Sunday, October 23, 2011

War in Somalia: Clear objectives needed


Sunday Nation 23 October 2011

Last week, we declared war on the al Shabaab militia that was accused by our government of masterminding kidnappings and attacks on targets within our territory. A declaration of war is not a light thing, and certain procedures needed to be followed.

Since we were committing our military and economic resources to the objective of eliminating the terror threat to our country, one would have expected the commander-in-chief of the Kenya Defence Forces address the nation, laying out the reasons for the declaration of war, the objectives of the war, and how we will know when we have achieved those objectives.

Instead, we got a press statement from the ministers for Defence and Internal Security. To their credit, the ministers outlined a cogent case for a war, enumerating the long chain of events that eventually led to the decision to attack al Shabaab deep within Somali territory. From their presentation, it is clear that the war is fully justified. What is not clear, however, is the objective of the war.

“Pursuing the terrorists wherever they may be” makes a good soundbite, but it provides very little information on the specific objectives of the conflict. A second bit of information that was missing from the statement concerned the end-point and exit strategy. Citizens do not expect to get fine details of the campaign, understanding that secrecy is part of military strategy.

Broad goals

However, broad goals of a conflict must be enumerated in order to help Kenyans to track the progress of our forces, and know when the time comes to pull out and let others continue with the war. This information needs to be provided by the commander-in-chief, who was technically given that responsibility by the Kenyan voter.

HG Wells, writing in “Outline of History”, says that “war is a horrible thing, and constantly more horrible and dreadful, so that unless it is ended it will certainly end human society”. It is for this reason that a nation must not contemplate the decision to go to war lightly, and when it does, the strategy, objectives and end-points must be very clear both to the soldiers and to the general population.

In our case, those of us that support this action can imagine one main short-term objective for this war, with a related secondary objective riding on it.

The main short-term objective, in my view, should be to create a buffer zone between Kenya and Somalia.
This zone should be heavily policed to ensure that no militiamen enter our country to terrorise Kenyans with impunity.

The secondary aim of this incursion into Somalia should be to use the buffer zone to enable the transfer of the refugee camps in the North-Eastern region of our country to Somalia. Creating a secure buffer zone will provide an environment that will allow the international humanitarian community to operate within Somalia, and free Kenya of the risks and responsibilities inherent in hosting a refugee population containing potential terrorist militia.

In the long run, it will then fall on the international community to provide support for the refugees nearer to their homes within Somalia, making it easier to re-integrate them into normal life when the situation improves in the rest of their country.

However, whatever the reasons for this war, we must continue to support our soldiers as they engage this amorphous enemy, and wish them quick success.

Dr Lukoye Atwoli is secretary, Kenya Psychiatric Association and lecturer at Moi University’s School of Medicine.

Sunday, October 16, 2011

Mental Health: Well done, but we can do better

Sunday Nation 16 October 2011

Last week on Monday I attended the World Mental Health Day commemoration at Mathari Hospital together with colleagues from all over the country. Workers of all cadres at the hospital put up quite a show, and included both the patients and the neighbouring community in the organisation of the event. The minister for Medical Services graced the occasion, despite having just arrived in the country from an official trip to India.

During the event, guests were conducted on a guided tour of the hospital, and one could not help but notice the great enthusiasm with which the management and board of the hospital are going about improving facilities and services at the hospital. Many of the wards were under renovation, the grounds were neatly kept, and the staff appeared to have some intrinsic motivation as they went about their duties.

All these are commendable achievements in the wake of international media revelations of patient abuse and inadequate services to clients at the only national referral hospital for mental health in the country. It is difficult to blame the staff who are doing the best they can under the most difficult of circumstances to serve the most neglected segment of our society.

It is, however, important to note that whatever little has been achieved by this facility has been done under the most formidable odds possible. The national hospital operates with the budget of a district (or sub-county) hospital, and is graded as Level 4 as far as allocation of resources is concerned. The buildings being spruced up at the facility were built in the early 20th century, and most cannot be certified for human habitation if they are properly inspected.

Indeed, the hospital board seems to have realised just this, and during our visit to the hospital they presented to the minister and Afya House officials a blueprint for a new hospital to serve as the national referral facility for mental health.

This, in my view is the crux of the matter. The minister promised to do all in his power to ensure that the master-plan was implemented, and undertook to present a Cabinet briefing to his colleagues to initiate the sourcing of funds to make it a reality. He also promised to advocate for increased allocation to the hospital, and to mental health services in general, to better address the mental health of our nation.

In my opinion, we must hold the minister, and by extension the entire government, to account over this promise. We must interrogate the government’s spending priorities to ensure that mental health is included at all levels of health expenditure, and that mental health programmes are designed and implemented all over the country.

We must do these things not because any particular individual stands to benefit from the resultant improvements, but because it is the right thing to do.

Better funding

We must insist on better funding for mental health and health programmes because no nation in the whole world has ever prospered without ensuring that the whole population has access to the highest quality of health care services available within its borders.

We must recognise that failure to improve our mental health services guarantees several generations of mediocre leadership and under-achieving technocrats, leading to continued retrogression and needless suffering.

Dr Lukoye Atwoli is the secretary, Kenya Psychiatric Association and lecturer at Moi University’s School of Medicine

Monday, October 10, 2011

Why budgeting for mental health care is crucial

Sunday Nation 9 October 2011

Every year, October 10th is marked as the World Mental Health Day all over the world. This year’s theme is “Investing in Mental Health”, an issue that has been on top of the agenda for the mental health community for a long time.

