MENTAL HEALTH Progress in the Third World
'What do hospitals know
Which would you choose - electroshock treatment, Valium and
Largactyl, or herbal potions, ritual and ceremony? Wendy Hollway
reports from Zimbabwe, where many people prefer the witch-doctor
of the South to the witchdoctor of the West.
Photo: P Piletet / WHO
IN a Zimbabwe village a child overturns the family cooking pot and burns herself severely. Immediately the nganga (traditional healer) is called, whose diagnosis is that the spirit of the child’s great grandmother is angry because the family neglected certain rituals at her funeral. Her muzima (spirit) would have to be placated with a special ceremony, the nganga advised. But he also urged the child’s mother to take her daughter to have her burns treated at the nearest hospital.
With penga (madness) too, Zimbabweans often consult both the Western-trained doctor or psychiatrist as well as their local nganga. In fact one study found that between 25 and 75 per cent of urban and rural people believed that a visit to the nganga , or a combination of nganga and hospital advice, was the best way to deal withpenga. Overall 58 per cent of respondents claimed that madness was due either to witchcraft, to malevolent spirits called ngosi,or to an ancestor’s muzima.
Ngangas are ubiquitous and older than recorded history. They are central to the life of most Zimbabweans - in town and country - and are important actors in the Shona belief system in which ancestors’ spirits play a vital role. The nganga can be woman or man, young or old, rural or urban, honest or exploitative, wealthy or poor, cooperative or hostile to Western medicine. Some specialise in herbal medicines or have power to communicate with ancestors through throwing bones, sacrificing animals or mixing potions. And it is they who know what charms should be worn to protect people from ngosi. Some can cast spells to punish - or even kill - wrongdoers. And most, particularly in the countryside, know enough about family and village affairs to act as mediators in problems or feuds and give advice in the name of the ancestors.
Westem psychiatry, on the other hand, is a more recent phenomenon. Like Western medicine, it came to Zimbabwe with the colonisers for the colonisers - hence the tiny number of psychiatrists (about five to serve a population of about ten million) and their distribution (most attached to the teaching hospital in a wealthy suburb of Harare). As one psychiatrist put it: ‘With this ratio we are forced to see the more disturbed, bizarre, psychotic segments of the population.’
Ingutsheni, the country’s main mental hospital in Bulawayo - designed by the same architect who designed the prison - has only two part-time psychiatrists to look after a psychiatric population of around 680 - a population which has been halved in the last twenty years. Many of the patients who are left are really crazy, the effect of years of institutionalisation in an overcrowded, physically and socially deprived environment with nothing to do.
A trip through these wards, like any ‘loony bin’, leaves you feeling embarassed at the bizarre behaviour, the wailing and tearing of clothes and the insistent friendly attention to any newcomer. But at least there are now enough beds and mattresses so that inmates do not die of hypothermia on freezing floors in winter. And a few valiant occupational therapists do try to provide some activities (sorting buttons for a local company was one I saw).
But the biggest achievement is the reductions in the numbers of inmates. One psychiatrist, using her own resources, was preparing to settle some ex-patients in a house in Bulawayo. And a few other inmates are being moved to a half-way settlement in a rural area where they are being retaught basic skills of self-sufficiency.
The trouble with a catalogue of such successes is that it is based on the premise that what is needed is more of the same: more psychiatrists, psychiatric nurses, occvpational therapists. And policy documents from the Ministry of Health indicate that government Ministers, even when they are black Zimbabweans, still hold the colonial attitude that traditional healers are witch-doctors with primitive beliefs based on supersti tion rather than science. One document talks about the necessity of identifying the communities’ indigenous coping mechanisms. But that only highlights the policy makers’ ignorance of what these are! And recently a trainer of psychiatric nurses was rebuked by the medical profession for including an examination question about the ngangas role in mental health care.
So what works best - Western psychiatry or the indigenous practice of the nganga? Obviously it depends on the cause of the problem and on the beliefs of those afflicted. A person with epilepsy can be stabilised by Western medicine. Whereas a nganga would only be able to help the family and sufferer to cope with it.
With schizophrenia the case is not so clear cut. Many psychiatrists believe that early treatment by Western medicine is vital and that if schizophrenics delay consulting a psychiatrist while they first try the local nganga then the chances of a cure are drastically reduced. They have no way of testing this, though, because they never come into contact with those sufferers who are cured by a nganga.
To take another example: I heard of a young gardener working for a white household in Harare, far away from his family in the countryside. His employers began to notice that something was wrong - he was getting very thin, listless and seemed unhappy. So they took him to the hospital. There he was judged physically fit - and passed to the psychiatrist who diagnosed depression and prescribed a course of drugs. But he just got worse.
