The World Health Organization says mental health disorders make up more than 12 percent of all diseases, and will likely rise to 15 percent by 2020. Researchers see a link between poverty and income: poverty may increase the risk of mental disorders, and those with mental problems may not be able to earn an income. Among the areas of the developing world working on establishing better mental health systems is Africa. From Washington, reporter William Eagle describes some of the challenges to improving mental health on the continent – where economic and political instability are common.
Experts say the range of mental illness is roughly the same in the developed and developing worlds – hitting rich and poor, from Hollywood to Bollywood, and from London to Soweto.
The WHO says one in four people will develop at least one mental or behavioral disorder in their lifetime. Sometimes these illnesses are genetic, which may be passed down from generation to generation. And sometimes they may be triggered by traumatic events, including conflict.
Dr. Frank Njenga is the president of the African Association of Psychiatrists and Allied Professions in Nairobi, Kenya.
"[Some of] the biggest challenges in Africa," he says, "are really the relationship and connection between poverty and mental health. The factors that drive poor mental health in Africa are the same as those that drive poverty – wars, internal displacement, HIV/ AIDS and the fact that 60 percent of Africans live below the poverty line. There’s also the fact that so many people who are afflicted by infectious disease, and are so many wars and displaced across Africa. These are the main drivers to depression, post-traumatic stress disorder, alcohol and substance abuse."
Children are a special concern for Njenga. At least 10 percent of all African children are AIDS orphans or child soldiers.
He says, "Anyone who tries to project what may happen to the neglected African child who is a victim or survivor of post traumatic stress disorder, as a result of seeing parents, teachers or siblings mutilated in war…would be guessing."
"One begins to project and understand that in the course of time children who witness genocide in Rwanda are likely to become adults with unresolved grief, PTS disorder, substance abuse issues, depression.… In fact, just thinking about the likely consequences of the traumatic events the African child is going through, we anticipate in 30 years time, we are going to have large African population of deeply traumatized and unstable populations."
It’s not easy to get treatment. Njenga says there’s about one psychiatrist for every half million people in Africa. In Zimbabwe, he says there are only two psychiatrists for every 20 million. Some countries have none at all.
On the other hand, work is being done to make the most of scarce resources. Efforts are being made to integrate mental health into overall national health care systems. Efforts are also being made to decentralize services and bring help to local communities. This means training nurses, health care workers or volunteers to help monitor the mentally ill, or prescribe simple medications. These steps are among the few models being tested in Africa.
Dr. Fred Kigozi is the executive director of the Butabika National Referral and Teaching Hospital in Kampala, and an advisor to the Ministry of Health.
He says one, which has been tested in Nigeria and Tanzania, placed the mentally ill in what were called rehabilitation villages. Kigozi says in Tanzania, the villages offered psychiatric services similar to those in hospitals. Also on staff were agricultural and livestock officers, nurses, traditional healers and occupational therapists. A psychiatrist and medical social worker would make weekly visits.
"These were based on the concept that mentally sick people will be shunned, marginalized with no access to opportunities," he said. "So some researchers asked 'but why keep them in a hospital when they’re symptom free?' So, the concept of rehabilitation villages came in. It was confinement, in a demarcated area and they were assisted maybe to do some gardening. But [the idea] never spread… It was transferring stigmatization from the hospital setting to an [isolated village] which was a no-go area (for those who were not ill)."
Another model being used in Ghana, Tanzania, Uganda and Kenya is called the “sustainable livelihood” approach. The mentally ill are not removed from their home villages, and are supported with consultative workshops and self-help groups. Government and NGO partners provide micro-financing and other training to help patients get back on their feet and regain a measure of stability and independence.
This model, social workers say, is closest to the one encouraged by the World Health Organization. The sustainable livelihood approach brings psychiatric support down to the village level, where medications and other simple assistance can be provided by trained nurses and others working under a psychiatrist.
According to Kigozi, "Instead of having patients in hospital or coming back to the hospital to get drugs, [the scheme asks]: can you organize near-by health centers or through civic leadership, help people access drugs in an easier way. Can you assist them with microfinance so that through their own initiative but with the assistance of a development worker be able to set up an income generating activity? Can you organize them so there is a revolving fund, where some can put in money and buy drugs. "
He says the system allows those mentally ill and their families to serve as role models, encouraging others to get mental help if they need it.
And, it keeps them out of what has become an unpopular remnant of colonial policy – institutionalizing the mentally ill. There, patients live in sub-standard conditions, often without treatment or legal recourse to leave. Health care advocates compare that solution to incarcerating a patient – and throwing away the key. They say advances in mental health care since colonial times have left that solution outdated, and unwanted.