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MIND OVER MATTER

What it took to spark a mental health reckoning for Africa’s doctors

A monitor shows the vital signs of a mock coronavirus patient during an exercise simulating the treatment of a large number of patients due to the spread of the coronavirus disease (COVID-19) at the Aga Khan University Hospital in Nairobi.
Reuters/Baz Ratner
In the midst of the pandemic, a shift is taking place in the approach to mental health treatment.
Published Last updated This article is more than 2 years old.

Laide Akinsemoyin has been working as a volunteer doctor in an isolation ward for coronavirus patients in Lagos, Nigeria since April. Each day, before her shift, she has to enter a “donning room,” to slowly and carefully put on the personal protective equipment that stands between her and possible infection from Covid-19.

Akinsemoyin previously worked as a general practitioner in private practice. Since starting in the isolation ward, she says, the biggest adjustment has been building “pauses” into her work—to make sure she has on her PPE before rushing to a patient in distress, for example, or to consider which procedures she can’t do because of the risks involved.

“The way you move, the way you interact, the things you would normally do by rote as a regular doctor in an emergency situation, in this instance you can’t,” Akinsemoyin says. “You’re constantly having to revise the way you do things and still give patients the best care.”

Part of that calculus is about preserving her ability to care for patients. Akinsemoyin, who has been self-isolating in a nearby hotel since she started working at the isolation ward, says she’s come to rely on group counseling sessions held for the ward’s medical workers—the first time in her career that she’s been offered mental health support as part of her work.

“It seems like everyone looks fine, but at therapy you realize everybody is dealing with something, having to do with the death of patients, the environment, the isolation from home… being cut-off from the rest of the world in a way,” she says. All of this is exacerbated by the novelty of the disease, the stigma associated with struggling, the inadequacies of Nigeria’s healthcare system, and uncertainty around how long this situation will last.

On the list of urgent health priorities facing African countries, mental health has long taken a back seat. When basic medical treatment is difficult to provide, dealing with the matters of the mind can seem like a luxury. But the nature of Covid-19—fast-moving, highly contagious, and with so many unknown variables—is highlighting the interplay between mental and physical wellness.

Not only is the pandemic inducing high levels of anxiety amongst the general population, it is having a significant impact on medical personnel. A recent study found that young doctors in China treating Covid-19 patients experienced a deterioration in their mental health as pandemic began subsiding, reporting symptoms such as a “fear of violence and a decline in mood.” The stress of battling an outbreak, research shows, can put doctors at risk for short and long-term mental health problems.

“I’m aware that we’re doing the most we can with our situation, and we’re seeing good results,” Akinsemoyin says, “but it’s still scary sometimes, because you’re constantly worried about how things might get bad, and what happens if it gets so bad and…it gets out of control.” She says it helps to remember that she’s actively contributed to mitigating the virus. “I constantly tell myself: ‘You’re doing this for people that need it, you’re making a difference, you’re helping any way that you can.’”

Medical professionals in Africa are well-acquainted with trauma. But some mental care providers are reporting that the pandemic—a unique crisis that has mobilized a frenetic response across the world—is bringing the issue of mental health to the fore in ways that people in power, from governments to funders, are finding hard to ignore.

Momentum for mindful medicine

Many African countries suffer from a dire lack of mental healthcare professionals, and extremely limited infrastructure to deal with mental wellbeing. A legacy of brutal colonial practices, and the outsourcing of treatment to traditional medicine practitioners and charities, has at times resulted in inhumane treatment approaches. “People with mental health conditions frequently experience extensive human rights violations,” reported a 2011 paper (p.309) looking at mental healthcare systems in Zambia, South Africa, Uganda, and Ghana.

Governments have historically failed to allocate the resources and policies mental health requires, reflecting a broader perception that it is not a priority.

“The limited number of mental health professionals is in part because of low investment, but also because mental ill health is so stigmatized that people do not consider working in mental health as a career option,” write the organizers of a 2019 conference addressing the issue. “To make the situation worse, because there is also a shortage of mental health personnel in high-income countries, there is a very high level of brain drain in this sector.”

But a shift appears to be happening. Mounting evidence of the interplay between mental health and poverty, and the impact of mental illness on the global burden of disease, have compelled some governments and civil society to take action.

Last December, media coverage of a rash of suicides prompted the Kenyan government to convene a task force to look into the stressors contributing to mental illness, as well as the availability of treatment. For the country’s few psychologists and psychiatrists, who were accustomed to mental health being treated as an afterthought, it was an extraordinary move. “We were getting to a place of hope,” says Edith Kwobah, head of psychiatry at the Moi Teaching and Referral Hospital in Kenya.

