Rwanda : mental care for all / by Franz Baro

RWANDA Mental care for all confront the disease in the non- material realm. To enter this world, protection and the long experience of the healer are needed. The continent of Africa is a mosaic of cultures with an amazing variety of traditional therapeu- tic practices. In Rwanda, therapeutic rituals are often addressed to Ryangombe, a divinity who is the source of peace, love and fertility. by Franz Baro This traditional medicine should not be underestimated or rejected by modern medicine. Besides the cultural affinity between the patient and the healer, the fact that both belong to the same community - where the healer commands great authority - helps to make patients and their families feel more secure. The assistance of healers helps mental patients, for as long as they abide by family and public order, they will never be locked up. " D octor, there's a new patient - and it's a man and a woman at the same time!" cried the nurse, very excited, interrupting my dinner. I had just anived and it was my first evening in Rwanda, in November 1978. I was staying at the Ndera Neuropsychiatric Centre and had asked to be called as soon as a new patient was admitted. The agitation of the staff was under- standable. The physical appearance of the young man of 18 brought by the mayor of his village was indeed strange: he had well-developed breasts but his penis was that of a child. From my experience of genetic disorders, I was certain that this was a case of Klinefelter's syndrome, a genetic aber- ration due to the presence of three sex chromosomes, XXY. The effect of the superfluous X chromosome is that males (who normally have XY) develop breasts at puberty, while their male organs fail to develop beyond their childhood state, resulting in sterility. On examination, the young man, whose name was Seraphin, proved to be ecstatic at the idea that he was "pregnant of himself." The mayor told his story. Seraphin had become an orphan at puberty and had been charitably adopted by the neighbours. At that point he was quite normal. It was only later that his problems began. His aberrant sexual development made him the laughing-stock of his peers. Neither he nor his adoptive parents understood what was happen- ing. The healers they consulted were no help. Seraphin gradually sought refuge with his adoptive mother who lavished care upon him. When he reached the age of 17, he demanded the sexual initiation of which he was so cruelly deprived. His mother, frightened, told her husband, who punished Seraphin mercilessly for what he described as "misconduct and ingratitude." The mayor had to intervene to save 26 Seraphin from the worst. He forbade him to stay any longer with his adoptive parents and, in a spirit of solidarity, gave him a hut and a plot of land above the village in the hope that he would manage. But Seraphin soon became totally isolated from the com- munity. Then, a few months later, he came running joyfully down to the mayor and announced that God, who had created him man and woman, had permitted him to impregnate himself, and that in a few days' time he would give birth to a very special child. Flabbergasted by these deluded ramblings, the mayor decided to bring Seraphin to the hospital at Ndera. Or Franz Baro is Professor of Psychiatry at the Catholic University of Louvain . and Medical Director of the Uni- versity Psychiatric Clinic Sint- Kamillus 1n Bierbeek. Belgium . To encourage the integration of traditional medicine, the government of Rwanda has set up an association of healers, though no evaluation of their methods of treating mental diseases has yet been possible. Modem medi- @ cine tends to demystify certain poorly j understood concepts such as poison- ~ ing and magic, and to emphasise the c.: need for proper diagnosis and ~ treatment. In the case of Seraphin, for -€ example, one can hardly attribute a ] genetic accident (XXY) to the "evil ~ eye" or the transgression of a taboo. - Simultaneous recourse to traditional U·~ and modem therapies gives rise to serious ambiguity, as there is no integ- ~ ration between these two disCiplines. .,. Senior officials often disparage the procedures used by the healers but still A busy market in Kigali, the capital of consult them discreetly for their own Rwanda. and their families' problems. Continu- Thus, like most patients, Seraphin only came into contact with the mental health service after a long evolution of his condition and the failure of tradi- tional healers. Among the people of Rwanda, mental disorders are tradi- tionally perceived as a battlefield for invisible forces - God, local spirits, dead ancestors, sorcerers and enemies. Evil, represented by the disease, is always the effect of another evil. Any therapy which hopes to succeed must ing collaboration between the mental health services and the healers as a well-organized group is needed to overcome this ambiguity. Mental health services have only recently been introduced in Africa. Some people even maintain that the problems of infectious diseases and malnutrition are so