by David Lamb
Until Idi Amin came to power in 1971, Uganda had sleeping sickness pretty well under control. Consider, though, this tragic scenario: the tsetse flies lay their eggs in the shade of lantana bushes, which grow in Uganda’s coffee- and tea-producing regions. The plantations there were owned by Asians. They were smart producers and they cleared the scrub from their land to make more room for their crops and to improve health conditions. But Amin expelled the Asians from Uganda and devoted half his national budget to defense. There was no money left to clear, drain and spray the hazardous areas, nor was there anyone who understood the need for continuing the control procedures. The plantations became overgrown and the bushes spread again like weeds. The Ugandan army started smuggling the reduced coffee crop across Lake Victoria into Kenya. To get to the lake, the smugglers had to pass through the reinfected areas, and in the course of four or five years they picked up the parasite and carried it back to heavily populated areas. Sleeping sickness was again a major health problem in Uganda, and with two thirds of Uganda’s 1,650 doctors having fled the country during Amin’s reign, there were not enough medical experts available to treat it.
Long ago a terrible scourge struck the people along the Volta River basin in West Africa. It stole their sight, turned their young old, and made their skin as wrinkled and leathery as elephant hide.
Even now, after so many generations of suffering, the old and wise chief of Wayen village in Upper Volta does not understand the source of his people’s misery. All he knows with certainty, he explains, is that as long as anyone can remember, the people have fallen sick and blind in great numbers, and he supposes they always will.
Chief Tonsana Ba is a tall, handsome man of simple dignity. He nodded approvingly at my offering of a dozen kola nuts, and finding a comfortable spot on the ground, hunkered amid a group of villagers, dispatching one of the youngsters to fetch a chicken as a gift. The people around him carried wooden hoes. Their legs were thin as twigs and their eyes were flooded with milky whiteness. Perhaps, the chief said, one third of the adults in Wayen were blind, but almost everyone was sick. The children, who act as guides for the sightless adults, sat scratching their arms and legs with rough stones, trying to soothe their cracked skin that burned with the itch of buried worms. At night they rest uneasily and sleep fitfully, tormented like their elders by a mysterious fate they cannot comprehend.
Their disease is called onchocerciasis, or more commonly, river blindness. It is transmitted by tiny black flies known as buffalo gnats, which breed along the banks of fast-moving waters. When the female sucks blood from a human already suffering from onchocerciasis, the fly becomes infected and passes on the disease when it attacks another human and lays eggs on the bitten area. The larvae become worms, which live and breed under the skin of the victims’ scalp, ribs and limbs. It takes years to become seriously infected, but eventually a victim may harbor hundreds of worms. They penetrate the eye, causing partial or complete blindness, and destroy the elastic layer of skin, causing itching so constant and painful that suicide is common. The World Health Organization has been trying to control the disease since the mid-1970s—no one talks about eradicating it in West Africa at this point—and if the campaign is successful, the implications will be substantial.
The land near the Red, White and Black Volta rivers is the most fertile in Upper Volta. But because people associate onchocerciasis with the rivers, whole villages were abandoned when tens of thousands of Voltans moved into the plateaus, thus overtaxing the fragile land that has little to give in the first place. Brides, traditionally drawn from villages that have not been stricken, refuse to leave home for fear of becoming infected, and the young men head for the cities of Ouagadougou and Bobo-Dioulasso before they, too, become blind. As the rural population shrinks, the rate of bites per person increases and more people fall sick. The crops are neglected and a listlessness slips over the villages, now inhabited only by the prematurely old and the very young.
In many ways onchocerciasis symbolizes the difficulty man has in finding accommodation with the land of Africa. Though the land may support him and feed him, the African, in the end, remains the slave of his environment. The land owns him and dictates his destiny.
The World Health Organization is spending $10 million a year trying to conquer onchocerciasis (which is also common in the parts of Latin America that imported African slaves). WHO’s campaign in Africa involves complex monitoring systems, medical studies, onsite research, clearing and draining land, and spraying the flies’ riverside breeding areas with a low-toxic biodegradable compound. In some lesser-infected countries such as Kenya, similar programs have destroyed the flies and eradicated the disease, river by river.
Ending river blindness in East Africa is another reminder that man is capable of bringing decent health standards to the world’s unhealthiest continent. The most dramatic proof of this came in 1980 when a fourteen-year WHO attack on smallpox succeeded, marking the first time in history that man had totally eradicated a disease. Only a decade earlier, smallpox had been claiming up to two million lives a year in the Third World, and in West Africa had either killed, blinded or left mentally retarded one of every ten children. Travelers in the Ivory Coast had long recognized the meaning of a dead bird hanging from a twig. It warned: “We have smallpox in this village—stay away.”
The Smallpox Eradication Program cost $300 million between 1967 and 1980 (about one quarter of what gamblers lose in Las Vegas every year) and entailed the global efforts of 200,000 men and women who dispensed 2.4 billion shots of vaccine. Medical authorities had focused on smallpox for two reasons: the disease is spread only by an afflicted human being, who is contagious for just four weeks; and a vaccine, taken from the skin of a living calf, had already proved to be an effective preventative.
