ADDIS ABABA, Ethiopia — There was a young boy in a Manchester United jersey and an old woman whose face was tattooed with an Orthodox cross. There was a businessman in a finely tailored suit and a police woman in uniform. There were two women in black niqab head coverings and two others in short, brightly colored skirts.
It was a Monday morning in October at the Sitota Center for Mental Health Care in the Ethiopian capital and, in the waiting area in front of a bustling reception desk, the weary faces of a rapidly changing nation were on full display.
Although still one of the poorest nations in the world, Ethiopia is the fastest growing economy on the planet, according to the World Bank. That's in no small part the result of decades of international aid, foreign capital and charitable giving that came in the wake of the nation's infamous famine in the 1980s.
That investment has come in big ways, like the $487 million in foreign assistance the U.S. government spent in 2017 on health, education and security projects. And it has come in small ways, like the Utah-based Children of Ethiopia Education Fund, which seeks to help girls from heavily impoverished communities get quality schooling, a mission that costs $30 per child, per month. It has come to address specific crises, as in the case of LDS Charities, which has worked with International Relief and Development to bring water to 22 villages along the drought-striken border with Somalia. And it has come to address broad issues, as is the case for what is arguably the most famous American charity in Ethiopia, Save the Children, which supports myriad projects aimed at health, nutrition, safety and sanitation.
Now those investments are finally paying off. The rapid development has pulled millions out of abject poverty, prompted a mass migration into the nation's urban center, stoked a growing middle class, and put the tools of the information age in the hands of an increasingly tech-savvy population.
But those changes have come with side effects that few saw coming: A skyrocketing demand for psychiatric services that has left mental health providers feeling helpless to keep up. And that could offer some vital lessons to the international community as it looks to replicate Ethiopia's economic "miracle" in other places in desperate need of help.
When Wubeshet Abebaw first sought help for his depression three years ago, he was admitted without delay to Sitota's in-patient treatment program.
"At that time, if you knew that you needed help, and you knew about the center, and you had the money to pay for treatment, it was easy to get help," Abebaw said. "The wait was only minutes."
But when Abebaw returned to Sitota for an emergency visit following a close friend's suicide in late October, the waiting room was packed.
Past the reception desk, in a spartan office decorated with Van Gogh prints, Dr. Yonas Baheretibeb was trying to keep up with the deluge. It was early afternoon, and he was already far behind on appointments.
When Baheretibeb, a jovial and energetic man in his early 50s, began practicing psychiatry in Ethiopia a quarter-century ago, a very busy day might include visits from four or five patients. Today he regularly sees 30 in a day.
And those are the fortunate ones — the ones who recognize they need help, are able to travel to Baheretibeb's clinic in Addis Ababa, and can afford to pay for private medical care. The World Health Organization estimates there are more than 15 million people who suffer from mental illness in the world's most populous landlocked country. But there are only a handful of clinics that specialize in psychiatric care here. And despite an economic boom that some have called a "miracle," in a country still remembered in much of the world as a place of mass famine, it is only a small number of people who can afford the care.
Meanwhile, the number of care-seekers is growing. And fast.
It's not that there weren't mental health problems in Ethiopia in the past, Baheretibeb said. During its modern history, Ethiopia has battled widespread starvation, political turmoil and civil war, with predictable psychiatric consequences.
Ethiopians — among the world's most religious people — have always sought help from their religious institutions, Baheretibeb said. A plurality belongs to the Ethiopian Orthodox Church. There are also substantial populations of Muslims and Protestants. There are Catholics, Rastafarians and a quickly growing number of Mormons.
Confronted by anxiety, emptiness or hopelessness — common symptoms of mental health struggles — most Ethiopians "would first seek relief from holy water," Baheretibeb said.
"They would visit their priest or the leader of their mosque," he said. "And there was absolutely nothing wrong with that approach."
Religious communities can be a powerful force in giving people the support they need to overcome mental illness, Baheretibeb said. Whether one believes in the power of prayer or the power of placebos, he said, "it doesn't matter if it works."
But belief alone, he noted, won't cure everyone.
That was the case for Viti Luwigi's brother, who suddenly began feeling despondent about three months ago.
"First we brought him to the church to pray," said Luwigi, the daughter of an Ethiopian mother and Italian father. "The church father said, 'don't worry, he will be in the healing system very soon. Just keep praying. Pray harder. He needs to tell himself he is fine, and then he will be fine.'"
Although dedicated to her church, Luwigi said she was pretty sure her family was getting bad advice.
"He was only getting worse," she said.
She quickly sought medical help, and was able to secure an in-patient bed for her brother at Sitota. A month later, her brother's health has significantly improved, she said.
"If we'd kept going to the church leaders, he would still be in the same condition, and he probably would be worse," she said.
It wasn't long ago, Baheretibeb said, that when the advice of spiritual leaders failed, Ethiopians just gave into their fates.
"Now when people want more answers, they Google it," he said. "They quickly come to learn that there is medication and treatment for mental illness."
About 15 percent of Ethiopians had access to the internet as of June, according to the United Nations. By way of contrast, nearly 90 percent of neighboring Kenyans are internet users.
But Ethiopia's internet penetration rate was 400 percent higher in June than it was just 18 months earlier. And Baheretibeb said the patients he is seeing are accessing information about mental health in other ways, too.
