Monday, August 31, 2009

Dare to Care: Stop the Exclusions!

Some insurance companies are making health policies in Kenya which exclude treatment for mental illnesses. As if to demonstrate further ignorance in this area, they are even naming suicide attempts (often a sign of severe mental illness and distress) as exclusions.
I have seen policies that specifically exclude depression, 'psychological problems', suicide attempts, alcohol related problems and other mental disorders from their cover.
Many Kenyans accept these exclusions
1) due to ignorance and
2) due to a stigma that presupposes that mental illness only affects the 'other' person, so the exclusion is not important.

For the second group, I have news for you: Mental illness is more common than you think! About 1% of most populations suffer from a serious mental disorder called schizophrenia. Twice that number suffer from Bipolar Disorder, another severe mental disorder. Studies have shown that upto 25% of the population have suffered an episode of depression in their lifetime.
Indeed, in Kenya, upto 50% (yes, half, or one in two!) of patients seeking health services in a general setting (casualty, outpatient, private clinics, etc) suffer from depression, ranging from mild to severe.
What this means is that a large proportion of the population is at risk of developing one mental illness or another, and therefore insurance coverage will come in handy for their treatment.
It is for this reason that the Mental Health Act, Cap 248 of the Laws of Kenya, specifically provides for insurance cover for persons with mental disorders.
Which brings me to the first group above. To address their ignorance, I attach below (In quotes) the full text of s46 of the Mental Health Act (1989):

"46. Insurance for treatment of persons suffering from mental disorder.

46. (1) Every person in Kenya shall, be entitled, if he wishes, to insurance providing for his treatment as a person suffering from mental disorder and no insurance company shall make any insurance policy providing insurance against sickness, which excludes or restricts the treatment of persons suffering from mental disorder
(2) An insurance company which makes any insurance policy which expressly excludes or
puts restrictions on the treatment of any person suffering from mental disorder shall be guilty of an offence."

Please be informed, and insist on your right of coverage for mental disorder. Indeed, even if a company has an explicit exclusion for mental disorders, the exclusions are illegal, non-binding, and may attract prosecution!
For representatives of insurance companies, all I can say is : Dare to Care! Stop the Exclusions!

Count should have data on place of ‘usual residence’

Sunday Nation 30 August 2009

This past week, over a hundred thousand enumerators have criss-crossed the country in an effort to establish just how many people there are in this country.

There does not seem to have been any serious problem with the census itself, and all indications so far are that any reported hitches in the process have not significantly affected its integrity.

Indeed, even the emotive issue of tribe seems to have been handled relatively well, with the enumerators in most cases employing tact and respect for their clients’ views. In some cases where the enumerators seemed unsure of codes for certain items on the questionnaire, they entered the data exactly as given, promising to confirm the codes later.

That said, an interesting phenomenon was observed in many urban centres just before the census began early last week. There was a sizeable exodus of some urban dwellers to their rural homelands ostensibly in order to be “counted at home” together with their tribal kin. Many people closed shop on Monday afternoon and made a beeline for their rural homes, and the presidential declaration of a public holiday on Tuesday in fact served to facilitate this movement.

Innocuous as this phenomenon may seem, it offers a window into the mind of the ordinary Kenyan as far as the meaning of a census is concerned.

It would seem that many treat the census in much the same way as they do an election. A similar exodus occurs in this country on the eve of any election, and many city-dwellers are registered to vote in their rural areas.

The “being counted at home” mentality therefore indicates clearly that as a nation we are unaware of the true value of a census as a planning tool, and are more preoccupied with perpetuating our ethnicised politics. In this sense, therefore, we lose the right to harangue our leadership about nepotism, tribalism and all other “isms” that continue to drag the country away from its development goals.

Statisticians have told us that the role of the census is to provide data that is crucial for planning and resource allocation. The data will be used to determine infrastructural needs, health facilities, education and other services. This being the case, the unit of planning will not only be based on raw numbers, but also on geographical dispersal of the population.

Presumably, these services will be concentrated in areas with greater populations than those that are sparsely populated.

Unfortunately, we also know that when the numbers are released later this year or some time next year, many will hold their collective breaths for the ethnic composition of our population and start making plans for new ethno-political alliances in order to win the next General Election.

