Insurance ‘exclusions’ a breach of the law

By Lukoye Atwoli
Sunday Nation 19 January 2014

People with mental illnesses tend to be poorer than those in good mental health for several reasons. First, poverty appears to increase the risk of several mental illnesses, especially the more severe, debilitating ones. This is because the social environment plays an important role in determining an individual’s mental health, apart from their physical and psychological condition.

Second, mental illnesses inevitably interfere with an individual’s ability to attend to their daily activities, reducing their potential to earn an income and achieve prosperity. Obviously, then, poverty and mental illness create a vicious cycle that obviates the need to attempt to discover which of them came first.

Eventually, in order to address either condition, one must deal with the other. Thus in treating mental illnesses, measures must be taken to ensure continued productivity of the patient and, similarly, poverty eradication must build in measures to address mental ill-health.

In Kenya, most people pay for their health care out of pocket, and only a tiny minority can afford medical insurance. This is more so for those suffering from mental disorders. Getting a chronic illness, such as a mental disorder, is therefore often a ticket to poverty for most Kenyans. 

EXCLUSION CLAUSE

Unfortunately, it is now emerging that even having medical insurance is not enough for many people with mental illnesses. Many insurers are getting into the habit of using the flimsiest of excuses to exclude payment for the treatment of mental illness. The commonest excuse is that there is a mental illness exclusion clause in the policy.

Other insurers, who purport to cover mental illnesses as well, often refuse to pay for treatment of specific conditions. The most commonly encountered “exclusions” are alcohol and substance abuse and suicidal behaviour. It is time we put an end to this inhumane behaviour that causes so much suffering for families that are already distressed.

Section 46 of the Mental Health Act, Cap 248 of the Laws of Kenya, provides that “no insurance company shall make any insurance policy providing insurance against sickness, which excludes or restricts the treatment of persons suffering from mental disorder.” Part two of this section makes it an offence to make such an insurance policy.

What this means is that every person in Kenya who has any insurance against any sickness is covered for treatment of mental illness. No insurance policy can reverse this. Therefore all those purported “exclusions” are in breach of the law, and any insurer who engages in such behaviour can be sued and compelled to pay for the treatment of mental illness. 

LEGITIMATE EXCLUSIONS

As to the argument that alcohol and other substance-related disorders can be legitimate exclusions, this is what Section 2 of the Mental Health Act has to say:

“Person suffering from mental disorder” means a person who has been found to be so suffering under this Act and includes a person diagnosed as a psychopathic person with mental illness, and person suffering from mental impairment due to alcohol or substance abuse (emphasis mine).

In other words, alcohol and substance abuse (and related disorders) are rightfully considered as mental disorders for the purposes of Section 46, and no insurer can refuse to cover them for any reason whatsoever.

Unless insurers stop this discriminatory behaviour, they must prepare for the flurry of litigation that will inevitably come as Kenyans increasingly become aware of their rights! 

Dr Atwoli is a consultant psychiatrist and senior lecturer at Moi University’s School of Medicine. lukoye@gmail.com

Enough of blaming others for our mistakes

By Lukoye Atwoli
Sunday Nation 12 January 2014

Observing social discourse in Kenya, one notices a subtle shift in explaining the distribution of poverty and under-development in certain areas and among individuals. In the past, within relatively homogenous groups of Kenyans, the discussion invariably veered towards “marginalisation” by the dominant tribe(s) in government.

One community, or coalition of communities, would be labelled as oppressors of the majority, and all members of this group would be accused of all sorts of ills that resulted in most others sinking into poverty and want.

Among the so-called “oppressors,” however, the explanation for the opulence in their midst would be put down to hard work and innovative entrepreneurship. They would argue that they worked as individuals to build their wealth, and that those who enjoyed any favours from the State were in the minority and often transcended the tribe barrier.

They would cite examples of people from other tribes who have been engaged in large-scale looting of State resources, and were extremely wealthy, while their own communities remained largely dirt-poor. 

REPETITION OF INCOMPLETE NARRATIVES

This group was also more likely to explain the high poverty levels in the rest of the country as being a product of laziness, excessive politicking, or lack of the entrepreneurial spirit.

Both these groups exemplify how insulating operating in an echo chamber can be. Repetition of these obviously incomplete narratives turned them into some sort of fact, gradually growing into self-fulfilling prophecies. Many otherwise able-bodied youth would resort to begging or extortion, or other more serious criminality, arguing that due to “marginalisation”, they were unlikely to make it legitimately in this country.

Almost all members of the “marginalised” group would be astounded whenever one expressed a contrary opinion placing the larger share of the blame on the complainers themselves. On the other hand, the wealthy “oppressors” would be shocked to learn that there are genuinely hard-working Kenyans who had been shafted by the system, whose property had been looted, and whose opportunities had been shrunk by operation of the largely ethnic-based system of cronyism.

