Mentally Ill, Alone and Forgotten – Seite 1

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A woman slowly and silently stretches her skinny arm through the closed lattice gate. A few steps further on, a man is trying to push his head through the bars of a window, screaming in a drawn-out, hoarse cry. Gaunt figures lie about on the cement floors of two courtyards, each measuring roughly eight-meters (26-feet) square. The men are on one side, the women on the other. Some of them rise up from the ground, hoping to touch the visitor – or speak with him.

Everything about the place is reminiscent of a badly run-down prison: the bars, the metal beds, a room smelling strongly of excrement. But this is not a correctional facility. Rather, it is a provincial hospital – and it is the only hospital in Nakuru, the large city in western Kenya, that has a psychiatric ward.

"Many families drop off relatives here and then never come back," says the nurse who is leading the visitor on a tour and who does not wish to be identified by name. She points to a woman lying listlessly on the ground and says: "She is from Rwanda and has been here for 10 years." The ward primarily treats psychosis cases and acute depression using medication and sometimes electroconvulsive therapy. Apart from the nurse, the only other non-patient present is a burly security guard. The doctor, the nurse says, has no time at the moment. There is just one doctor on staff for the facility's more than 40 long-term patients, the nurse says, and she is also responsible for the 200 walk-ins each day.

The state-run facility is an extreme case, but far from the only such instance. One reason is that for years, Kenya's focus – with the support of the WHO and other international donors – has been on controlling deadly diseases. First came illnesses like malaria, tuberculosis and HIV, for example, before the spotlight later shifted to chronic, non-infectious maladies like high blood pressure, diabetes and cancer. Mental illnesses were ignored for far too long. The consequences can be seen today: There are only an estimated 100 psychiatrists in the entire country, which means that each mental health expert is responsible for an average of a half-million people. The health-care gap in mental health is thus higher than in almost any other sector of clinical medicine.

A trip through western Kenya, from the city of Nakuru via Eldoret and Turbo to the rural hinterlands, shows that in many places, there is a lack of knowledge, financial resources, trained experts and belief in psychological care. Despite the fact that mental illness is one of the most serious health care challenges in the world, millions of people in Kenya suffering from schizophrenia, epilepsy or depression have no access to adequate care. But the trip also demonstrates that the situation is improving.

Private Clinics: Dignified but Expensive

Not luxurious, but humane: The Lighthouse Hospital © Jakob Simmank für ZEIT ONLINE

A four-hour drive north of Nakuru is the private Lighthouse Hospital and Rehabilitation Centre, suitably isolated in an affluent neighborhood of Eldoret, surrounded by large homes with fenced yards. There isn't even a sign hinting at the clinic's presence and the guard only opens the black iron gate when a car turns into the driveway. The parking lot in front of the single-story rambler is surrounded by a boxwood hedge and occupied by a classic Mercedes. The grass is neatly mowed while a vegetable garden supplies the kitchen with cabbage and other greens. Inside, the rooms are clean and orderly, and patients are sitting in a common area watching a Tom Cruise action movie. The patients receive both individual and group therapy and have access to the yard for fresh air. In addition to psychologists and specially trained nurses, there are three psychiatrists on staff, each of whom cares for around 20 patients.

Emadau Papa is one of the psychiatrists. In addition to his job at the Lighthouse Hospital, Papa also works at the state-run hospital in Iten, an hour's drive from Eldoret. There, he is the only psychiatrist on staff and can see the shortcomings on a daily basis. "The number of patients has been rising for years," he says, "and we don't have our own unit, we don't have enough personnel and drug availability in the hospital pharmacy is also insufficient." For years, the local government has been promising him dedicated rooms for his patients along with specialized nurses. Meanwhile, the Lighthouse Hospital is completely different. On the afternoons that he works here, he says, he has plenty of time for his patients in addition to well-trained colleagues and enough medications. It is a situation that really should be the norm.

Unfortunately, only a small minority of generally affluent Kenyans can afford such care. The costs for private clinic care often rise into the hundreds of euros and are not always paid for by health insurance – which many Kenyans don't have anyway. In more rural areas of Kenya, where many people work their own land and live in poverty, other approaches are needed.