Several hospitals have held campaigns to raise awareness of the need for mental health care, particularly among the nation's large homeless and refugee populations. National journalists have been encouraged to attend workshops on how to report compassionately on mental health issues.
Awareness is generally a good thing, Baheretibeb said, but in a nation with just a few specialized clinics, it also creates a problem.
"We don't have the capacity," he sighed. "We can't treat everyone who is in need."
Rather than creating hope, the availability of information without the availability of care can create despondency. It might, Baheretibeb said, be making things even worse for some people.
Abebaw said that every time he visits the clinic he sees people who are unable to get an appointment or simply cannot pay.
"It breaks my heart," he said, "because I know exactly what they are going through, and I think 'why do I deserve help but they don't?'"
Luwigi feels the same way. Her brother's 29-day stay at Sitota cost 24,827 bir — about $920. That might be a bargain by American medical billing standards but, notwithstanding the tremendous economic growth it has experienced in recent years, Ethiopia is still a country where a third of the population lives on less than $2 a day.
"We're very fortunate to have the ability to pay," said Luwigi, whose family owns and operates an auto mechanic shop. "If we couldn't help him, if we couldn't afford it, it would be devastating. Seeing people leave the hospital without treatment, outside and suffering, makes me feel very bad."
Ethiopia has a rudimentary socialized medical system that is bolstered by a network of charitable hospitals. Under the tenets of Ethiopia's National Mental Health Strategy, every state-run hospital is supposed to offer mental health services that are "either free or affordable and accessible to all" and "fully integrated into the primary and general health system."
But with copious other priorities — from fighting malaria and HIV to building roads and bridges to providing clean water and electricity to everyone — that goal is still very much a goal.
After two in-patient visits and a lot of follow-ups at the private clinic, Abebaw said, he ran through his savings very quickly. When he went looking for more affordable care, it was impossible to get an appointment with a doctor at a state hospital.
"A whole hospital might have one doctor," he said.
The National Mental Health Strategy, which was adopted and theoretically put into action in 2012, also calls for "close-to-home" care, services that are "culturally and linguistically appropriate," programs that address "skill development and that lead to improved functioning and employment opportunities," and treatment specifically designed to help "vulnerable groups with specific needs."
No one is arguing with the compassion behind those goals but, five years later, access to the most basic of services at public hospitals remains hard to come by. And that has prompted more psychiatrists to hang out a private shingle.
That is how Lebeza Psychiatry Center in Addis Ababa came to get started about a year ago. The center's general manager, Dr. Asmeret Andebirhan, said the rising rate of addictive substance abuse — and lack of resources to treat it — was key in her decision to help open a new private clinic.
Khat, a mild psychotropic plant that is openly sold on street corners across Ethiopia, has long been a concern for public health officials in Ethiopia. Traditional honey wine and beer also factor into the addictive environment.
But as more Ethiopians move to the city, and away from their traditional support networks — and as they have more disposable income in their pockets — Andebirhan said abuse of marijuana, cocaine and other street drugs is rising.
Substance abuse isn't the only mental health problem linked to urbanization. Andebirhan said there are clear mental health consequences when families that have lived in a community for generations are suddenly split apart.
"Raising a child, in the old days, was the responsibility of the society," Andebirhan said. "Neighbors, other mothers, grandmothers and grandfathers, they would all help. But now, because of the distance between families, children are being raised only by their parents."
And those parents, Andebirhan said, are often working multiple jobs. "We're seeing a lot of depression and anxiety in middle-income young women, especially those who are working and who have families and children," she said.
"We've compromised the traditional support system we have," she said. "Our lifestyle is changing. You could say it is changing in a good way. Or you could say it is changing in a bad way. However you see it, it's changing in a big way."
One of the biggest ways Ethiopian lives are changing comes by way of the information revolution.
"Now we have the Facebook generation," Baheretibeb said. "Ethiopians today watch movies from Hollywood and listen to CNN. Everything is more American. The expectation of what mental health treatment looks like is very Western."
But the reality, he said, "is really quite different."
"There's no mediation. There are no appointments available," he said. "There is a big discrepancy between what they see in the media and what they experience in reality. And the reality is that not only are they struggling to get mental health care; sometimes they are struggling to eat three times a day. They aren't just struggling to get treatment for anxiety; they're struggling to find treatment for malaria."
Abebaw, the former soldier who lost a comrade to suicide in October, knows all about how hard it can be to get state hospital treatment for malaria. He's had it — five times.
"And depression is far, far worse," he said. "If I have to choose between depression and malaria, I'll choose malaria."
He manages his depression and anxiety with a variety of prescriptions, now, and "most days are good days, but there are still bad ones."
And the day he learned about the loss of his friend was a very bad one.
That night, Abebaw sat in his car, plugged his headphones into his iPhone, and listened to a recording of the Bible in Amharic. The next day he saw his doctor, who upped his dosage of antidepressants.
Given that there's a long way to go before her nation comes anywhere close to achieving its lofty goals for making mental health care accessible to all, Andebirhan thinks Abebaw's approach — continuing to turn to faith while also pursuing the best psychological care they can find as the country's mental health capacity continues to grow — might be the right one for a lot of other Ethiopians.
"For centuries, we were depending on religion and depending on spiritual practices," she said. "I'm highly supportive of holistic care. The solution, I think, is going to be both a modern and a traditional one."