great that it is premature to provide mental health services, given the limited resources. With a per capita gross national product of US$ 260, Rwanda is W ORLD HEALTH. March 1990 classified among the poorest countries. This small, landlocked country in the heart of Africa, known as the "land of a thousand hills," has a scattered population living in isolated farms and is criss-crossed by an extraordinary patchwork of small fields, with only a small area of bush, forests and swamps. For health, the annual per capita spending of US$ 2 falls far short of the needs. Health personnel are lacking, with one doctor on average for every 25,000 inhabitants, one medical assistant for every 18,000 and one nurse for every 7,000. The population (90 per cent rural} is now over seven million (a density of 265 per square kilometre), and is increasing at an annual rate of 3 .7 per cent; it is feared that it will exceed 10 million by the year 2000. The country's predominant policy concerns are self-sufficiency in food and control of demographic growth. For 20 years, however, the Rwanda government has been convinced that ~ the prevalence of mental illness justi- 0 fies the same active intervention as in ~ other medical fields . Collaboration between the government and the Con- gregation of the Brothers of Charity made it possible to open the "Caraes" Psychiatric Centre, with 120 beds, in 1972 at Ndera, near Kigali, the capital. Soon between 1,500 and 2,000 urgent cases were being admitted each year, while consultations rose to 10,000 annually. · Three objectives In 1975, Rwanda approached WHO for special collaboration, with three objectives: to make mental health care available to all the population; to integrate mental health care into the primary health services; and to place emphasis on prevention. Overseas cooperation, especially from Belgium and France, helped to implement this programme. Anxious to cooperate with the African Mental Health Action Group, Rwanda joined this group in 1977. During the last decade, it has carried out such activities as training in mental health, starting up a specialised dispensary and building sheltered housing. But the most important step has been and continues to be the integ- ration of mental health care into primary health. There are now 15 health centres providing mental health services, which are accessible to patients from two-thirds of the country's communes. These centres are visited regularly by a mobile team from Ndera, consisting of a physician, a medical assistant, a nurse and a W ORLD HEALTH. Ma rch 1990 A water-carrier cheerfully bears his load. The burden of mental ill-health aBlicts poor countries as well as rich; Rwanda has recognised this and is trying to make mental health care available to all the population. social worker. The team helps the staff to assess the patients and set up the necessary treatment. The staff receive further training in the form of a one-month refresher course at Ndera every two years. In this way, nearly 10,000 patients are being followed at the pilot centres by rural personnel supervised by the mobile teams, and few of them need to be confined to hospital. There is no shortage of problems. It RWANDA is a landlocked republic. with Uganda. Zaire. Burundi and Tanzania as its neighbours. Its popu- lation in an area of 1 0.200 square miles is 7.276.000. and its capital is Kigali. • is difficult to obtain supplies of psycho- tropic drugs. Inadequate training leads to mistakes in treatment. Overcrowd- ing at Ndera results in early discharge of patients, unmet needs and overwork for the staff. Mental health consul- tations need to be available in all the general hospitals, with a few beds for serious cases of acute psychoses. A division of mental health is needed at the Ministry of Public Health to improve coordination and evaluation of the national programme. Legislation on mental disorders is also needed, so that patients are not neglected, mal- treated or unreasonably deprived of their freedom and rights. Rwanda is one of the countries where the inci- dence of AIDS is reaching alarming proportions and this will particularly test the mental health services; mental patients are a risk group for infection, while AIDS may in turn give rise to mental and neurological problems. Betterunder.Handiog So what became of Seraphin? With the help of treatment, his delusions disappeared after six weeks. He was able to return and settle in his village, which has shown solidarity through better understanding and acceptance of his psychosexual handicap. There can be no doubt that getting to know each other better - Africans and non-Africans - and working in closer cooperation will lead us to a practice of mental health in which our values and knowledge are reciprocally respected and enhanced. The success of the integrated men- tal health care project in Rwanda will depend on the combined efforts of national and international agencies, the devotion of the health personnel and the support of all those for whom the promotion of mental health is important for the country's future. • 27