Back in the 1970s I was in the US Peace Corps in Kenya East Africa. I worked in an all boys school as a chemistry teacher. The school was about 100 miles north of Nairobi on a high plateau next to Mt. Kenya. On the weekends my fellow volunteers and I would drive over to the closest town for a Coke and an inexpensive snack at the White Rhino Hotel. In those days a Coke or a bottle of beer would cost about a Kenyan Shilling (KES) and a meat pie or a samosa would cost about a Shilling and a half. One Shilling was about 14 cents American. Outside the hotel was an apparently homeless man. He would beg for money often by creating disturbances. He would obstruct people in the street going to and from the hotel. He would shout out the word "Chai, Chai..." repeatedly while spitting down the front of his shirt. "Chai" is the Kiswahili word for tea. He would appear agitated and tearful at times. He was not tolerated very well by hotel security or the local people - people who could speak fluent Kiswahili and the local Kikuyu language. Some of them would become physically aggressive toward him and cause him to run down the street. At other times he would show up with a can of dirty water and try to clean auto windshields by wetting down a newspaper and wiping the water all over. These attempts were always unsolicited and the drivers would become enraged because their windshields were always less clean than when he started. We eventually referred to him as the Chai Man because nobody ever knew his name. The Chai man clearly struggled, alienated practically every person I ever watched him interact with, and he got minimal assistance from anyone. At the time he reminded me of homeless men I would see in my local public library. It was the only they place they could go in a small town to get a break from the weather. They would occasionally ask for money, but for the most part avoided people. When you are down and out and mentally ill, most people seem to know better than to ask.
By the time my fellow teachers and I made it to our placement north of Nairobi we had contact with hundreds if not thousands of people living on the street as beggars. Many had physical deformities to the point that they were unable to walk. Coming into town from the airport was enough contact to convince the most altruistic Peace Corps volunteer (PCV) that they personally did not have nearly enough resources to address the problem. PCVs had to learn to not look at the people begging on the street and walk quickly by or risk people coming out and grabbing their leg or arm until they were given money. Like the US, only certain streets and areas allowed for the aggregation of these homeless beggars. PCVs were not rich by any means but when we got to our eventual destinations, they were usually places where there were no homeless people in sight. We were rather scruffy ourselves but we could sit in classy places like the New Stanley Hotel and sip on a Coke.
I thought of the Chai Man last night as I listed to a program on "The World" on MPR about a mental health initiative in Kenya (reference 1). The focus of the program was a young woman Sitawa Wafula started mental health crisis intervention service on her own. It is a formidable problem. The program describes how children and adults are "locked up" by their families and may not see the light of day. Neighbors often do not know that a mentally ill brother or sister exists. This is reminiscent of Shorter's description of the problem of psychosis in Europe and how it was handled in the early 20th century. It also happened in my own family in the early 1950s. In Kenya, there are currently 79 psychiatrists or one for very 500,000 people. Ms. Wafula gets a number of calls to her crisis intervention service and says that if the problem involves suicidal thinking many people with that problem have had two previous suicide attempts. The World Health Organization puts Kenya in the top quartile of suicide rates in all countries worldwide.
I was picked up by a Kenyan physician once when I was hitchhiking back to Nairobi one day. I asked him what was available in terms of psychiatric services at the time. He said there was only one hospital and that the basic medication being prescribed by physicians was chlorpromazine. At that time, the chlorpromazine generation of antipsychotics were the only ones available and antidepressants were more difficult to prescribe. Medical care in general was difficult to access. I would typically get scabies at least one a month. When I was initially infected I made the mistake of going to a local clinic and standing in line in the hot sun. I was about number 300 in the line and it moved about 4 or 5 spaces every hour. I realized that I could hitchhike 100 miles to Nairobi and back and pick up the appropriate treatment from the Peace Corps physician in less time than it took to go to the local clinic. Eventually I just picked up a large bottle scabicide and applied it whenever I got infected. At the time Kenya also had one of the fastest growing populations making it more difficult to provide medical and psychiatric care.
About 8 years after I left Africa, I was sitting in a seminar full of fellow psychiatry residents at the University of Wisconsin. The topic of the day was whether or not the prognosis of schizophrenia was better in what was then called the "the third world" based on some outcome studies available at the time. Our job was to critique the literature and it was apparent that there were technical differences in studies and in many areas the follow up and methodology was different. At one point I suggested that exposure to antipsychotic medications may lead to negative outcomes and that raised an eyebrow or two. I also pointed out that that at least half of the people I was treating had significant alcohol and drug problems and were not interested in quitting. I doubted that many of the people in these studies had widespread access to street drugs that were known to precipitate psychotic states. I remembered the Chai Man very well, but knew better than to introduce my anecdotal experience from Kenya. That axiom about better prognosis in the developing world has since been re-examined (reference 2) and there are clearly more problems with that theory than originally thought. Like many areas in psychosocial research it may depend more on your political biases before you read the research. The Scandinavian research on brief psychosis and brief reactive psychosis from about the same time frame certainly suggested similar rates of spontaneous recovery.
These experiences make me smile at couple of levels. Any time someone "confronts" me with the evidence of prognosis in schizophrenia and the World Health Organization (WHO) studies, I can point out I had a better and more thorough discussion about it with fellow psychiatrists in 1986. I have also lived in a developing country and saw how people with presumptive mental illnesses were treated. I have applied that experience and knowledge to clinical practice in this country.
There is the curious parallel of access to psychiatrists in both countries. How do the citizens who need them the most get access to them? The public radio story suggests that only people with resources (I take that to mean money) can get access to the limited number of psychiatrists in Kenya. This country is headed in the same direction largely because rational psychiatrists do not want to be ordered around by insurance companies. In the case of access for the severely disabled, individual states have different plans but the overall plan has been to ration access and incarcerate rather than hospitalize people with mental illnesses. In the US, there is generally an order of magnitude greater number of psychiatrists, but that does not translate to more access. I have talked to too many people who stop seeing a psychiatrist when their insurance stops. The insurance industry, state governments, and the federal government all have an interest in restricting access to psychiatrists. If people only see psychiatrists if they have poor insurance coverage and psychiatrists are fleeing insurance - this is a chronic problem that will only get worse.
In the meantime, I hope that Ms. Wafula continues to be successful in her crisis intervention program and raising awareness that severe mental illness is a public health problem that needs to be addressed. Families should have more resources and more help. The WHO program to raise awareness about suicide also seems like a good idea.
George Dawson, MD, DFAPA
References:
1. Emily Johnson. Fighting the 'funk:' How one Kenyan battles her mental health problems by helping others. PRI The World. March 3, 2015.
2. Cohen A, Patel V, Thara R, Gureje O. Questioning an axiom: better prognosis for schizophrenia in the developing world? Schizophr Bull. 2008 Mar;34(2):229-44. Epub 2007 Sep 28. Review. PubMed PMID: 17905787
Supplementary 1: The map graphic is from the CIA Factbook in the public domain.
Supplementary 2: WHO Infographic on Suicide.
Supplementary 3: I mention the New Stanley Hotel in this post, but sometime after I was there it was blown up by terrorists. The replacement versions (at least according to Google) continue to be threatened by terrorists, who apparently want to target the tourist business in Kenya.