In the absence of clear tribe data, others will use a proxy such as provincial and district figures for political bargaining, always assuming ethnic and political homogeneity in these provinces and districts.

Rushing to our rural homes for the census, and even for an election, only serves the interests of our political elite, and we should not raise a finger when they use the numbers arising from census and voter registration data to trade for political positions. Such use is indeed more appropriate than any planning use the data may be put to.

Due to the census and election “migrations”, the data on population densities is inaccurate and of little use for decision-making purposes. For instance, a health centre may be sited in some rural area due to the reported large numbers of people in the area when, in fact, majority of the reported “residents” only show up during public holidays, elections and censuses.

Conversely, an area in Nairobi or Mombasa may be neglected due to reportedly low population figures when, in fact, it holds a huge population of “up-country” people who are never counted during the census.

Simplistically, this anomaly may be said to be responsible for the lack of accountability among our politicians and especially among the ever-fighting councillors in our urban areas during mayoral elections.

Politicians in urban areas do not owe allegiance to all the residents, while those in rural areas were installed by urbanites who are never present to hold them to account!

Several strategies may be employed by the statistics bureau if the statisticians are truly interested in accurate data for planning purposes. The most useful one, in my view, would be to redesign the questionnaires to include a question on the place of usual residence regardless of where one is found on the night of the census.

Indeed, short of banning travel in the days leading up to the census, this seems to be the only effective way that would ensure that data is captured on true population density and distribution across the entire country.

Dr Lukoye Atwoli is a consultant psychiatrist and lecturer at Moi University’s School of Medicine

Monday, August 24, 2009

Harness revolutionary moment for positive change

Sunday Nation 23 August 2009

Last week, I spent some time with a poor family on the outskirts of Eldoret town in Kenya.

The first time I met the family they were the most politically opinionated group I had ever met.

They were optimistic that the 2007 General Election would bring real change to the country at last, and they would not hear of any argument running counter to their expectations.

They were ecstatic whenever they heard their candidate speak, and would switch off the television set or radio whenever they heard his opponent speak.

They would have done anything to ensure their candidate won and, indeed, they did do everything in their power to campaign for him. Suffice it to say that despite the war that broke out after the General Election, their candidate is today one of the principals in the grand coalition government.

The above family represents most Kenyan homesteads in the run-up to the last General Election. Only a minority managed to stay away from the euphoric mood preceding the most closely contested election in our independent history, and the subsequent events have affected all Kenyans.

Last week when I sat down with some members of this family, the mood was decidedly different. There was a sense of dejection that was informed by a perception of betrayal by “their” principal.

Reminded of their enthusiasm before the General Election, most of them just shrugged their shoulders.

They claimed that they had hoped for better things than they have experienced since the election. They had hoped for constitutional change, better infrastructure, improved governance and a sense of pride in being Kenyan.

Instead they had been rewarded with post-election violence, famine and hunger, political instability, water and electricity rationing and rising unemployment.

This disillusioned family is a microcosmic representation of the state of the Kenyan nation at this point in time. Disillusioned youth all over the country’s shopping centres are hankering after anyone peddling hope, but are instead coming away with more hopelessness and despondency.

People are vowing never to vote again, and even the chair of the Interim Independent Electoral Commission was recently heard lamenting about the apathy attending the forthcoming by-elections.

The rulers of the land are tottering from crisis to crisis, appearing singularly uncoordinated in their interventions, and promising special funds for one proposal after another.

As has been argued eloquently by others before me, the land is ripe for revolutionary change. Those of us that dismiss this talk of revolution are only expressing our comfort with the status quo and fear the unknown consequences of radical change.

One thing we learn from history is that change is inevitable, and those that stand in its way are often swept aside and replaced by those that prepare for it and ride it to a new dispensation.

The tragedy with unmanaged change is that it often develops a life of its own, and is prone to being hijacked by diverse forces with interests ranging from the truly altruistic to completely personal ones.

My visit with this family on the outskirts of Eldoret town left me convinced that unless something drastic happens, this country is headed into such a dark hole that it may not manage to emerge from it whole.