What WHO had to do, then, was to immunize the population in smallpox areas and locate and isolate the remaining cases. Not surprisingly, the world’s final cases were tracked down in Africa. To find them, international health officials hired local “surveillance agents” to infiltrate warring tribal groups and look for telltale scabs. Other agents were strung out along the Ethiopian-Somali border to check the nomads who drifted from country to country. Bounties of up to $1,000 were offered to anyone reporting a new case. WHO doctors, aided by army soldiers and college students, traveled through the Horn of Africa on foot and in planes and four-wheel-drive vehicles. They carried with them a powdered vaccine that had been developed specially for the Third World. It did not need refrigeration and it was injected with a simple two-pronged needle that anyone could use merely by lightly jabbing the skin.
The last endemic case in Africa—and the world—was located one October morning by a WHO “search and vaccinate” mission in the ramshackle Somali town of Merka. He was a twenty-three-year-old hospital cook named Ali Maow Maalin. He recovered after treatment, and in 1980 the World Health Assembly meeting in Geneva issued a triumphant statement: “Smallpox is dead.”
The smallpox breakthrough showed what a determined international medical effort could do for Africa’s physically sick. But for the mentally ill, there is less room for optimism. In many African countries, mental disorders are still treated with aspirin and witchcraft. Psychiatry is a stigmatized or nonexistent profession. Kenya, though far more advanced than its neighbors, has only seven psychiatrists—one for every 2 million persons. In the Swahili language there are no words to describe mental illness and none to express degrees of emotion. A person who wants to say that he is depressed will use the word “unhappy.” If he is overjoyed, ecstatic or mildly pleased, he has the choice of only one word—“happy.”
“Facilities for the mentally sick are disastrous in black Africa and the general picture is terrible,” said one of East Africa’s top psychiatrists, Dr. Joseph Muhangi, a British-educated Ugandan. “By the year 2000, mental health is going to be the number one public health problem in Africa. Anyone looking beyond his nose can see that, but no one, it seems, is making any pl
ans for dealing with the inevitable.”
I joined Muhangi one Thursday morning at Kenyatta General Hospital in Nairobi. By the time he entered the building at seven-thirty and headed down the long open-air corridor to Clinic No. 17, the rows of steel folding chairs were already filled. On other mornings of the week the plain room with whitewashed walls, adorned only by a black-and-white photograph of Kenya’s president, served as a diabetic clinic. But for four hours each Thursday morning it became the psychiatric clinic, the only one in Kenya and one of a mere handful throughout black Africa.
There were perhaps 150 patients waiting for Muhangi and his four colleagues. A receptionist had ascertained that their disorders were mental, not physical, and everyone sat quietly, holding his admission card, neither comprehending his illness nor knowing that he was about to see a psychiatrist. Apparently he understood only that some evil deep inside had twisted his life and brought fears and visions he could not explain.
Although there is a scarcity of reliable research, growing evidence suggests that Africans are no less susceptible to social pressures and resultant mental disorders than people in the developed world. If anything, doctors say, suicide, alcoholism, hysteria and various forms of neurosis are increasing as the competition for jobs, education and financial security becomes greater.
“Old ideas die hard,” Muhangi said, arranging the case files on his desk. “It wasn’t too long ago that doctors came to Africa from the West and believed the noble savage was free from the pressures of civilization and thus free from psychological pressure. This just wasn’t so. Take a man with five wives and twenty children and a little plot of land he’s trying to farm with primitive tools. Do you think this man isn’t under pressure?
“And how about the pressures exerted when entire societies in Africa are in transition, when social structures are changing, rural populations are shifting to the cities, traditional values are being replaced by Western-oriented values, and young men are competing to get ahead and succeed as never before in Africa?
“Everything considered, there’s really far greater pressure on Africans today than there is on a person from the Western world.”
None of the outpatients who came to see Muhangi that morning attributed his depression or insomnia or hallucinations or physical pains to mental disorders. When Muhangi asked each what had caused his illness, most replied without elaboration, “I have cholera.”
Phillip Ng’eno, a hulking, handsome man of forty-nine, sat down in front of the doctor, his face impassive, his eyes focused on an imaginary spot on the floor. He earned $100 a month as a technician in a medical lab, half of which he spent on school fees for his thirteen children. The heavy rains had spoiled the coffee harvest on his eight-acre plot. The pain in his arms and his general lethargy had grown steadily worse since one of his wives died, but previous medical tests had shown no physical ailment. He feared that soon he would no longer have the strength to father more children or to work his fields.
“Tell me, Phillip,” the doctor said, “do you sleep well at night?”
“No, I do not sleep at all. I am up before the roosters. I am always tired but sleep does not come.”
“What do you think the problem is?”
“Cholera,” Phillip said. “I have been cursed with cholera.”
“Ah yes, but how about the things that are frightening you? Let me explain how the mind controls and causes pain. When I was a small boy tending goats in Uganda, sometimes I would cut my leg running through the thickets. I would feel no pain because I was so intent on keeping the goats together. Then when I got home and my mother saw the blood and asked me what happened, the pain would start.”
