World Mental Health Day, 10th October 2021 (3) Mental health in Nigeria

11 October, 2021

Neil,

Thank you for sharing this interesting article that looks at one of the very sad consequences of Nigeria’s weak health system and lack of a modern Mental Health Act, that meets global acceptable standards for caring for Nigerians with mental illness.

It is a long story that has been tragic for patients with mental ill health for centuries dating back to when the British colonialists constructed the country Nigeria from two separate entities, referred to as Northern and Southern Protectorates. The North was governed themselves using Islamic Law, while the South had their Traditional Cultural customary Laws. The British had their own British Laws, therefore on colonizing and amalgamating the North and Southern protectorates they created a country with three sets of Laws. The Criminal code was created in 1916 in their attempt to harmonise the three Laws in their new territory. That was the beginning of criminalizing mental health. In 1958, a Lunacy Act was enacted partly in response to decades of complaints by several local and external groups about the inhuman act of criminalizing an illness : ‘Lunacy Act defines mental illness as lunacy; and according to this law, ‘lunatic’ includes idiots and any persons with unsound mind, i.e. (a) it is discriminatory and discretionary in nature; (b) it is far from the World Health Organization (WHO)’s definition and description of mental health and persons who suffer mental health issues; and (c) it is derogatory to people with mental health needs which is a violation of human rights’’ (Sanni et al. and Westbrook ).

The consequences for mentally sick patients is tragic, including that the Lunacy Act ‘does not give protection to the persons who fall under the category of lunatic, does not separate mental health institution from criminal justice system, and the so-called ‘lunatics’ were often mistreated as criminals even though they were just mentally ill, they are detained in asylum without therapeutic treatment (Heaton). The Act also states that a person who is found to be lunatic will be detained with or without treatment for seven days for observation, which leads to situation whereby a medical practitioner or magistrate may over exercise power by not only detaining the mentally ill person in jail or mental institutions but as well chain the person in question in asylum. (per Kabir et al., Westbrook and Ude).

It is important to note the colonialists rationale for establishing such an inhuman Act, which was at variance with the mentally sick were treated humanely in England: ‘the (Lunacy Act) was in response to the concern that arose with the massive repatriation of Nigerian immigrants who were said to have developed mental illness while in the UK as a result of their inability to assimilate into British culture. Since those repatriated could not get adequate attention from both relatives and the government, the result was that Nigeria came to have many mentally ill persons on the streets From the 1950s, however, change began to occur in the asylum system, and a full time psychiatrist was employed to work in the asylums. The Lunacy Act was enacted, thus, requiring involuntary admission of patients into the asylums after a medical practitioner and a magistrate have determined that the individual in question is lunatic or insane’’.

Many efforts have been made to reverse the awful circumstance that mentally ill persons face in Nigeria with very unsatisfactory results : In 1961, The Aro, Abeokuta centre was created by an icon of Psychiatry medicine in Nigeria, The Late Prof T. A. Lambo, to world acclaim because it introduced humane, community centred care for the mentally sick. Sadly, while this innovation was taken up in other countries including high income countries, Nigeria is yet to replicate the initiative across the country. Mental health has largely remained in the tier of teaching and specialist hospitals in the country. There is still the Lambo Centre in Islington, North London to this day. In 2004, an initiative was started in Cross River State as part of the 12-pillar Clinical Governance programme to replicate community health care of the mentally sick anchored on a cadre of community mental health nursing. Sadly, we hear that the effort and the gains may have fizzled away since about 2010!. A current on-going effort to step down care of the mentally sick to the primary health care tier is promoted by the PACK Nigeria programme for primary health care (PACK is ‘Practical Approach to Care Kit).

Even more tragic is that the efforts made at the National Assembly to amend the 1958 Lunacy Act (enacted by the colonialists two years before Independence in 1960) remains the Law that governs mental health in Nigeria: ‘Ever since this enactment, the Act has not been repealed two occasions, but was never passed the senate, namely in 2003, Sen. Ibiapuye Martynes-Yellowe and Sen. Dalhatu Tafida introduced a Nigerian mental health bill to the National Assembly, however, the bill was withdrawn in April 2009, and later was reintroduced again to National Assembly in 2013, thus waiting to be enacted’. Sadly, It is still not enacted to-date!.