Urgent measures must be taken to start tackling the root causes of the huge gap between the rich and the poor. Long-term plans to tackle hunger and unemployment must be activated, and the results must begin to be felt sooner rather than later.

The recent frantic efforts by the two principals to deal with the famine in the country, though laudable, are in fact a continuation of old thinking and approaches.

Most of their actions betray a certain difficulty appreciating novel realities that demand new approaches in dealing with the challenges of the 21st century.

Continuing bickering over matters of national importance such as environmental conservation, health care and even taxation demonstrates a dangerous insularity on the part of our political class, and the consequences to national well-being are obvious to any observer.

Those that have coined the phrase “Round hii si mchezo” (This time it’s no joke) have no idea just how far the movement they are unleashing may be willing to go for real change in the country.

It is useful to remember that most of those that participated in the post-election violence were youth who felt they had no stake in the national economy and were, therefore, willing to destroy the very infrastructure that supports it.

Unless the coming revolution is harnessed and used to introduce a radically new order in this country, it will inevitably be hijacked by blood-thirsty brigands who will not hesitate to destroy whatever they can lay their hands on in the name of correcting “historical injustices”.

Dr Lukoye Atwoli is a consultant psychiatrist and lecturer at Moi University’s School of Medicine

Sunday, August 16, 2009

Opportunity to define place of mental health in Kenya

Opportunity to define place of mental health in Kenya
Sunday Nation 16 August 2009, Page 31

This week, the Kenya Psychiatrists Association (KPA) holds its first annual scientific conference in Mombasa from 21 to 23, 2009. The theme of the meeting is “Transforming Mental Health Services in Kenya: Challenges and Opportunities”, and various sub-themes run the entire gamut of mental health theory and practice.

Historically, mental health has been narrowly defined in the context of psychiatry, which deals mostly with disorders of the various mental functions and how to treat them.

Within this narrow definition, mental health has been characterised as the poor relation of “more important” medical specialties including internal medicine, paediatrics and surgery. This has led to a false dichotomy between “mental health” and other areas dealing with the human mind such as counselling, psychology and even drug rehabilitation.

Contrary to this narrow definition, mental health deals with all functions of the human mind and their behavioural and social correlates. The World Health Organisation in fact defines mental health as “a state of well-being in which the individual realises his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community”.

By holding the first meeting of its kind in this country, KPA is signifying the coming of age of mental health as a super-discipline encompassing all the areas of human existence.

This meeting will be attended by specialists from all fields of mental health, and not just psychiatrists, indicating a convergence of all the positive forces that are struggling with limited resources to deal with problems that would eventually overwhelm the fabric of the state.

An indication of the role mental health has played in our history comes from an unlikely source. The colonial government was once so peeved by the challenges to its power that it declared some freedom fighters “insane” and dealt with them as such. One Elijah Masinde of Dini ya Musambwa was said to be delusional for stating that the white man would not rule Kenya forever, and for his troubles he was “admitted” to the Mathari Hospital!

Some of the people who were incarcerated in concentration camps in the 1950s are still alive today, and a recent study found that over two-thirds of them have suffered a severe mental disorder (post-traumatic stress disorder) as a result of their detention experience.

Due to the official neglect of these individuals, they continue to suffer without any hope of succour, and their offspring enter the same vicious cycle of poverty and despondency.

Violence and mental health have been demonstrated to have an intricate relationship. Exposure to violence, as in the case of the concentration camp survivors, increases the risk of development of mental disorders. Indeed this is the rationale behind offering counselling and other mental health services to survivors of rape and other forms of interpersonal violence.

On the other hand, certain mental illnesses can also increase the probability of an individual becoming violent or even inciting violence. It is a fair bet that at least some of the perpetrators of the violence that rocked this country last year had some sort of mental disorder that made it easier for them to contemplate violence rather than other means of conflict resolution.

Poverty also enjoys a dual relationship with mental illness in that it may act as a stressor, precipitating mental illness in a vulnerable individual, or it may occur and worsen as a result of mental illness.

The productivity of mentally ill people drops drastically unless the illness is treated, and mental illness remains very expensive to treat in this country given that most of the treatment is covered by out-of-pocket expenditure by families.

It can thus be powerfully argued that poverty will be that much more difficult to eradicate as long as the mental health of the population remains unaddressed.

