeisa Group Hospital is a terrible place but the building, staff, and patients have received some hope in the form of support from GRT, a small Italian NGO that is trying to rehabilitate infrastructure as well as patients. The World Health Organisation (WHO) says 1 in 3 Somali’s suffer from some kind of mental illness. From the camps for Internally Displaced People dotted around the region to the bombed out streets of Mogadishu is a generation of Somalis who’ve only known war, famine, displacement, and loss. The most common response though is forcible restraint. The use of chains in homes – or as is more common in huts or under trees outside the home - to restrain a family member with a mental illness is widespread. WHO says that in the last decade 90% of the treated patients it surveyed were subjected at least once in their lifetime to chaining. Chaining patients is seen as an alternative medication, which not only leaves the patients stigmatized but also causes physical injuries on hands and legs. Some of the chained patients end up committing suicide. The person is usually chained not only during the ‘acute crisis’ but throughout his or her life. To say there is a skills shortage in mental health practitioners in Somalia would be an understatement. WHO say there are only 3 psychiatrists in the whole region and that their skill levels are insufficient. Photo Robin Hammond/Panos. May, June 2011, Somalia. © 2011 Robin Hammond

The Mental Ward at Hargeisa Group Hospital is a terrible place but the building, staff, and patients have received some hope in the form of support from GRT, a small Italian NGO that is trying to rehabilitate infrastructure as well as patients. The World Health Organisation (WHO) says 1 in 3 Somali’s suffer from some kind of mental illness. From the camps for Internally Displaced People dotted around the region to the bombed out streets of Mogadishu is a generation of Somalis who’ve only known war, famine, displacement, and loss. The most common response though is forcible restraint. The use of chains in homes – or as is more common in huts or under trees outside the home - to restrain a family member with a mental illness is widespread. WHO says that in the last decade 90% of the treated patients it surveyed were subjected at least once in their lifetime to chaining. Chaining patients is seen as an alternative medication, which not only leaves the patients stigmatized but also causes physical injuries on hands and legs. Some of the chained patients end up committing suicide. The person is usually chained not only during the ‘acute crisis’ but throughout his or her life. To say there is a skills shortage in mental health practitioners in Somalia would be an understatement. WHO say there are only 3 psychiatrists in the whole region and that their skill levels are insufficient. Photo Robin Hammond/Panos. May, June 2011, Somalia. © 2011 Robin Hammond

The Mental Ward at Hargeisa Group Hospital is a terrible place but the building, staff, and patients have received some hope in the form of support from GRT, a small Italian NGO that is trying to rehabilitate infrastructure as well as patients. The World Health Organisation (WHO) says 1 in 3 Somali’s suffer from some kind of mental illness. From the camps for Internally Displaced People dotted around the region to the bombed out streets of Mogadishu is a generation of Somalis who’ve only known war, famine, displacement, and loss. The most common response though is forcible restraint. The use of chains in homes – or as is more common in huts or under trees outside the home - to restrain a family member with a mental illness is widespread. WHO says that in the last decade 90% of the treated patients it surveyed were subjected at least once in their lifetime to chaining. Chaining patients is seen as an alternative medication, which not only leaves the patients stigmatized but also causes physical injuries on hands and legs. Some of the chained patients end up committing suicide. The person is usually chained not only during the ‘acute crisis’ but throughout his or her life. To say there is a skills shortage in mental health practitioners in Somalia would be an understatement. WHO say there are only 3 psychiatrists in the whole region and that their skill levels are insufficient. Photo Robin Hammond/Panos. May, June 2011, Somalia. © 2011 Robin Hammond

In Hargeisa, the capital of Somaliland, there are 7 private clinics ‘treating’ people with mental disability. They house at least 600 patients. I went to see 4 of these institutions. All but one used chains. In 2 of the clinics up to 80% of the patients were shackled. Treatment at these places is the bare minimum – they are in fact businesses that take advantage of desperate families and a population denied a say in their care. The families of patients pay up to $US120 a month. A large sum in Somalia. For this the patients receive some food and some medication. What I saw were often confused people crowded into dark spaces on dirty mattresses lined up side by side. Many told me they wanted to leave but were not allowed to. One articulate young man agreed he needed treatment “I am sick” he said, “you put sick people in hospital, not a prison.” Hargeisa, Somaliland. The World Health Organisation (WHO) says 1 in 3 Somali’s suffer from some kind of mental illness. From the camps for Internally Displaced People dotted around the region to the bombed out streets of Mogadishu is a generation of Somalis who’ve only known war, famine, displacement, and loss. The most common response though is forcible restraint. The use of chains in homes – or as is more common in huts or under trees outside the home - to restrain a family member with a mental illness is widespread. WHO says that in the last decade 90% of the treated patients it surveyed were subjected at least once in their lifetime to chaining. Chaining patients is seen as an alternative medication, which not only leaves the patients stigmatized but also causes physical injuries on hands and legs. Some of the chained patients end up committing suicide. The person is usually chained not only during the ‘acute crisis’ but throughout his or her life. To say there is a skills shortage in mental health practitioners in Somalia would be an understatement. WHO say there are only 3 psychiatrists in the whole region and that their skill levels are insufficient. Photo Robin Hammond/Panos. May, June 2011, Somalia. © 2011 Robin Hammond