Enacting the modern Mental Health Bill into Law will provide legally backed humane treatment of the mentally sick, including stopping suicide being seen as a crime in Nigeria. And it can’t happen soon enough!.

References:

1. Gewertz, K. (2006).A Short History: Psychiatry in Modern Africa. Harvard News Office. 2. Ude P (2011) Treatment of mental illness: The case of Nigeria. Pangaea Global Connections 3: 44-51.

3. https://www.nami.org/Learn-More/Mental-Health-Conditions

7. Kabir M, Iliyasu Z, Abubakar IS, Muktar HA (2004) Perception and beliefs about mental illness among adults in Karfi village, northern Nigeria. BMC Int Health Hum Rights 4: 3.

4. Njoku OC (2012) Translating the divine in the encounter of the gospel and cultures: A pneumatological perspective. In: Doak M, Houck A (eds), Translating Religion, Orbis Books, Maryknoll, New York.

5. Heaton MM (2013) Black Skin, White Coats: Nigerian Psychiatrists, Decolonization, and the Globalization of Psychiatry, Ohio University Press, Ohio.

6. Sanni AA, Adebayo FO (2013) Nigeria mental health act, 2013 assessment: A Policy towards modern international standards. AM Acad Scholarly Res J 6: 1-13.

7. WHO (2011) Mental Health Atlas. Department of Mental Health and Substance Abuse.

8. WHO (2001) Mental Health: New Understanding New Hope. World Health Report.

9. Porter R (2002) Madness: A Brief History. Oxford University Press, New York. 10. Ana , J. ‘Whole SYSTEM change of Failing Health Systems’. 2009. ISBN:978-978-49487-0-8

11. Using a mentorship model to localise the Practical Approach to Care Kit (PACK): from South Africa to Nigeria. BMJ Global Health Oct 2018, 3 (Suppl 5) e001079; DOI: 10.1136/bmjgh-2018-001079.

Joseph Ana

AFRICA CENTRE FOR CLINICAL GOVERNANCE RESEARCH & PATIENT SAFETY

@Health Resources International (HRI) WA.

National Implementing Organisation: 12-Pillar Clinical Governance

National Healthcare Standards and Quality Monitor and Assessor

National Implementing Organisation: PACK Nigeria Programme for PHC

Publisher: Medical and Health Journals; Books and Periodicals.

Nigeria: 8 Amaku Street, State Housing & 20 Eta Agbor Road, Calabar.

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Website: www.hriwestafrica.org email: jneana@yahoo.co.uk ; hriwestafrica@gmail.com

HIFA profile: Joseph Ana is the Lead Consultant and Trainer at the Africa Centre for Clinical Governance Research and Patient Safety in Calabar, Nigeria. In 2015 he won the NMA Award of Excellence for establishing 12-Pillar Clinical Governance, Quality and Safety initiative in Nigeria. He has been the pioneer Chairman of the Nigerian Medical Association (NMA) National Committee on Clinical Governance and Research since 2012. He is also Chairman of the Quality & Performance subcommittee of the Technical Working Group for the implementation of the Nigeria Health Act. He is a pioneer Trustee-Director of the NMF (Nigerian Medical Forum) which took the BMJ to West Africa in 1995. He is particularly interested in strengthening health systems for quality and safety in LMICs. He has written Five books on the 12-Pillar Clinical Governance for LMICs, including a TOOLS for Implementation. He established the Department of Clinical Governance, Servicom & e-health in the Cross River State Ministry of Health, Nigeria in 2007. Website: www.hriwestafrica.com Joseph is a member of the HIFA Steering Group and the HIFA working group on Community Health Workers.

http://www.hifa.org/support/members/joseph-0

http://www.hifa.org/people/steering-group

Email: jneana AT yahoo.co.uk