In Nigeria, where some mentally ill patients are still chained and mistreated, efforts have sprung up in frustration at the government’s inaction. User-led organizations are raising awareness around mental health issues and studies are being conducted on the impact of burnout on Nigeria’s doctors.

And in October, researchers in South Africa released the findings of its first comprehensive study of mental health support in public healthcare. The country had been roiled by a report revealing the death of more than 140 mentally ill patients after they were moved into unlicensed care facilities by the government between 2015 and 2016.

The necessity of mental healthcare for practitioners has also been illuminated. The suicide of a talented cardiologist in 2018, Bongani Mayosi, the first black person appointed as head of University of Cape Town’s Department of Medicine and Groote Schuur Hospital, prompted South Africa’s medical schools to start experimenting with wellness initiatives such as yoga and mindful wildlife walks for its young doctors.

“The timing of the pandemic was almost ripe for us to take this forward and consolidate the responses that we are now doing,” says Bonga Chiliza, the head of the psychiatry department at the University of KwaZulu-Natal. “A lot of people are now seeing that the mental health care of frontline workers is hugely important. Our doctors are humans—their humanity must not be undermined.”

A pandemic push

When the coronavirus hit, Kwobah was worried that Kenya’s momentum behind mental health interventions might stall. But as her hospital compiled training materials on treating coronavirus patients, the psychiatrist was surprised and “lucky,” to be included, she said, speaking on a recent webinar on mental health in Africa during the coronavirus pandemic, organized by the Harvard T.H. Chan School of Public Health.

In the hospital’s training materials, Kwobah was able to include how coronavirus healthcare workers might recognize and cope with stress and anxiety related to their work, including staying connected with family and exercising. It was just two slides in a presentation, but those slides evolved into guidelines on mental health and psychosocial support for the Ministry of Health, and weekly webinars to support healthcare workers.

Her department was also asked to provide counseling for hospital managers, who were under intense pressure to prepare for an influx of coronavirus patients. It was a significant shift for the psychiatrist, one of only about 120 in the country of 51 million. “Suddenly people are recognizing: ‘I need to talk to someone,’” Kwobah says. “I think we’ve moved some steps ahead. And if Covid never happened, we probably would have remained where we were.”

Similar efforts are emerging across the continent. In South Africa, a group of volunteer psychologists and psychiatrists formed the Healthcare Workers Care Network in June, to offer free counseling sessions for the country’s frontline workers.

The World Health Organization has long provided psychosocial and mental health support to communities exposed to traumatic experiences, from the Ebola outbreak in Sierra Leone and Liberia to the Boko Haram insurgency in Nigeria. The organization has incorporated lessons from these past experiences into its advice for Covid-19.

“During the West Africa Ebola epidemic, we learned that it is very important to take into account the mental wellbeing of the healthcare workers and other responders,” says Florence Baingana, a psychiatrist and public health specialist based in Brazzaville, Congo, who is a regional advisor for mental health and substance abuse for WHO. “Everybody now increasingly recognizes the mental health and psychosocial issues impact, not just on healthcare workers but on the general population as well,” Baingana says.

Kwobah believes governments are paying attention because the virus is democratic in its selection of victims. “Most other [diseases] affected the poor, people in the slums, minorities from political groups,” she told Quartz. “The fact that even the elite, the class that has the power, were affected—I am convinced that they also experienced some degree of anxiety. It probably made them realize, ‘Oops, it should have been at the forefront all this while.’”

An ongoing need

With the mental impacts of the coronavirus pandemic expected to linger for some time, some argue that the mind needs to be prioritized as much as the body. “There will be no vaccine for [the] mental health impacts of the Covid-19 pandemic,” a group of public health professionals recently wrote in the British Medical Journal. “It is time to urgently invest..in meeting our fundamental and complex human needs.”

The pandemic won’t change things if governments aren’t motivated to dedicate money and legislation to this issue, Chiliza says. He’s encouraged by the fact that the South African government is considering developing a funding stream for mental health, separate from healthcare—a strategy that has allowed devoted investment for HIV, tuberculosis, and child health. A group of researchers is hoping to push this forward by presenting a business case for preventative mental health care, as a way to reduce healthcare costs overall. “There is some understanding from the government that there is a huge amount of trauma that people are dealing with,” he says.

And there’s hope that the conversations happening amongst health professionals today about their own psychological needs might lead to a great empathy and awareness of the mental health needs of the patients and the communities they serve.

“Psychiatry has for a long time [felt] stigmatized by our own colleagues,” Chiliza says. “I think their own humaneness has now made [frontline medical workers] realize that psychiatric and psychological issues are important and one needs to deal with them.”

If you or someone you know is in crisis, in the US you can call the National Suicide Prevention Lifeline, 24/7, for confidential support at 1-800-273-8255. For hotlines in other countries, click here.