By Reuben Abati

THE report this week that medical doctors are seeking the passage of the Mental Health Act, which has been before the National Assembly for eight whole years, is interesting, but the doctors' demand does not go far enough. They want a Mental Health Act focussing on the mode of practice for medical doctors, but what is really required is not just a code of practice, but a law on mental health, which emphasises this important aspect of medical practice in Nigeria and seeks particularly to raise standards. Do I need to remind us that this is essentially a country of mad people? The refusal of the lawmakers to consider the Mental Health Act is in part a reflection of public attitudes towards mental health in our society.

Nobody wants to be associated with madness. It is considered a stigma. And yet running up and down our streets are persons who are suffering from all kinds of neurotic psychosis. In transforming the health profile of this country, the challenge of mental health must be addressed. Yesterday, a certain Professor Emmanuel Ekanem, writing on the opinion page of The Guardian ("Healthcare Services: We have made progress") had argued that Nigeria has made a lot of progress in healthcare services in the last eight years (I disagree with him and I guess many others would. He talks about machines being bought and acquired, and surgeries that can be done, but he does not talk about the quality of medical services and access to affordable healthcare). However, it is noteworthy that he does not write about progress in relation to mental health services.

The first Neuro-Psychiatric Hospital in Nigeria was established in Abeokuta in 1944 by the colonial authorities, Before then, there was a sanatorium in the Eastern part of the country. Since then, a number of other psychiatric hospitals have been set up, but for the most part, policy makers overlook mental health facilities. They are hardly remembered in the budget for health. Nigeria is a signatory to many protocols on the need to place greater emphasis on mental health care as a component of a national health policy. But the reality is that mental health care is treated as a fringe aspect of medical practice and public health governance. Government is more likely to devote resources to the treatment of malaria, HIV/AIDS and other health conditions., albeit inefficiently even in that instance. The official attitude is one of neglect resulting in a situation whereby the nation's Neuro-Psychiatric hospitals are cash strapped, under-equipped and conveniently overlooked.

Two years ago, the administrators of the Federal Neuro-Psychiatric Hospital in Enugu considered the option of raising funds publicly in order to be able to provide basic facilities needed for the running of the hospital. But how many Nigerians will publicly donate money to a mental home? Other Neuro-Psychiatric hospitals are similarly poorly circumstanced. Better funding of mental health hospitals is necessary in order to address the challenges of infrastructural inadequacy. But the starting point is for government at all levels to see a connection between the status of mental health care in the country and the health of the Nigerian society, and a national mental health policy, codified as law, which treats mental health care as a component of primary health care. Many of the persons in need of mental health care are in places where their only contact with orthodox care is at the primary health centre. A greater majority also includes persons in high places who would rather not be seen near a mental home because of the stigma. The proposed law must deal not just with practice, but also, this stigma and the narrow conception of mental health which is at the heart of the problem.

Ocassionally government, public figures and government officials express concern about the mental health of the Nigerian society and its people. Please remember that President Olusegun Obasanjo was one of the first persons to ask for a psychiatric examination of Nigerian leaders. Tongue in cheek? Current EFCC Chair, Farida Waziri has also made a famous statement about madness in high places. Definitely, all those people stealing more money that they can use, or that their children can spend in three generations are mad, all that they need is just official certification and treatment. Long before now, precisely on October 22, 2007, the Ogun state Government announced a decision to subject traffic offenders in the state to compulsory psychiatric tests. Such offenders would only be allowed to drive again in the state upon the presentation of a certificate of mental fitness duly issued by the Neuro-Psychiatric Hospital, Aro, Abeokuta. Nothing has been done in this direction obviously.

And there is nothing original in both the stament and the inaction of the Ogun state goverrnment. Two years earlier, a similar measure was announced by the Bola Tinubu administration in Lagos state. And with the return to democratic rule in 1999, and the misconduct of the political elite, one of the recurrent suggestions about how the political leadership elite can be made to behave more decently and responsibly is the demand for psychiatric tests for public officials.

There is an almost universal concensus that Nigeria is one vast sanatorium, from the okada rider who terrorises commuters and motorists alike, to the service provider who abuses you instead of providing service, to the pastor who tells you that if you subsidise him with your hard-earned resources, God will bless you ten-fold, to the police man who pushes a gun in your face at the slightest provocation and threatens to shoot, to the politicians who tell lies as a matter of course, to the motorist dead drunk with high pre centage alcoholic beverage, but who seizes the wheel and announces that the Lord is in charge, to the careless pedestrian who ignores the footbridge and rushes across the highway on foot, insisting that he is covered by the blood of Jesus! ..Should I add more?

Nigerians love to talk about madness. Mad persons have become part of the tourism scenography of Nigeria. They provide entertainment to those with a morbid sense of humour. There are parts of Lagos where mad men control the traffic at major junctions, and supposedly sane motorists have been heard to remark than mad men are better traffic controllers than the Nigerian police!. Often times, the lunatics on the roads are knocked down by hit and run drivers and their corpses are left to rot in the open. Female lunatics are raped by morbidly randy men.