One of the greatest barriers to achieving mental health in this country is the overwhelming stigma attached to people with mental disorders and those that care for them. This stigma not only emanates from the lay population, but also from well-educated professionals, including medical personnel. It stands in the way of people seeking timely mental health services, resulting in unnecessary complications and loss of productivity.

The people and the Government of Kenya owe it to themselves to start thinking about innovative ways of dealing with this stigma among other challenges that face the country today. The KPA meeting later this week will therefore provide an important forum to initiate an action plan leading to the development of a mental health policy that will help propel this nation to the greatness it aspires to.

Dr Lukoye Atwoli is a consultant psychiatrist and lecturer at Moi University’s School of Medicine

Sunday, August 9, 2009

President’s ‘two-tribe’ remark a recipe for disaster

Sunday Nation 09 August 2009, Page 33

Two weeks ago, President Mwai Kibaki visited Nyanza Province accompanied by Prime Minister Raila Odinga. A lot of what transpired during this tour was lost in the hype over the new-found rapprochement between the erstwhile foes, and much of the subsequent discussion has focused on this issue.

Lost in the cacophony was the very significant statement made by the President in an attempt to crystallise the problem with our country. In his considered opinion, the problem with Kenya could be linked directly to the relationship between “our two communities”.

At a public rally in Ugenya, he declared: “Each time we have worked together, Kenya has done well. And every time our two communities have fallen apart, Kenya has suffered.” The equanimity with which this statement was received seems to indicate that most Kenyan leaders consider it a truism not worth debating.

It seems we all agree that the history of this nation is largely the story of the relationship between the Kikuyu and the Luo, and that other tribes have only played supporting roles in the entire saga.

While exhorting the local community to help the nation’s leadership end tribalism, the President went ahead and asked them to work with “his community” for the betterment of the nation. The fact that nobody noticed any contradiction in these statements serves only to indicate that ours is still a nation in which the leadership has nothing to fear, no matter what they say or do in public.

These remarks constitute a massive slide back to our colonial past where no Kenyan had any identity beyond his or her tribe, and the sins of the leaders would be visited on their tribesmates across the breadth of the country.

Whatever imperialist structures were left behind were inherited lock, stock and barrel by the independence leaders, most of whom we can, with hindsight, characterise as being perfect examples of spectacular leadership failure.

Manifestly, our top leadership is still labouring under the same tribal millstones their forebears had to deal with, while the youth remain rudderless because they were brought up on a staple of lies about a united nation called Kenya where one is judged by the “content of his character” and not the surname of his paternal grandfather!

The view that the destiny of this country depends on the relationship between the two tribes further perpetuates the fallacy that the President and Prime Minister are indeed anointed leaders of their tribes, and locks the door on any idea of leadership change in their communities and, by extension, in Kenya.

It also indicates a disdain for the other tribes that make up our diverse nation, insinuating that their roles in the formation of the independent republic were at best peripheral. The President has, with this statement, only added fuel to the fire of the “Tribe Kenya” initiative which refuses to entrust data on tribe to a cabal that is determined to use this information for political deal-making and not for any other useful purpose.

For the avoidance of doubt, it must be clarified that the President is not alone in proclaiming this tribal philosophy. He joins the infamous company of politicians who keep calling for alliances between their tribes and others for purposes of winning political contests.

Terms like the Western Alliance, Kamatusa, Gema and more recently the KK (Kikuyu-Kalenjin) alliance have become such permanent fixtures in our political lexicon that nobody raises an eyebrow when they are mentioned.

It must be stated for posterity that Kenya is bigger than any single individual, and that the nation is greater than the sum of its tribes. Assertions of tribal collaboration and affinity are therefore inimical to the national interest, and only go to entrench some of the poison that has been responsible for most violent confrontations in this country.

As a matter of fact, the post-election conflagration that these leaders are deigning to gloss over with their camaraderie was partly triggered by the perception that the election was primarily about tribes rather than parties or even individuals.

The problem with Kenya has nothing to do with any two tribes failing to work together, but everything to do with our political leadership taking advantage of our ethnic identity to ride roughshod over the national interest in the name of fighting for “our community”.