Throughout his illness he maintained that his ancestors were angry. But the doctors just ignored him. Finally, fearing he would die, his employers sent him back to his family who took him immediately to the local nganga. After they performed the ceremonies he recommended for placating his ancestors, the boy recovered.
In Shona culture illness and madness always are understood in terms of their cause. If someone is hurt in a bus accident, the family will go to a nganga to discover why. There is no such thing as an ‘accident’ or a ‘natural death’. But this system of beliefs does not revolve around individual responsibility or blame as psychiatry does (he can’t cope with his job, he is continally undermined by her mother-in-law, her father is violent). The muzima is angry with the whole family. And it is their collective responsibility to make amends.
In the case of the gardener his depression probably stemmed from his isolation and the general stress produced by living in a strange urban environment, in considerable poverty without family support. This is what most Western observers believe to be the main explanation for the increase in mental illness in the urban areas of Zimbabwe. But because the gardener understood his problems through the traditional Shona belief system, he experienced the cause and cure as being linked to his family and ancestors. And indeed that idea is not inconsistent with the more sociological explanation outlined above. Changes in lifestyle that occur in the urban areas mean the muzima will be increasingly neglected and thus more vengeful.
Belief in ancestral spirits has beneficial practical consequences in that the whole family rallies round and the afflicted person gets the care, attention and financial help s/he needs. And, if the nganga is local, s/he will know enough about the family dynamics to make skilful use of these in healing ceremonies.
But Western psychiatry has shown itself capable of crossing some of the gap that yawns between it and traditional healing in Zimbabwe. In one psychiatric ward at Harare I watched a trainee black Clinical Psychologist run an open therapy group. He suggested a topic for discussion: what did they think caused mental illness? Because he was familiar with the patients’ culture and language - which were the same as his own - he did not adhere rigidly to Western methods. And for a moment I found it strange that people took it in turns to stand up, sometimes moving into the centre of the circle of benches before speaking. And then I realised that this is how village meetings are conducted.
Many believe that ngangas will die out as Zimbabwe becomes more ‘developed’. Meanwhile, villagers continue to use ngangas, doctors and psychiatrists and feel no inconsistency as long as what they are given helps. As one rural woman put it:
‘What do hospitals know about witches?’
Wendy Holiway lectures at Birkbeck College, University of London, in Applied Psychology. She spent several months in Zimbabwe in 1983 looking at changes in psychology and mental health since Independence.
Worth reading on... MENTAL HEALTH
Critical Psychiatry: the Politics of Mental Health. Edited by David Ingleby; Penguin, 1981. A collection of lively, provocative papers with penetrating political analysis and, given the difficulty of the subject, mercifully jargon-free. Not for the casual reader.
Mind Control. By Peter Schrag; Marion Bovars Publishers, 1978. A technicolour critique of the US psychiatric system: complete with the facts and figures that we love to hate, such as the numbers of ‘icepick lobotomies' and deaths from electroconvulsive treatment.
In Our Own Hands: A Book of Self-help Therapy. By Sheila Ernst and Lucy Goodison; The Women ‘s Press, 1981. The authors are based at the Women’s Therapy Centre in London, where a group of feminists are creating their own brand of psychoanalysis (see below) and have collected together in this book a number of self-help therapy techniques that any committed group of people can try out for themselves. Highly recommended.
Outside In, Inside Out. By Susie Orbach and Louise Eichenbaunm; urn; Penguin, 1982. Also from the Women’s Therapy Centre. A sensitive, readable reworking of psychoanalytic theory for women.
Psychiatry in Dissent: Controversial Issues in Thought and Practice. By Anthony Clare; Tavistock Publications, 1980. One of the most popular and influential books on the subject at the moment. But its title is a misnomer. Glare is not a dissenter with standard psychiatric attitudes. However, it is an excellent account of what those attitudes are. Read Critical Psychiatry first!
Mental Illness in the Community: the Pathway to Psychiatric Care. By David Goldbetg and Peter Huxley; Tavistock Publications, 1980. A well-written, though slightly academic, account of what actually happens to people in mental distress when they seek help.
Open Mind. This is MIND’s bi-monthly magazine: bright, interesting, campaigning; concerned with the mentally disabled as well as the mentally ill. Obtainable from MIND, 22 Harley Street, London WI, UK. Telephone 01-63 7-0 741. This is also where you can find out about joining MIND, an active organisation fighting for education and change in the field of mental health.