The long and short of this piece is to demonstrate how things have changed today. A new coalition of “complainers” is emerging, and it has succeeded in resurrecting an old ghost to aid its cause. Today, the colonialist and his neo-colonialist ally are the main cause of our problems, and any indigene who thinks otherwise is dismissed as their lackey simply doing the bidding of his “foreign masters”.

Growing up in the 80s and 90s at the peak of Nyayo’s power, one was made acutely aware of the actual meaning of such terms. Being called a subversive under the influence of foreign powers always meant the withdrawal of the privileges of citizenship, and existence at “president’s pleasure”.

Critically examining the re-emergence of this phenomenon leads one to only one conclusion: We are constantly looking around us for scapegoats that can explain our failures in life, and we are averse to taking responsibility for the negative consequences of our actions.

In 2014, one can only hope that we shall discard this time-wasting habit, examine our own actions and resolve to make better decisions and accept the concomitant results. In order to develop this lovely country of ours, we must leave the West (or the “other” tribe) out of it!

We determine our own destiny!

Dr Atwoli is a consultant psychiatrist and senior lecturer at Moi University’s School of Medicine. lukoye@gmail.com

Suicide a leading cause of death among youth

This post was delayed due to multiple mishaps in the office that would merit full posts in their own right! My apologies, though, for this late posting.

Enjoy your read!

By Lukoye Atwoli
Sunday Nation 05 January 2014

Last week, an acquaintance of mine on social media committed suicide. I had never met him, but he would occasionally comment on my posts and carry on very “normal” online conversations. By all appearances he was a successful professional. He had been married for a couple of years and, at the time of his death, he had a one-and-a-half-year-old son. All this information could be gleaned from his Facebook profile.

I learned of his death one morning when I noticed many messages mentioning his name and following this up with the initials RIP. One of his friends posted: “Why did you have to do this? Was there no other way?” My curiosity was aroused and, on scrolling through his page, I came upon a post in which a close friend of his indicated that he had committed suicide.

That same week, a colleague called me to discuss a mutual patient. Some time in the past he had referred the young man to me for treatment of his mental illness with frequent suicide attempts. We had achieved a measure of success in his management but, after some time, he stopped coming for follow-up.

My colleague was calling to inform me that the young man had also committed suicide. He had seemed well in recent months, and was even enrolled in university pursuing a prestigious course. One day he simply did not leave his room, and when his colleagues went to check on him, they had to break down the door to get in. They found him lying lifeless in bed, having taken a lethal concoction.

I have gone to great lengths to modify the identifying information in these stories in order to protect the privacy of the grieving families, but they do represent an epidemic that is happening all around us. Suicide is emerging as a leading cause of death among young Kenyans in their most productive years, rivalling well-known killers such as road crashes, Aids and other chronic diseases.

Traditionally, suicide was frowned upon in most societies, and some had even developed very elaborate funeral rituals for those that died by suicide. In some communities in western Kenya, for instance, a person who died by suicide would be buried by strangers at night without any honours. There would be no proper mourning or memorial ceremonies and his name would be erased from the community narrative. No child would be named after him. Similar rituals exist in most communities.

The upshot of this is to make suicide appear as a personal choice, a manifestation of weakness or evil on the part of the attempter, and a reason for punishment rather than assistance. The result is that those that unsuccessfully attempt suicide are ridiculed and ostracised, often being urged to find other ways of dealing with their problems.

The unfortunate truth is that suicide is often a manifestation of serious psychological or social problems, and the attempter has reached a determination that these problems are so intractable that the only solution lies in killing themselves. Such a person needs help rather than condemnation.

I believe it is time the government declares suicide a national disaster and unveils measures to address this growing problem. 

Dr Atwoli is a consultant psychiatrist and senior lecturer at Moi University’s School of Medicine. lukoye@gmail.com

Looking forward to a happier new year

By Lukoye Atwoli
Sunday Nation 29 December 2013

In a couple of days, Kenyans will welcome the year 2014, largely hopeful that it will be a better year than 2013 in more ways than one.

Firstly, we all hope the security situation will be better next year than it has been this year. Since the beginning of this year, it seems our savage instincts were unleashed, and criminal violence has been reported all over the country. From so-called “cattle-rustling” through terror attacks to “normal robberies” with fatal consequences, no location in Kenya has been spared.

Despite the resolve displayed by the government in dealing more firmly with the security crisis after the Westgate terrorist attack, things have gone back to “normal”, with no visible changes in the security apparatus to increase the citizens’ confidence. One hopes that this will change in the coming year, and that the security of Kenyans will take precedence over other considerations in this government.

