Mr. Malanda’s scornful quip captures the general African attitude, held as much by officials as by ordinary people, towards an epidemic of mental illness on the continent.
In Mr. Malanda’s own country, which is one of the more stable in Africa, health experts have estimated that a fourth of the Kenyan population of 44 million suffers from a range of mental diseases, including schizophrenia and other psychotic disorders, bipolar disorder, depression and severe anxiety.
Kenya has only about 80 psychiatrists and 30 clinical psychologists, fewer than its 500 psychiatric nurses, of which only 250 work in mental health. According to the World Health Organization (WHO), yet the country spends only about 0.05% of its health budget on mental health. About 70% of mental health facilities in the country are located in the capital, Nairobi.
The mental health sector is only marginally better in more prosperous South Africa, which boasts 22 psychiatric hospitals and 36 psychiatric wards in general hospitals. Inequality, however, skews these facilities in favour of only about 14% of the population of 53 million, of which one-third are afflicted with mental diseases, according to experts.
About 75% of mentally ill South Africans have no access to psychiatric or therapeutic care, experts say. The National Health Insurance programme, which could boost access to mental health care, will not be fully implemented until 2025, perhaps later.
Oil-rich Nigeria offers a more dismal picture. Both South Africa and Kenya have more psychiatrists per capita, as well as more psychiatric beds per capita. The WHO estimates that fewer than 10% of mentally ill Nigerians have access to a psychiatrist or health worker, because there are only 130 psychiatrists in the country of 174 million people. WHO estimates that the number of mentally ill Nigerians ranges from 40 million to 60 million. Disorders like depression, anxiety and schizophrenia are common in Nigeria, as in other countries in Africa.
In 2012, Ghana took a significant step forward in addressing the nation’s mental health when it passed Act 846, also known as the Mental Health Act, becoming one of the few countries in Africa to set out a mental illness policy.
Early that year a report by Human Rights Watch (HRW), a non-governmental organization, estimated that 2.8 million Ghanaians (out of a population of 25.9 million) had mental illness.
Ghana has three psychiatric hospitals and about 20 psychiatrists currently. The HRW report cited the then-director of Accra Psychiatric Hospital, Dr. Akwasi Osei, as saying that drug-related psychosis affected 8–10% of all mental patients, while 20–30% of patients were diagnosed with schizophrenia, 20% with bipolar disorder, and 15–20% with major depression. Sadly, 97 out of 100 mental patients who need health care have no access to these services.
Some politically stable countries that have enjoyed economic growth in the past decade also report high incidences of mental health disease, often linked to narcotic use. In Kenya, Nigeria and South Africa triggers of mental illness such as unemployment and violent crime are at critically high levels. The mental health picture is far worse in poorer countries, especially those that have recently experienced civil wars and conflicts, including Liberia and Sierra Leone.
Sierra Leone was a mental health pioneer in Africa. The British established the Kissy Mental Home (now Kissy National Referral Psychiatric Hospital) more than 100 years ago, describing it in an inscription as the “Royal Hospital and Asylum for Africans Rescued from Slavery by British Valour and Philanthropy”. A place of confinement for traumatised freed slaves repatriated by British abolitionists, it was sub-Saharan Africa’s first, and for many decades only, Western-style mental hospital.
It remains Sierra Leone’s only psychiatric hospital. There were a total of 104 patients at the hospital in 2015, of which 75 were men. Most of them were 40 years old or below. Patients live in deplorable conditions, and several of them wear chains.
A 2016 report by Sierra Leone’s auditor general states that the hospital does not have a trained psychiatrist except for Dr. Edward Nahim, who is on contract since he retired years ago, and three psychiatric nurses. There is no clinical psychologist, no social worker, no occupational therapist, and no medical officer. The hospital is in a near-derelict state, and parts of it are in total disrepair.
The WHO estimated early this year that 450,000 people in Sierra Leone—which has a population of just over 7 million—suffer from depression every year, and that 75,000 suffer from schizophrenia. There are only 250 hospital beds for psychiatric patients in the country.
Sierra Leone emerged from a brutal civil war 14 years ago. A 2002 report by Dr. Soeren Buus Jensen for the WHO estimated that 400,000 of the country’s citizens suffered from mental health disorders like depression and post-traumatic stress disorder—partly the result of their exposure to “severe potentially traumatic events” during the war. Sierra Leone’s best treatment institution for mental illness is the privately owned City of Rest, which has 70 rooms, and began as a Christian charity.
The mental health picture in Liberia, which similarly suffered a prolonged civil war, may be worse. Dr. Bernice Dahn, Liberia’s minister of health, stated in October 2015 that 400,000 Liberians (out of a population of about 4 million) suffer from various kinds of mental illnesses. About 43% of 1,600 households surveyed in 2008 met the diagnostic criteria for serious depressive illness, major depressive disorder or post-traumatic stress disorder.
Liberia’s only psychiatrist, Dr. Benjamin Harris, told the Voice of America in 2010 of the growing problem of drug addiction linked to mental illness among young Liberians. He said that 27% of those surveyed out of 1,600 households had had “substance-abuse related problems.” He added that substance abuse was a growing problem in Liberia and warned that the situation could get worse.
Liberia has only one psychiatric hospital, E. S. Grant Mental Health Hospital, now part of the government-owned John F. Kennedy Medical Center in Monrovia. It has 80 beds and housed 68 patients (48 males) in October 2015. The country has no rehabilitation centre for drug users.
The widely held view in Africa that mentally ill patients brought the disease upon themselves by using illicit drugs may be one reason African governments do not prioritize mental health.
Experts have also pointed to a tendency in Africa to view acute mental health diseases as supernatural afflictions that can be cured only through spiritual or traditional medicinal interventions. Families of the mentally ill often turn for a cure to these interventions, or to “prayer camps”—retreats where the sick person is often chained to trees and prayed for. This practice is especially prevalent in Nigeria.
The most visible sufferers of mental disease—those often seen roaming the streets of overcrowded cities in Africa—are poor and unemployed, and are therefore designated as vagrants. Vagrancy is a crime in many African countries, which is why many mental health hospitals in Africa serve as prisons—places where poor and vagrant youths are chained, away from respectable society.
In September 2015 the United Nations General Assembly included mental health and substance abuse in the global Sustainable Development Goals, marking the first time world leaders recognized mental health as a global priority. African countries can begin to act on this recognition by increasing their spending on mental health; currently African countries dedicate on average less than 1% of their health budgets (themselves minuscule) to mental health, compared with 6–12% in Europe and North America.