Concerns about under-investment in mental health are backed by global budget figures, with the World Health Organisation (WHO) estimating that most low and middle income countries invest less than 2 per cent of their total budgets in mental health activities, the bulk of which goes to fund mental hospitals and pay workers.

In Kenya, our government continues to pay lip service to the Abuja Declaration that suggested that at least 15 per cent of the budget should be dedicated to health, and our health expenditure as a proportion of total expenditure has been declining steadily over the years. Additionally, health expenditure on mental health remains abysmal at less than 0.5 per cent, most of which goes to pay salaries and allowances of staff at ministry headquarters.

Mental ill health contributes a significant burden of disease globally, more so in low income countries such as Kenya. According to the WHO, depression is currently the leading cause of disability worldwide, and it is further estimated that one in four people will be affected by a mental
disorder at some point in their lives.

These statistics are even worse in Kenya, where no community-level intervention exists to reduce the burden of mental ill health.

No care

Due to under-investment in mental health, it is estimated that over 80 per cent of people with mental disorders in our country do not receive any sort of care, and many go through life believing that it is normal to suffer as they do.

The reason the government continues to ignore mental health in the budget might be attributed to the false perception that mental illnesses do not kill. Quite to the contrary, mental illnesses can and do kill millions of people annually.

For instance, a person commits suicide every 40 seconds somewhere in the world. Most of those that commit or attempt to commit suicide have severe psychological and social distress that can only be addressed by properly organised and funded mental health services.

Additionally, 2.5 million deaths annually are due to harmful use of alcohol, an area of immense concern in mental health. Kenya is among the countries identified as having a large proportion of people with harmful alcohol use, and it is conceivable that many of our “road accidents” are due to alcohol and other substance use.

Mental ill health also increases the risk of acquiring and dying from other serious medical conditions, including HIV/Aids, Diabetes, Cancer, and infectious diseases. Investment in mental health will, therefore, be useful in bridging the service gap in these areas, enabling the provision of care at different levels for people with mental

Budgeting for increased training of mental health personnel, improved infrastructure, hiring more staff, and providing medications and other resources must be prioritised if we are to make a dent on the burden of mental ill health.

Finally, as part of full implementation of the Constitution, the government must take steps to actualise the citizens’ constitutional right to, among other things, the “highest attainable standard of health”, a right that includes access to good quality mental health care.

Dr Lukoye Atwoli is secretary, Kenya Psychiatric Association and lecturer at Moi University’s school of medicine

Monday, October 3, 2011

A December election date is a recipe for a disaster

Sunday Nation 02 October 2011

The Constitution of Kenya, Article 118(1)(b) provides that Parliament shall “facilitate public participation and involvement in the legislative and other business of Parliament and its committees”. This is the spirit in which the following piece has been written.

Recently, the minister for Justice published a Bill seeking to amend the Constitution to provide for, among other things, a change of the election date from “the second Tuesday in August to the third Monday in December of every fifth year”.

In the memorandum of objects and reasons for the amendment, a couple of brief sentences purported to explain the reason behind the change of dates.

In the first paragraph, the Memorandum reads: “The Bill further seeks to bring clarity and certainty to the term of the tenth Parliament while also removing any doubts as to the date of the next general elections under the Constitution of Kenya 2010.”

The other sentence concerning the election date reads: “The Bill also proposes to amend Articles 101(1), 136(2)(a), 177(1)(a) and 180(1) of the Constitution by introducing a date that settles all controversy surrounding the date for the next general elections.” There is no mention of the budget cycle, a popular explanation from government, nor is the nature of the controversy discussed.

Legal scholar

Opinions expressed on this matter have been largely meant to justify firmly held positions. Indeed, just last week, eminent legal scholar, Prof Yash Pal Ghai and colleagues argued that the Sixth Schedule of the Constitution provides for an election in early 2013.

In reality, the only date provided for in this schedule is in part 3, Article 9(2), which provides that in case the government “is dissolved and general elections held before 2012, elections for the first county assemblies and governors shall be held during 2012”.

Obviously, the framers of this section anticipated that, all factors remaining constant, the General Election would be held “during 2012”, with the only date provided for being the second Tuesday of August.
Quite apart from the legal and constitutional reasons against a change of date from August to December, it is important for Kenyans to contemplate for a moment the implications of a December election date on the national psyche.

Let us for a moment flash back to the 2007 post-election violence. Majority of the perpetrators and victims were thought to have been young males aged between 15 and 25 years. Many of them were school-going youth, and some had just undergone initiation ceremonies that are often held during the long December school holidays. All of them were idle, and provided the perfect substrate for politicians in need of cheap hands for hire.

Research has shown that this demographic segment is the most violence-prone, especially when they are poor, unemployed and have weak social support networks. One of the ways other societies have reduced violence is by keeping these youth in school, providing employment, and offering opportunities for fulfilling social interactions when they are idle.

Is it not conceivable, therefore, that an August election date would potentially be less violent than a December one? Due to the short holiday, students busy preparing for national examinations will probably not be available for “political violence”.

If only for the sake of peaceful elections next year, we must avoid a December election date by all means.

Dr Lukoye Atwoli is a consultant psychiatrist and lecturer at Moi University’s school of medicine