Traditional healers for mental health care in Africa

G lobal mental health is primarily concerned with reducing inequalities in the access to health care and health outcomes for people with mental illness within and between countries (1). Reducing the vast treatment gap and promoting the rights of people with mental illness to live with dignity are major goals of adherents of the field such as the Movement for Global Mental Health (www.globalmentalhealth.org). In this context, the thesis by Abbo summarised in her PhD Review paper in Global Health Action (2) is a timely reminder of the role of a key player in the mental health care system in African countries where the biomedical treatment gap is notably large the traditional healer. Her series of studies in Uganda show that a variety of indigenous labels are used by traditional healers to describe what biomedical psychiatry categorises as psychotic disorders and that these are associated with a range of explanatory models, from supernatural/spiritual causes to somatic causes such as HIV. The prevalence of any mental illness amongst patients seeking help from traditional healers is very high and, notably, the vast majority of persons with psychotic disorders were also concurrently seeking help from the biomedical sector. There was a strong association of mental illness with indicators suggestive of poverty, such as lack of food or indebtedness and, amongst those patients who had a psychotic disorder, being in debt was associated with poorer outcomes. These findings serve to replicate a rich record of evidence from several countries in the region, going back several decades that testify to three major findings: severe mental illness is clearly recognised as causes of illness and suffering by indigenous communities, poverty and mental illness frequently co-exist, and traditional healers plays a prominent role in mental health care. Each of these findings has important implications for global mental health. Firstly, the demonstration that not only were descriptions based on the biomedical classifications of psychoses recognised by the traditional healers, but that the indigenous taxonomy closely mapped on to the biomedical categories, is a major piece of evidence in support of the universality of these diagnoses across cultures and is consistent with the observations made in a review of explanatory models of mental illness in sub-Saharan Africa (3). This is a particularly relevant observation in the context of critiques of biomedical classifications of mental illnesses, which argue that they are largely derived from a cultural construction of ‘western’ thinking about mental health and represent an ‘Americanization of mental illness’ (http://www.nytimes.com/2010/01/10/ magazine/10psyche-t.html). That traditional healers with a completely different orientation to biomedicine should utilise a comparable framework to understand mental health problems serves, at least in part, to validate the biomedical framework and to demonstrate that people experiencing such psychological phenomena consider themselves sick or, at the very least, struck by some misfortune and have sought help from times well before biomedicine became established. Put simply, this evidence demonstrates that severe mental illnesses are not the fabrication of a universalist biomedical psychiatry. Secondly, the demonstration of the strong association between indicators of poverty and the prevalence and outcome of mental illness is consistent with the large body of evidence from all regions of the world that poverty and mental illness frequently co-exist (4). While Abbo’s research does not offer clues to the mechanisms that underlie this relationship (2), it is clear from other evidence that the pathways between mental illness and poverty are complex and bi-directional (4). Crucially, this evidence not only demonstrates that living in poverty increases the risk of developing a mental illness but that, as Abbo’s work also shows, living in poverty is associated with a worse outcome of the illness. A key question that arises is the potential for interventions targeting the alleviation of poverty on mental health; a recent systematic review has found that the evidence on the mental health impact of poverty alleviation interventions was inconclusive, with the exception that some conditional cash transfer and asset promotion programmes showed benefits (5). The inconclusive evidence was largely due to the very limited quality research addressing this