Our national leaders will do well to focus on true national reconciliation and enable an enlightened debate on Kenyan nationhood.

Without an attitude change where each individual Kenyan is considered important in his or her own right, and not as a member of some tribe, the existence of this country as a cohesive entity in the next few decades is in serious doubt.

Dr Lukoye Atwoli is a consultant psychiatrist and lecturer at Moi University’s School of Medicine,

Sunday, August 2, 2009

Constitution: Furore over Kadhi Courts much ado about nothing

By Lukoye Atwoli
Sunday Nation 02 August 2009, Page 46

This past week Christian clerics of all shades and descriptions have been falling all over themselves pontificating against the inclusion of Kadhis' courts in the constitution of Kenya. The clerics are also arguing against the decision by the Committee of Experts to exclude these courts from the list of contentious issues and would like the debate to be reopened.
The uproar from these Christian religious leaders has not come as a surprise to those who have keenly followed the events surrounding this country's repeated attempts at constitutional review.

These leaders always emerge during critical periods to vociferously oppose having the Muslim courts entrenched in the constitution. As a matter of fact the Wako draft was rejected at the 2005 referendum partly because of these Christian clerics' protests.

These clerics know full well that their loud opposition to the Muslim courts in the constitution will result in equally forceful arguments in favour of the courts from Muslim clerics and faithful all over the country. They know in fact that arguing against these courts that are already provided for in the current law is tantamount to campaigning against a new constitution.

It is, therefore, not such a wild jump of logic to suppose that these clerics have no interest in a new constitution and are, therefore, using the Kadhis' courts as an excuse to cause such a furore that the whole process is rendered ineffectual. If this is true, then these Christian religious leaders must be exposed as one of the major stumbling blocks to achieving a new constitutional dispensation in our lifetime.

That being the case, they must be told in no uncertain terms that despite the assertion that the majority of Kenyans are identified as ``Christian'', most are in reality nominal Christians who cannot identify with the kind of fundamentalist posturing being exhibited by these pastors and bishops.

It is clear to most thinking Kenyans that despite their existence in our legal justice system for decades, Kadhis' courts have not been demonstrated to cause any harm to non-Muslims as they go about their day-to-day business. Nobody has yet been subjected to Sharia law in this country against his will; nor has anyone shown that application of the Kadhi court system has resulted in any harm to those that do not submit to it.

Assertions that Kadhis' courts constitute a misuse of taxpayers' money on one religion do not hold water, since Muslims are not ``one religion''; they are Kenyans with the same rights as all others. If they perceive the current laws to be inadequate as far as their personal matters are concerned, they have a right to use their own religious law to resolve them.

Quite to the contrary, it can be amply demonstrated that use of Kadhis' courts for personal law and religious matters serves to reduce the strain on the rest of the judicial system, thus saving the taxpayer a lot of money that would have otherwise been wasted on delays and other wastages in our courts.

Another argument being advanced is that the presence of Kadhis' courts in the constitution implies that Islam is the only recognised religion in the country.
This argument is fallacious since it assumes that the constitution controls every single function in the life of a citizen.


Ideally, the constitution only mentions certain specific issues on the premise that not doing so would result in possible injustice to segments of society. Not providing for Kadhis' courts would be putting Muslims at a disadvantage in matters of personal law.

Further, establishment of a state religion cannot be a tacit affair, and must be explicitly stated both in government policy and in the basic law of the land.

Christian clerics are called upon to play a major role in achieving a just and cohesive society, and fighting the Kadhis' courts goes against this noble ideal.

Any misgivings about the manner of implementation of these courts in the new constitution can be more soberly debated without the emotive rhetoric being currently employed.

As it is, the dispute is already generating a lot of unnecessary heat with Muslim clerics organising themselves to respond forcefully to the perceived onslaught on their faith. This is tantamount to adding fuel to an already raging fire, and must be contained at all costs.

The clamour for a new constitution will only end when we agree on a process of give and take, given that these zero-sum games only end up perpetuating the status quo.

If everyone were to predicate their acceptance or rejection of a new constitution on a single clause, Kenyans would do much better waiting for Godot than anticipating a new constitution.

Dr Lukoye Atwoli is a consultant psychiatrist and lecturer at Moi University's School of Medicine