Good morning Hank, it's Tuesday. Sara and I spent last week in Sierra Leone learning about the healthcare system there and along the way we visited Kissy Psychiatric Hospital-a 199 year old facility that is the only mental health hospital in the country.

This was of some personal interest to me because I have been, at one level or another, a psychiatric patient for most of my life.

The hospital is led by Dr. Abdul Jalloh, one of the only psychiatrists in Sierra Leone-a nation of over seven million people.

He explained that as recently as a year ago, life in the hospital was extremely dire for both staff and patients.

"No medication. No water supply. No electricity. The toilets were not functional. Almost everything was in a state of collapse."

Dr. Jalloh keeps a picture in his office to remind him of what the hospital looked like recently. It was truly horrific.

Perhaps most disturbingly, many patients were chained to their beds for much of the day and night. As we walked around, a staff member showed me a poster about chaining that had been sent to the hospital years ago. The poster was really frustrating to the staff because everyone wanted to end chaining but without medication or any functioning infrastructure, they couldn't find another way to keep aggressive patients from harming themselves or others. They didn't need posters-they needed support.

The staff walked me through one ward where the tile had been broken up to prepare for renovations but otherwise it looked as it had for decades. We visited what was, until recently, the hospital pharmacy and I was told that these shelves had long been nearly empty.

I mean imagine no water for showers or to flush toilets. No medications to treat the immensity of psychic pain. Very few clinicians to offer cognitive therapy and no electricity.

There were generators-two huge ones donated years ago by a charity-but they turned out to be much too powerful for the hospital's electrical grid and shorted everything out. Had the charity asked, the staff would have explained what kind of generator they needed.

But no one asked--at least not until Partners in Health began working with Sierra Leone's Ministry of Health, along with Dr. Jalloh, his staff, and the patient population to improve the hospital.

They brought in the right generator and now the hospital wards have lights and functioning fans. They also worked increase staffing at the hospital and brought medications in-hundreds of medications actually, stored in a climate controlled room.

The beds and mattresses were replaced and running water was restored so that toilets and sinks and showers would work again. And because medications and other treatments are not available, many patients have been able to move out of the hospital and live at home.

As one nurse explained to me, "We have patients that are now working in offices. Some are doing their businesses and also doing well in their daily activities."

Just a year ago, almost everyone who received care from Kissy stayed at the hospital. Now most of their patients are able to live at home and, criticially, the practice of chaining has ended. Patients now walk freely about their care area and when patients do become a threat to themselves or others, humane restraints are used. But even that is now rare.

Several patients took the time to talk with me and one long-term patient spoke of how life has changed at Kissy in the past two years: "We enjoy the lights. We enjoy the fans. We enjoy the television. We enjoy our new beds you [helped give to us]."

Of course no one wants to be a patient at a psychiatric hospital. Chronic mental illness is extremely difficulty to live with, even in the best of circumstances.

And there is still a long way to go at Kissy-more areas to be renovated and opened, including this room which will become a lecture hall to train the next generation of Sierra Leonean clinicians and this soon to be opened ward that will serve as the country's first dedicated drug addiction rehabilitation center.

And as Sierra Leoneans begin to trust that the mental health care system can offer effective treatment, the demand for services will continue to rise, which will lead to new challenges.

But the transformation so far is truly profound and it has immeasurably improved the lives of the patient population here.

I feel a kinship with them because I owe my life to effective mental health treatment. The kind of treatment that these patients are at last beginning to receive.

We saw again and again in Sierra Leone that individual interventions of poster campaign, a donated generator often failed to be transformative, in part because it's not one thing or another that needs to change--it's the system.

The problem isn't infrastructure or chaining or staffing or medicines or running water or electricity--all of this must change together. Isolated investments often yield isolated results but if you invest in systems, you can get systemic results-and by investing I don't just mean money. I also mean investing the time and attention to listen carefully rather than just barging in with preconceived solutions.

That's what our community has learned from working with Partners in Health for the last decade. PIH is successful because it builds systems and because it listens to the people it seeks to serve. It's no coincidence that 96% of PIH Sierra Leone's employees are Sierra Leonean.

In the coming months and years, Hank and I will be focusing more on providing ongoing, long-term support to strengthen the health care system in Sierra Leone and that will be the biggest project we've ever undertaken on this channel by far--which is intimidating, but the need is immediate and it is critical.

And when I look at what the staff and patients at Kissy Psychiatric Hospital have accomplished in the last two years, I know that real change is possible.

We'll be talking much more about this in the coming months but in the meantime, I really hope you'll sign up for our new newsletter about the Sierra Leone project to learn more. There is a link the doobly-doo below. I will also be in comments to answer your questions. Lastly, a huge thanks to everyone at PIH and Kissy Psychiatric Hospital for sharing their time, experiences, and expertise with us.

Hank, I will see you on Friday.