33 year old Khadar Mohamed Farah lives in a tin shack in an IDP camp in Hargeisa, Somaliland. He has been in chains for 11 years. 24 hours a day 7 days a week he is locked up. Hargeisa, Somaliland. The World Health Organisation (WHO) says 1 in 3 Somali’s suffer from some kind of mental illness. From the camps for Internally Displaced People dotted around the region to the bombed out streets of Mogadishu is a generation of Somalis who’ve only known war, famine, displacement, and loss. The most common response though is forcible restraint. The use of chains in homes – or as is more common in huts or under trees outside the home - to restrain a family member with a mental illness is widespread. WHO says that in the last decade 90% of the treated patients it surveyed were subjected at least once in their lifetime to chaining. Chaining patients is seen as an alternative medication, which not only leaves the patients stigmatized but also causes physical injuries on hands and legs. Some of the chained patients end up committing suicide. The person is usually chained not only during the ‘acute crisis’ but throughout his or her life. To say there is a skills shortage in mental health practitioners in Somalia would be an understatement. WHO say there are only 3 psychiatrists in the whole region and that their skill levels are insufficient. Photo Robin Hammond/Panos. May, June 2011, Somalia. © 2011 Robin Hammond

13 year old Ahmed Adan Ahmed spends his days walking in circles, or sitting running his hands through the sand at his feet. For 10 years he has been tied to a stick under the tarpaulin of a tent in and IDP camp in Galkayo. His mother Fawzia sees no other option – if she doesn’t tie him he will run away. Refugee Camp, Galkayo, Puntland. The World Health Organisation (WHO) says 1 in 3 Somali’s suffer from some kind of mental illness. From the camps for Internally Displaced People dotted around the region to the bombed out streets of Mogadishu is a generation of Somalis who’ve only known war, famine, displacement, and loss. The most common response though is forcible restraint. The use of chains in homes – or as is more common in huts or under trees outside the home - to restrain a family member with a mental illness is widespread. WHO says that in the last decade 90% of the treated patients it surveyed were subjected at least once in their lifetime to chaining. Chaining patients is seen as an alternative medication, which not only leaves the patients stigmatized but also causes physical injuries on hands and legs. Some of the chained patients end up committing suicide. The person is usually chained not only during the ‘acute crisis’ but throughout his or her life. To say there is a skills shortage in mental health practitioners in Somalia would be an understatement. WHO say there are only 3 psychiatrists in the whole region and that their skill levels are insufficient. Photo Robin Hammond/Panos. May, June 2011, Somalia. © 2011 Robin Hammond

Ahlu-Kheyr Public Mental Hospital, Mogadishu, Somalia. Many Somalis will take their mentally ill relative to traditional or Khoranic healers for treatment. The World Health Organisation (WHO) says 1 in 3 Somali’s suffer from some kind of mental illness. From the camps for Internally Displaced People dotted around the region to the bombed out streets of Mogadishu is a generation of Somalis who’ve only known war, famine, displacement, and loss. The most common response though is forcible restraint. The use of chains in homes – or as is more common in huts or under trees outside the home - to restrain a family member with a mental illness is widespread. WHO says that in the last decade 90% of the treated patients it surveyed were subjected at least once in their lifetime to chaining. Chaining patients is seen as an alternative medication, which not only leaves the patients stigmatized but also causes physical injuries on hands and legs. Some of the chained patients end up committing suicide. The person is usually chained not only during the ‘acute crisis’ but throughout his or her life. To say there is a skills shortage in mental health practitioners in Somalia would be an understatement. WHO say there are only 3 psychiatrists in the whole region and that their skill levels are insufficient. Photo Robin Hammond/Panos. May, June 2011, Somalia. © 2011 Robin Hammond

A nurse at Galkayo Mental Health Centre in Puntland comforts a patient. Galkayo Mental Health Centre in Puntland . 44 year old Fatima Farah is a British trained Counseling Psychotherapist at Galkayo Mental Health Centre in Puntland “people still attach a huge stigma to mental health, they don't know how to handle mental ill patients, they chain them, they isolate them, they take them to any source of spiritual healers and all of that; and the last thing they result to is bring them here for medication. I’ve seen patients who have been ill for the last 7 years and have never been taken to a mental hospital. I've seen people who have been brought in chains and you think like they have been possessed by some evil spirit, and you just tell them look they are just sick, they just need medication, treat them like someone who has a headache and that's all.” Her facility is a zero tolerance for chains. Regardless of the patients state of mind, all chains are removed at the gates. Fatima has no doubt why there are so many people with mental illness in Puntland – “The instability in Puntland has had a huge impact on the mental stability of the patients we see here. Human beings need security and if there is no security then people are fearful. The last 20 years of civil war has affected the peoples well being and stability, they come here and talk about how a relative has been killed or a relative has disappeared. When the society is not in peace then the individual is not in peace.” The World Health Organisation (WHO) says 1 in 3 Somali’s suffer from some kind of mental illness. From the camps for Internally Displaced People dotted around the region to the bombed out streets of Mogadishu is a generation of Somalis who’ve only known war, famine, displacement, and loss. The most common response though is forcible restraint. The use of chains in homes – or as is more common in huts or under trees outside the home - to restrain a family member with a mental illness is widespread. WHO says that in the last decade 90% of the treated patients it surveyed were subjected at least once in their lifetime to chaining. Chaining patients is seen as an alternative medication, which not only leaves the patients stigmatized but also causes physical injuries on hands and legs. Some of the chained patients end up committing suicide. The person is usually chained not only during the ‘acute crisis’ but throughout his or her life. To say there is a skills shortage in mental health practitioners in Somalia would be an understatement. WHO say there are only 3 psychiatrists in the whole region and that their skill levels are insufficient. Photo Robin Hammond/Panos. May, June 2011, Somalia. © 2011 Robin Hammond