Nurses Are Expected to Treat the Mentally Ill Too

AMPATH informs locals about mental illness and other maladies in a village church. © Jakob Simmank für ZEIT ONLINE

An hour and a half by car from Eldoret, among the vast corn fields and sizeable herds of sheep beyond the village of Turbo, the asphalt road gives way to a red, gravel track. A mud-walled church with a roof of corrugated sheet metal stands next to a small river, surrounded by simple stone houses. Two dozen men and women have shown up, some in sweatpants, others in traditionally colorful robes. They are discussing how the money collected by parishioners should be used as they wait for representatives of the healthcare program AMPATH to show up, who arrive before long in two white Land Rovers. They start off by talking about how to avoid becoming infected by HIV and dietary measures for preventing diabetes. A psychologist then moves on to discuss mental health, hoping to sensitize villagers to illnesses that many here don't consider to be illnesses. In large parts of Kenya and sub-Saharan Africa, mental illness has long been associated with demons or considered divine punishment, while prayer, exorcisms and other rituals – and not psychiatrists – have been seen as the only cures. At the end of his presentation, the AMPATH team conducts one-on-one discussions and uses a questionnaire to try to find those who may be suffering from psychological ailments.

The idea for doing so comes from Edith Kwobah. It is fundamentally necessary that more psychiatrists be trained in Kenya, says Kwobah, a psychiatrist from Moi University in Eldoret, but "at the same time, we have to decentralize treatment." Even doctors who don't go on to become psychiatrists, she says, should be taught how to treat mental health patients whose conditions are not severe. It is the same principle as having nurses head up small medical practices in rural areas – or Clinical Officers, of whom there are many more in Kenya than fully trained doctors.

It is an approach that the WHO has been promoting for the past decade. In 2008, WHO the group published precise instructions for training non-specialists in recognizing and treating mental illnesses. The guidelines include typical symptoms and treatment strategies: How can you involve friends and family in the treatment of a patient suffering from depression? What drugs are available and how should they be dosed?

Kenya's Best-Known Psychiatrist Is Optimistic

Between corn fields and cattle herds: An hour and a half from Eldoret, not far from Turbo, AMPATH seeks to educate the populace. © Jakob Simmank für ZEIT ONLINE

Frank Njenga is convinced that such programs are the key to better care. Ten years ago, the Kenyan psychiatrist himself was part of a project that trained more than 4,000 Clinical Officers in rural Kenya (World Psychiatry: Jenkins, Njenga et al., 2010). Njenga is one of the best-known psychiatrists in sub-Saharan Africa. He has had his own television show for years, in which he educated viewers about mental illnesses, and he has also long lobbied the Kenyan government to invest more money in mental health (British Journal of Psychiatry: Njenga, 2002).

Despite all of the problems, Njenga is optimistic. Already, the situation for the mentally ill is much better than it has been in recent years. When asked when those improvements began, Njenga has a surprising answer. "Ironically, it started in August 1998, when – almost simultaneously – two car bombs exploded in front of the U.S. embassies in Nairobi and Dar es Salaam," he says, referring to the capital cities of Kenya and Tanzania. Hundreds were killed in the Islamist attacks and they triggered a broad public discussion about trauma and the psychological consequences that result. "That normalized the discussion about mental illness," says Njenga. Since then, he adds, the stigma attached to such maladies – supported by the internet – has waned as knowledge has increased. The number of trained psychiatrists may only be rising slowly, he allows, but there has been "an exponential increase in the number of clinical psychologists." And last year, Njenga says, the amount of money the Kenyan government spend on mental health finally increased.

All of those developments are cause for hope. And they are consistent with the extremely ambitious goal the Kenyan government set for itself this year: Guaranteeing all Kenyans access to medical care as soon as possible, including for mental illnesses. It may still be unclear exactly how the country intends to do so, but it is a clear shift in priorities.

Translated by Charles Hawley.

Note: The writer is a winner of the 2017 media prize presented by Deutsche Stiftung Weltbevölkerung (DSW). The prize was awarded as a reporting stipendium, which covered the costs of the trip. The DSW, however, had no influence on trip planning or on the content of the resulting article.