Omar Ibrahin was once a hard-working tailor at his own shop in Mogadishu, sewing uniforms for the army. As he worked, he hummed and sang to himself.
Then came the war. His shop was looted, his home was destroyed, and he became an unemployed refugee, living at a camp outside the city. With nothing to do all day, he began chewing qat leaves, a traditional drug with amphetamine-like qualities.
His chewing became heavier and his stresses grew worse. Finally he erupted into manic episodes – frantically singing the same songs that he remembered from his tailoring days, unable to control himself.
It's a common story here. After 20 years of war and violence, Somalia has one of the world's highest rates of mental-health disorders. An estimated one-third of its eight million people are affected by some kind of mental illness, yet there are only three trained psychiatrists in the entire country to care for them, according to the World Health Organization.
Many Somalis with mental disorders are simply chained to beds or imprisoned in criminal jails for years, leaving them with permanent trauma and physical injuries. "Degrading and dangerous cultural practices such as being restrained with chains are not only widespread but also socially and medically accepted," the WHO said in a recent study of Somalia's mental health care.
In rural regions, some Somalis with mental disorders are shackled to trees or rocks. Even if they're not chained, they face severe problems of discrimination, stigma, isolation and neglect. Their illnesses are often attributed to evil spirits or curses. Some are subjected to traditional "cures" – including a horrific treatment in which they are locked into a hut with wild hyenas, which are supposed to "eat" the evil spirit.
Mr. Ibrahin was one of the lucky ones. After he began fighting and abusing other refugees at his camp, he was brought to a mental-health institution run by Abdurrahman Ali, a doctor who does not believe in using chains or hyenas. Mr. Ibrahin was given sedatives and regular food, and he was taught to do physical exercises. Within weeks, he had stabilized, and he became the chairman of a committee of patients, supervising their daily chores.
Many others in the refugee camps are facing similar mental illnesses. "If you're only sitting and sleeping and doing nothing else, you think too much," Mr. Ibrahin said. "I was chewing qat because there was nothing to do, there was no work, and I was frustrated. I chewed qat so that I wouldn't have to think."
Dr. Ali, a tireless and passionate advocate for the mentally ill who is known by his nickname, Habeb ("hoarse"), opened his first mental-health hospital in Mogadishu in 2005. He now operates a network of four hospitals and rehabilitation centres, with limited help from the WHO and other international donors.
Post-traumatic stress, linked to the two decades of near-constant war and frequent drought, is one of the main reasons for the high rate of mental illness. Many people have endured torture, rape or crippling injuries, while others have seen their families suffer extreme violence. "A lot of patients have experienced shelling, and a lot have lost two or three family members because of war and hunger," Dr. Ali said.
When he hears of a patient who is chained to a tree or a bed, he sends out a mobile team to rescue them. He shows a video of a woman who was shackled under a bush in the countryside for eight years, and a man who was chained for 12 years. Both were rescued, given treatment and medicine, and recovered their health within a few months.
Lacking medicine and trained staff, some mental-health centres in Somalia continue to chain the vast majority of their patients. Up to 85 per cent are shackled at some institutions, Dr. Ali said. At one institution in Mogadishu, dozens of patients are chained to large rocks and cement blocks.
Overall, the WHO report estimates that 90 per cent of Somalia's mentally ill are chained at least once in their lifetimes.
Even at Dr. Ali's own institutions, despite his opposition to chains, he sometimes restrains a patient who would otherwise become a danger to himself. One patient is chained because he tried to jump over a wall, which could provoke a gunshot from nervous soldiers in the neighbourhood.
When a visitor notices the shackle, Dr. Ali removes it from the patient. "You are free," he tells the man, patting his head. "Don't jump over the wall. There are soldiers here and they don't know your language and they could kill you."
To overcome the isolation and depression of his patients, Dr. Ali organizes a regular quiz day, dividing the patients into two competing teams. He sits behind a desk in an open courtyard while the patients sit in neat rows in front of him, eager for the questions. He asks a series of questions about Somalia's history and geography, and the name of the current U.S. president, while the patients raise their hands and then walk to the front to give their name and their answer. When they get the answers right, everyone applauds, and Dr. Ali shouts "bravo."
The quiz helps to pull the patients out of their withdrawn shells, and they become more open and expressive. When there is an "interval" in the midst of the quiz, a man stands up and sings a song to the patients.
Then a sad-faced woman raises her hand. She tells Dr. Ali that she wants to sing a song "for my husband who hates me."
He encourages her, and she walks to the front of the patients, turning to face them. She begins singing, in a voice that is brave and solemn. "I will not cry for my husband again," she sings. The patients applaud.