Ahlu-Kheyr Public Mental Hospital, Mogadishu, Somalia. The World Health Organisation (WHO) says 1 in 3 Somali’s suffer from some kind of mental illness. From the camps for Internally Displaced People dotted around the region to the bombed out streets of Mogadishu is a generation of Somalis who’ve only known war, famine, displacement, and loss. The most common response though is forcible restraint. The use of chains in homes – or as is more common in huts or under trees outside the home - to restrain a family member with a mental illness is widespread. WHO says that in the last decade 90% of the treated patients it surveyed were subjected at least once in their lifetime to chaining. Chaining patients is seen as an alternative medication, which not only leaves the patients stigmatized but also causes physical injuries on hands and legs. Some of the chained patients end up committing suicide. The person is usually chained not only during the ‘acute crisis’ but throughout his or her life. To say there is a skills shortage in mental health practitioners in Somalia would be an understatement. WHO say there are only 3 psychiatrists in the whole region and that their skill levels are insufficient. Photo Robin Hammond/Panos. May, June 2011, Somalia. © 2011 Robin Hammond

Mogadishu’s Medina Hospital sees as many as 700 war wounded patients a month. Dr Mohamed Yusuf is the hospitals Director “kids they are coming from school, they are talking about what happened to them during the day and it suddenly come on them, a mortar shell. Many of them they don't survive, mutilated, cut in pieces and then the survivors come to the hospital, woman, old ladies, young one, kids... It is not infrequent that we receive some just, five days, six days old, they are just born you know, they come to the hospital with amputated legs, this kind of things... we receive this kind of things as you can imagine, the families that are suffering this kind of conditions of disaster, you can imagine how they get hit, mentally. You see that when they are getting their treatments, some of them they are totally absent.” Mogadishu, Somalia. The World Health Organisation (WHO) says 1 in 3 Somali’s suffer from some kind of mental illness. From the camps for Internally Displaced People dotted around the region to the bombed out streets of Mogadishu is a generation of Somalis who’ve only known war, famine, displacement, and loss. The most common response though is forcible restraint. The use of chains in homes – or as is more common in huts or under trees outside the home - to restrain a family member with a mental illness is widespread. WHO says that in the last decade 90% of the treated patients it surveyed were subjected at least once in their lifetime to chaining. Chaining patients is seen as an alternative medication, which not only leaves the patients stigmatized but also causes physical injuries on hands and legs. Some of the chained patients end up committing suicide. The person is usually chained not only during the ‘acute crisis’ but throughout his or her life. To say there is a skills shortage in mental health practitioners in Somalia would be an understatement. WHO say there are only 3 psychiatrists in the whole region and that their skill levels are insufficient. Photo Robin Hammond/Panos. May, June 2011, Somalia. © 2011 Robin Hammond

Former Somali government building in Mogadishu. Somalia’s fragile government has no budget for mental health. The TFG State Minister of Health Dr Mahamud Sheikh Hassan says the country is in crisis. He is very aware of the trauma his people are suffering. He says that while the will to make things better is there the resources are not. Mogadishu, Somalia. The World Health Organisation (WHO) says 1 in 3 Somali’s suffer from some kind of mental illness. From the camps for Internally Displaced People dotted around the region to the bombed out streets of Mogadishu is a generation of Somalis who’ve only known war, famine, displacement, and loss. The most common response though is forcible restraint. The use of chains in homes – or as is more common in huts or under trees outside the home - to restrain a family member with a mental illness is widespread. WHO says that in the last decade 90% of the treated patients it surveyed were subjected at least once in their lifetime to chaining. Chaining patients is seen as an alternative medication, which not only leaves the patients stigmatized but also causes physical injuries on hands and legs. Some of the chained patients end up committing suicide. The person is usually chained not only during the ‘acute crisis’ but throughout his or her life. To say there is a skills shortage in mental health practitioners in Somalia would be an understatement. WHO say there are only 3 psychiatrists in the whole region and that their skill levels are insufficient. Photo Robin Hammond/Panos. May, June 2011, Somalia. © 2011 Robin Hammond