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Can an African die of sadness? “I understand that a man hangs himself because his wife left him, he is unemployed, the neighbor bewitched him or he was caught kissing his mother-in-law. But killing yourself because you have depression is just not African,” wrote Kenyan satirist Ted Malanda in 2014. We must believe, he added, that some diseases only strike wazungu or middle class “. In short, the whites or the rich, those who can afford the luxury of consulting.
Taken from a column published in the daily The Standard shortly after the suicide of the American actor Robin Williams, the demonstration while clichés had caused controversy. This was precisely his goal: to magnify the line, to make fun of the taboo that surrounds mental illness to better subvert it. “In Kenya, like everywhere in Africa, depression and mental disorders are misunderstood, stigmatized, stifled by families”explains the columnist to the World. And even if today “the media treatment of suicides has changed, that there is more understanding and empathy, including in the school system, the infrastructures are still not up to scratch”.
Nairobi, the Kenyan capital from which Ted Malanda writes, is however not the worst off in Africa. According to the latest mental health atlas published by the World Health Organization (WHO), Kenya and its approximately 53 million inhabitants had more than 8,000 dedicated health professionals in 2020. Mali, with a population barely half as large, counted 46 in the same year. More generally, for the whole of Africa, only one psychiatrist practices, on average, for 500,000 inhabitants. A figure 100 times lower than international recommendations.
The needs may be immense, but mental disorders remain the poor relations of public health policies. The wandering of the sick in the big cities of the continent is “an invariant of African urbanity”underlines the Cameroonian anthropologist Parfait Akana. ” Since my childhoodhe says, I see people naked in the street, I see them eating in garbage bins, defecating in the middle of the road, rolling in the mire, copulating in public, attacking passers-by. I also hear stories of mad women being raped, mad people being murdered for ritual purposes. These patients are only really a subject of attention during major events where it is a question of “eviction” and “sanitation” of the city. »
Highest suicide death rate in the world
According to the WHO, African states allocate an average of $0.46 per capita to their care, “well below the recommended $2 per capita for low-income countries”. This under-investment, correlated with the many crises that cross the continent, has caused Africa to record the highest rate of death by suicide in the world, as the WHO pointed out in a press release on October 6, calling “to end the suicide and mental health crisis in Africa”.
A phenomenon that particularly affects the over 70s. And “this is only the tip of the iceberg”believes Florence Baingana, regional adviser for mental health and addiction at the WHO, who pleads for a drastic increase in investment in prevention programs.
But the scholarships are not expandable: the bulk of resources and the attention of donors remain focused on infectious diseases, which are very deadly, such as malaria, AIDS, tuberculosis, measles, Ebola or, more recently, Covid. -19. However, some programs devoted to the fight against drug addiction, few international partners have funds dedicated to psychiatric disorders.
In recent years, however, several African countries have placed mental illness on their political agenda. In 2021, five-year action plans were voted on in Kenya and Uganda, while Ghana and Zimbabwe are working with the WHO to develop their healthcare offer. “French-speaking countries are a little behind”remarks Florence Baingana.
Decompartmentalize the discipline
It has not always been the case. In West Africa, Senegal has long been seen as a pioneer state. Under the guidance of French psychiatrist Henri Collomb and his Senegalese colleague Moussa Diop – co-founders of the journal African Psychopathology –, the Fann university hospital center in Dakar made a name for itself by defending a practice that broke with colonial psychiatry. Like Thomas Lambo, Nigeria’s first psychiatrist, the “school of Dakar” wanted to be attentive to the socio-cultural environment of patients and open to traditional medicines. It spread in the 1960s and 1970s to other French-speaking countries such as Burkina Faso and Côte d’Ivoire.
But the model, for lack of means, ended up showing its limits. “Until the 2000s, in Senegal, psychiatry was really the business of psychiatrists, explains Doctor Jean-Augustin Tine, head of the mental health division at the Ministry of Health. We had a very institutional approach to the management of mental illnesses, whereas in other countries in the sub-region, such as Nigeria, a more community-based approach was preferred. »
To decompartmentalise the discipline, a turning point was taken in 2019 to train “front-line workers” who work in primary health centers to recognize illnesses such as schizophrenia, depression or bipolar disorders. An awareness-raising and training program for “community actors”, particularly from associations, has also been launched.
In many West African countries, the management of the mentally ill still largely depends on religiously inspired associations. Pentecostal churches are thus dominant in Madagascar. The “prayer camps”, where the “mad” are chained, still exist on a large scale in the Gulf of Guinea. It is to put an end to these degrading treatments that the Beninese Grégoire Ahongbonon, a former tire repairer, created, in the 1990s, the Saint-Camille-de-Lellis Association, which today manages seven centers in Côte d’Ivoire, as many in Benin and three in Togo. Tens of thousands of patients are treated there, with varying degrees of success.
“In absolute terms, NGOs like Saint-Camille do good”, concedes Jean-Augustin Tine. However, the Senegalese psychiatrist regrets that these establishments are not “stowed” to the health systems of the countries concerned. Institutions and associations can work in harmony. It is even necessary, believe more and more health professionals, given the popularity of centers of religious inspiration and traditional medicines. “70% of patients have recourse to traditional healers before coming to see us. Many go back and forth, observes Doctor Tine, convinced that attitudes are changing.
Summary of our series “Africa in therapy”