Muhangi glanced at the case file again and scribbled out a prescription for a tranquilizer. “I know your pain is real,” he said, “but can you see that the pain is in your mind, not your body?”
“That may be so,” Phillip answered in a soft voice, “but have you not some pill that will help my cholera?”
Phillip shuffled out the door. A young girl named Theresa entered with her mother. Theresa was fifteen years old, less than three feet tall and the brightest student in her class. The headaches, cramps and sleepless nights began about the time she learned that she was a midget. Her headmaster refused to advance her to the next class because she was so small, and a Kenyan physician she had seen tried to put her on display in a ward so medical students could see what a midget looked like.
“This headmaster, he is no use, a stupid man,” Muhangi muttered as he prescribed an antidepressant and wrote the headmaster saying Theresa should be graduated with her class.
“She is a smart girl,” Muhangi said to the mother. Theresa sat nearby, teary-eyed. “If she cannot do some things, at least she should be buying Mercedes-Benzes and writing books someday. After all, people who stammer also become orators. Theresa can still have a full, happy life. Do you understand, Mom?”
The mother said nothing and her face reflected no emotion. She waited for several more moments, but there was little else the doctor could say. She turned as she reached the door and said, “How can Theresa write books if she is so small?”
Muhangi’s weekly clinic represents a modest beginning in the treatment of the mentally ill. Yet throughout all of sub-Sahara Africa (excluding South Africa) there are only and estimated 100 psychiatrists serving 342 million people, and in most countries treatment is primitive or nonexistent. Generally only those who act totally made are considered in need of psychiatric help.
In parts of the Sudan, the insane are manacled and beaten twice a day in mental institutions. In at least ten countries there are no mental health specialists and no mental health facilities. Uganda once had the most advanced psychiatric care in black Africa, with twelve European-trained psychiatrists, outpatient clinics in a dozen rural towns, and a modern inpatient hospital at Makerere University in Kampala. President Amin’s rule of terror reversed that progress and by the time he was overthrown in 1979, all of Uganda’s psychaiatrists were dead or in exile and the mental health facilities were closed.
Kenya has only one in-patient mental health facility, Mathare Hospital. It was built to hold 1,000 patients but has twice that many, and one third of the patients are there on criminal charges. One ward has forty beds and 150 patients, and many patients never see a doctor; they are merely drugged for a few weeks and then released as sort of walking zombies. The admission ward, where all patients spend their first few days or weeks, is similar to a cage in a zoo. It has a cement floor littered with banana peels and human waste, towering bars and no roof. Inside are sixty or seventy patients, glassy-eyed, half-naked, trapped like animals.
Given such conditions, it is not surprising that the primary source of health care for Africans remains, as it has for generations, the practitioner of traditional medicine. Often called a witch doctor or sorcerer, he casts spells, removes curses, treats mental and physical ailments. Anyone who doubts his powers needs only to meet Satigi Soumaouro, as I did one morning in the sleepy West African city of Bamako, capital of Mali.
For three days and three nights Satigi had treated a steady stream of patients, so by the time I appeared at the door of his dark little room at the end of a dirt alleyway, he was weary. He sat barefoot on his mattress, rubbing sleep from his eyes. This was his operating theater and his consultation room, and on the cement floor were his instruments: gourds, rattles, springbok horns, chicken beaks, potions of herbs, several cattle hoofs and a jar of shiny brown beetles.
Satigi was seventy-nine years old. The face beneath his blue fez was lined and drawn, but in his very presence—in the strong, steady gaze, in the soft, melodic voice—there was an aura of power that transcended both his exhaustion and my doubt.
“My mother had these powers too,” Satigi said. “From her milk they were passed to me. My knowledge was born with me.”
This knowledge had made Satigi one of the most sought-after traditional healers in West Africa. His patients came from as far away as
Europe, and many had first gone to Western doctors to seek cures for their illnesses. But in the end they placed their fate in the hands of Satigi, partaking of his herbs, his incantations and rites, his knowledge of the universe’s intangible forces.
“There are some things that Western doctors cannot cure,” Satigi said, covering his feet with the long red robe that flowed from his shoulders. “There are things that will always be treated best by traditional medicine,” And for the time being at least, a major portion of the African medical community agrees with him. In fact, traditional medicine is undergoing a revival of respectability in Africa and is viewed by many competent medical authorities as an important adjunct to Western-style health care.
The traditional practitioners’ strength lies in the belief that man is more than a physical entity. His well-being is largely controlled by gods and spirits, and disease is a punishment for wrongdoing. Misfortune is the result of a curse, often uttered in the name of an enemy or a displeased ancestor. Some practitioners will cast evil spells. Others, like Satigi, operate only as the harbingers of good forces; they will remove but not cast evil spells. Both types of practitioners believe that spirits, both good and evil, emanate from one’s ancestors and that a precise balance between those conflicting forces guarantees an individual’s good health.