Until African states face the underlying problems of poverty and social stigma, they cannot address the issue of mental illness.
By Anthea Gordon
The way language is used to conceptualise mental illness is essential to its understanding and treatment. In Lesotho, there is no Sesotho (the local language) equivalent for the English term “counselling”. Instead, a discussion among local health workers leads to a range of alternative expressions, from “Ho tastaisa motho fihela qeto” (to guide someone to reach a conclusion), “Ho thusa motho ho hlokomela” (to assist a person to realise his problem, to solve it and accept it), and “Ho tsehetsa motho” (to support). A study in Uganda sets out to assess levels of depression in a community, only to realise the term “depression” is not culturally appropriate. The terms Yo‘kwekyawa – hating oneself – and Okwekubagiza – pitying oneself – are used instead.
A lack of mental health policy, as well as social stigma, has meant that in much of Africa mental illness is a hidden issue. Without developing a language to discuss the problem, avenues to treatment and understanding of the phenomena in an African context remain seriously under-addressed.
No health without mental health
In most African countries, mental health is seen as a peripheral and isolated issue. With other immediate physical health pressures, such as improving infant mortality and reducing AIDS rates, mental health does not necessarily rank as a priority. However, this approach is deeply misguided. 14% of the global burden of the disease is attributed to mental illness – which includes a broad spectrum of diagnoses, from common mental illnesses such as anxiety and substance abuse, to severe illnesses like psychosis. Mental health well-being is closely associated to several Millennium Development Goals, with areas as broad as education, maternal health, HIV and poverty all entwined with the problems of mental illness.
Dr Stevan Hobfoll, Professor and Chairperson at the Department of Behavioural Sciences at Rush University told me that “mental health is a deeply stigmatised area in most if not all of Africa.” One study in Nigeria showed that the participants primary response to a person with a perceived mental illness was fear, followed by avoidance and anger. This suggests a lack of education about the reality of mental illness. More seriously than this, sufferers of mental illness are vulnerable to human rights violations, to physical and emotional abuse and from discrimination both from health workers and the wider community.
Poverty and mental health
According to Vikram Patel, a Global Mental Health Expert and Professor at the London School of Hygiene and Tropical Medicine, there is “no question that several forms of social disadvantage make people more vulnerable to a range of mental health problems.” Mental ill-health and poverty exist in a “bi-directional relationship”, he said. Crick Lund, Professor and researcher at the Department for Psychiatry and Mental Health, agrees. He told Think Africa Press that poverty and mental health are “completely intertwined”, so people living in poverty are more vulnerable to mental illness, whilst those with pre-existing mental illnesses are more likely to become trapped in poverty due to decreased capacity in everyday functions.
Post-conflict Sierra Leone has established child-soldier rehabilitation projects which provide counselling and support to children traumatised by war, and the prevalence of gender-based violence in the Congo has resulted in the establishment of listening houses where women can talk through their experiences in a safe environment. However, Professor Patel suggests that though war, violence and insecurity lead to an increased risk of mental health problems, the strength of the community in which an individual lives is at least as important. Providing afflicted communities with practical as well as psychological support can mitigate the effects of instability.
Traditional healers provide some support, with a range of treatments including the enactment of rituals which try to maintain the well-being of a whole community. However, their role in healthcare is controversial. Their methods differ from conventional western approaches based on psychiatric science. This has provoked considerable debate about the cultural appropriateness of imposing western ideas about mental illness on Africa, and provoked challenges from western psychologists to the medical success and accountability of healers.
Vikram Patel is positive about the cooperation between traditional and conventional health workers. He says that “traditional medicine already exists alongside biomedical treatment, and complementary healers should be working in a mutually respectful relationship with other health workers as part of the health system, sharing a common goal for helping people address their mental health problems.” Dr Hobfall adds, “the West also have much to learn from Africa in terms of collective spirit and collective support. Often we should be looking at the most healthy communities and families in any culture and model care after them.”
Importantly, the approaches of traditional healers hint at the differing conceptions of mental health throughout Africa. This is in turn indicative of a cultural diversity which requires an equally diverse and sensitive response. The stigmatisation of mental illness is difficult to address, but can only be changed through increased awareness, greater prioritisation of treatment and enahnced support and education. Alongside the complex nature of mental illnesses themselves and their interaction with social situations, there is a need for “multi-sectoral development efforts“, which means there is no quick-fix solution for the problem of mental health treatment in Africa.
Filling the Mental Health Treatment Gap
Faced with the scale of the mental health treatment gap – most developing countries dedicate less than 2% of government health budgets to mental health care – the provision of services needs major development. According to a study by the Grand Challenges in Global Mental Health initiative, the biggest barrier to global mental healthcare is the lack of an evidence based set of primary prevention intervention methods.
Starting to address the research gap is the University of Cape Town’s recent Mental Health and Policy Project (MHaPP), which ran from 2005 to 2010. This aimed to “develop, integrate and evaluate mental health policy” in Uganda, South Africa, Zambia and Ghana. However, Crick Lund, Project Coordinator for MHaPP, explains that once polices are developed they will remain a “largely hypothetical concept” until important “intervention research” is completed to discover how best to translate them into practice.
Without engaging governments and integrating mental health treatment into pre-existing Primary Health Care, little change will occur. In order for integration to succeed, however, attitudes towards mental illness need to be transformed. Practices such as using community health workers and peer-based support to treat less severe mental illnesses offer pragmatic solutions to improving on the significant lack of trained psychiatric specialists. A cross-cultural approach which takes into account the requirements of individual communities is essential. It should also incorporate both local practices and the local languages used to express individual mental health needs. All this is only achievable if mental illness in Africa is promoted as a major health and social priority. The absence of the issue of mental illness from the Millennium Development Goals, the lack of mental health champions in Africa and the lack of a consistent and coherent message about mental ill-health have ensured it has remained untreated.
Slowly, the scale of the challenged posed by mental ill-health is being acknowledged. The World Health Organisation (WHO) recently published the mhGAP Intervention Guide for improving treatment, whilst in South Africa the upcoming conference African Footprint in Global Mental Health 2011 points toward the beginning of a public discussion. Yet this discussion needs to move beyond health specialists and into African governments, communities and the wider global media, so that, hopefully, the mental health treatment gap can be filled. Or as the Sesotho speaking health workers would say, “Ho tastaisa motho fihela qeto.”