There is a romantic appeal of madness in the land because it is seen as something external, whereas it is an inherent, widespread reality which must be tackled at the level of policy and concrete deliverables and action. I shall explain this presently. The biggest threat to mental health care in Nigeria is the stigmatization of mental ill-health, and a lack of understanding of its meaning and nature. The average Nigerian does not want to be seen with a mentally ill person or be associated with anything that is remotely suggestive of madness. The level of community intolerance is so high, and this has implications for the treatment of mentally ill persons or the integration of mental patients into society. And yet madness pervades the land.

The classic image of madness is that of the vagrant psychotic on the streets of our cities, dressed in rags, or naked, looking filthy, seemingly lost to society and self. The instinctive reaction is to keep away from such persons. To refer to someone as an "Aro or Yaba" patient is considered a grave insult indeed. The effect therefore is one of wilful denial, with lawmakers avoiding a discussion of the Mental Health Bill, lest their interest in the matter be misconstrued. Surely, the notion that mental health refers only to psychosis and neurological disorders is wrong. Mental health as a holistic concept covers a broad range of behavioural disorders which include stress management, personal care and identity, social relations, schizophrenia, bipolar disorders, depression, dementia, insomnia, hallucination, as well those affective disorders that may be occasioned by health conditions such as diabetes, HIV/AIDS and hypertension.

Explained properly to the public, the understanding of mental health care in Nigeria should improve, even if cultural and religious prejudices often mutate as worldview. Nonetheless, many Nigerians may well begin to realize that most of the otherwise healthy-looking persons in our society are actually in need of psychiatric help, and that there are more mad persons in fine clothing than there are under the bridges. Nothing poses a greater threat to the provision of mental health services in Nigeria than the attitude of society itself. Mental health refers to a holistic concept of well-being, it is at once cultural, sociological, educational and even spiritual. Incidents or circumstances which inhibit or destroy the capacity of the mind to develop and function effectively, relative to given social and cultural contexts, point to a state of mental morbidity. This is a national challenge which can be addressed thorugh a properly articulated policy and the political will to act.

However, the key activity is in the area of good governance. There is incontrovertible evidence, I dare say, at the risk of repetition, that the misgovernance of the Nigerian state is directly related to the rise in the crisis of mental morbidity. The spread of poverty, unemployment, the people's deprivation in the face of so much wealth, their lack of faith in the system, the alienation between government and the people, the loss of opportunities, the uncertainty of Nigerian life, discrimination against persons: all these have combined to produce a Nigerian populace that is insecure and anxious. The healthcare system is in itself comatose. The justice administration system has also become a factory for the production of psychotic patients as every encounter with the justice system from the police station to the prison seems to have been constructed to destroy the individual's sanity.

Reports of behavioural disorders have therefore not only become common and regular, lunacy is taken for granted as a necessary condition in Nigeria. Every psychotic conduct is easily attributed to the devil or the enemy, to witrches and wizards, who will have to be confronted with "Holy Ghost Fire"but what is at play mostly is the manner in which the Nigerian environment defines and conditions mental health. The level of anxiety and neurosis in the Nigerian environment can be reduced by a more people-oriented governance system. A national mental health policy, and a more qualitative national health care system should become part of the political agenda.

John Russell once remarked: "Sanity calms but madness is more interesting." Poets and philosophers are fond of romaticising madness. Aristotle once observed for example that "no great genius has ever existed without some touch of madness".

In Nigeria, the major challenge does not lie in the romantic appeal of madness, but in creating a much saner society by deepening the quality of, and access to mental health services, and developing strategies for the communal tolerance and understanding of mental health. Developing a pro-active national mental health policy must be based on the principle that mental wellness is useful to society.

Robot  # 1 | 24.10.2008 07:26

Beyond the romantic appeal of madness By Reuben Abati THE report this week that medical doctors are seeking the passage of the Mental Health Act, which has been before the National Assembly for eight whole years, is interesting, but the doctors' demand does not go far enough. They want a Mental Health Act focussing on the mode of practice for medical doctors, but what is really required is not just a code of practice, but a law on mental health, which emphasises this important aspect of medical practice in Nigeria and seeks particularly to raise standards. Do I need to remind us that this is essentially a country of mad people? The refusal of the lawmakers to consider the Mental Health Act is in part a reflection of public attitudes towards mental health in our society. Nobody wants to be associated with madness. It is considered a stigma. And yet running up and down our streets are persons who are suffering...Read the full article.

akuluouno  # 2 | 24.10.2008 09:09

Dear Sir, Thanks for another enlightening article. Formulation of a national policy on mental health is long ovedue. You will be surprised how many people are mad especially among the elites. Rather they hide under the veil of religion, culture/tradition, and immunity to perpetrate their madness on society. I think mental health care should be a canon of the national primary health care delivery. Politicians, drivers especially molue and okada, some villagers:D and those too numerous to mention need some madness reduction tonic:evil: I exempt some genuises like one Van Gogh:source, an artist who saw the world through the eyes of a madman out of this analysis. Thanks.