Secondly, it has lately become evident that the health sector is in disarray. Rushed devolution without first putting in place adequate structures resulted in a protracted strike by health care workers across the country. Despite clear constitutional provisions dividing health functions between the national and county governments, both levels of government spouted fallacious arguments that health is a “100 per cent devolved function”. Going by the chaotic processes of human resource management already being displayed, it is clear that it will become increasingly expensive for Kenyans to get sick in the coming days. 

Ironically, the relevant arms of government have belatedly discovered this danger and are now cautioning county governments against rushing to take over human resource functions that are currently still under the Public Service Commission. One can only hope that the government will listen to the grievances by public servants about ill-regulated devolution, and address them adequately in order to forestall further industrial unrest with the attendant suffering of hapless citizens.

Thirdly, the cost of living has been inching up inexorably over the past year. Government actions do not seem to inspire any hope of a respite in 2014. Increasing taxes and levies are constantly chipping away at the meagre earnings of Kenyans at the bottom of the barrel, and the year has ended with claims that State House is further pinching pennies from ministries for purposes of publicity.

Additionally, the President just signed into law legislation aimed at deducting a percentage of workers’ pay for purposes of social security, notwithstanding the fact that some may already be contributing to registered pension schemes. Unless government puts in place measures aimed at mitigating these escalating costs of living, there’s no telling where the situation will lead to!

Finally, we have spent most of this year under a cloud of uncertainty as to the legal status of our top leaders, who stand accused of crimes against humanity at the International Criminal Court at The Hague. Despite indications that at least one of the cases is severely weakened due to lack of witnesses, the prosecutor insists that she will go ahead with the case after further evidence collection. One hopes that this cloud will be lifted once and for all without jeopardising the prospects of justice for the victims and survivors of our post-election pogroms of 2008.

Notwithstanding all that though, may providence grant us a largely happy and trouble-free 2014! 

Dr Lukoye Atwoli is a consultant psychiatrist and senior lecturer at Moi University’s School of Medicine. lukoye@gmail.com

Distracted government allowing sabotage

By Lukoye Atwoli
Sunday Nation 22 December 2013

Last Thursday, I read a piece penned by the president’s speech-writer, decrying an unconstitutional parallel executive within the civil service. At about the same time, the health workers’ strike was entering the second week and the government was largely ignoring it. The Health cabinet secretary had dismissed the issues raised by health workers as frivolous and unconstitutional, and soon after that the president issued a similar statement asking the workers to end their strike.

Disturbing though it was, Eric Ng’eno’s piece captured very neatly the problem with our State at the moment. He argued that the constitutional executive is not in control of government, and a shadowy cabal is probably pulling the strings in the background. Indeed, the president and his deputy alluded to this during their recent Eldoret tour, accusing some Members of Parliament of having been bought by disgruntled businessmen who were losing out on government contracts.

The government is behaving like a creature under siege from all sides, lashing out at anything that moves in its vicinity. Some have commented that the Jubilee government is beginning to more and more mirror the Kanu State of the 1980s in which any dissenting voice was labelled an enemy of the people and an agent of foreign forces. Recent moves to stifle constitutional freedoms seem to confirm this retrogression.

It is difficult to understand why this is happening under this relatively youthful administration that seemed to be so connected to the needs of the populace that future election wins were guaranteed.

One needs not bother analysing Ng’eno’s claim that a powerful segment of the civil service stands in the way of reform and progress. Every administration inherits workers from the previous regime, and going out of one’s way to antagonise those workers has obvious consequences. In fact, despite expected resistance from those sections of the civil service, previous administrations achieved a significant measure of success in implementing their manifestos. This administration is in fact luckier than the government that took over from Kanu in 2002 which faced more inertia than any succeeding regime.

In my view, the main problem with this government so far is that the distinction between government business and personal affairs has been blurring progressively. The result is that whenever the leadership feels threatened, they act in ways that suggest that the entire nation is in peril. We have become the true embodiment of the old French imperial attitude that the King and the State are one and the same thing.

As it is, the president and his deputy have been for the most part distracted, dealing with one crisis after another, and it is obvious that the civil service remains unsettled by this. In the process, the business of government is suffering, and the voter is taking note.

People expected their lives to improve after the elections, not least because of the promises that were made during campaigns. When these improvements seem too late in coming, and what is said by government officials indicates that in fact some of the promises will be reversed, the citizen is bound to get restless.

The government will do well to step back from the strident rhetoric emanating from top officials, and develop a more coherent, forward-looking governance strategy. The alternative is to buckle up and prepare for planned or unplanned sabotage going forward. 

Dr Lukoye Atwoli is a consultant psychiatrist and senior lecturer at Moi University’s School of Medicine. lukoye@gmail.com