Zimbabwe Review Issue 21/2 June 2021 ISSN 1362-3168 The Journal of the Britain Zimbabwe Society BZS is 40! See page 15 for details of a special 40th anniversary meeting on 12 June 2021 What Kind of In-patient Psychiatry for In this issue ... Africa? Derek Summerfield reports 1 What Kind of In-patient Psychiatry for Africa? page 1 from Zimbabwe 2 Book Review: Blue Remembered Sky page 3 Global mental health is an expanding field. Yet 3 Names in Zimbabwe’s State capture page 4 little or no attention has been paid to evaluating 4 The Impact of COVID-19 on Student Life page 5 the culture of psychiatry prevailing in in-patient 5 Book Review: They Called You Dambudzo: a memoir by Flora Veilt-Wild page 6 services across Africa. 6 Book Review: Then a Wind Blew page 8 In Zimbabwe, in-patient psychiatry has been heavily 7 Remembering Joshua Mahlathini pathologising, with over-reliance on the diagnosis of Mpofu (1939 –2021) page 9 8 Obituary: Sister Janice McLaughlin page 10 schizophrenia and on antipsychotic polypharmacy 9 Zimbabwean gardens in the UK page 11 (using multiple medications simultaneously for one 10 News page 14 person). It is not helpful that the next generation of 11 BZS is 40! (Plans for our anniversary) page 15 African doctors are learning unmediated Western 12 Research Day 2021 (Zimbabwean Migration) page 16 psychiatry, with little credence given to background cultural factors and mentalities shaping presenta - which a person’s muscles contract uncontrollably), tions. Some of the psychiatric and social conse - which are commonly visible on the wards. There are quences of this for patients in Zimbabwe are also interactions between psychiatric medication and discussed here. the HIV treatment needed by many in-patients. People admitted after an event that might be time- A continuing legacy of colonial times limited – such as cannabis-induced intoxication or psy- Ingutsheni, in Bulawayo, is one of a handful of great chosis, or an episode of family conflict and violence to psychiatric asylums built by the British in the colo - property – are often discharged on open-ended antipsy- nial era across Africa. Today, it has around 725 in- chotics. There is no clinical case for this. Yet, if they patients, most admitted involuntarily, and the stop taking the medication, their families bring them majority have been there for years, even decades. back to the hospital, presuming that the doctors have Ingutsheni’s role in the regulation of a subject people deemed continuing use to be crucial to their health. was something the psychiatrist Franz Fanon, writing A further admission to restart unnecessary medica - in and about Algeria during that country’s war of in - tion follows. dependence, called the ‘pathology of colonialism’. I do not mean to point at the few doctors currently For the past three years I have been a visiting in post, rather at the continuing legacy of the psychi- lecturer in psychiatry at the National University of atric culture imported during colonial times. Science and Technology School of Medicine in The blanket use of an imported diagnosis such as Bulawayo, the country’s second medical school. ‘schizophrenia’ brings with it the negative reputation I observed that, at Ingutsheni, medical notes are it has had in Western societies – the assumption that often scanty but what stood out to me is the indis - the condition is chronic and an association with criminate use of ‘schizophrenia’ as a diagnosis, and disability in social roles and work. that, whatever the diagnosis or length of stay there, The senior sister on the ‘rehabilitation’ ward told virtually all patients are on ongoing antipsychotics, me that two-thirds of her patients, typically long-stay, invariably as well as anticonvulsant mediation, for were psychiatrically fit for discharge but that their unclear clinical reasons. families were reluctant to accept them back because These medicines have chronic side-effects such as Parkinsonism and dystonias (movement disorders in Continued on next page 1 Psychiatry: continued from previous page background is ignored and the Western psychiatric of stigma and the assumption that they would always canon is considered definitive. need medication and never be productive. A call to challenge ‘global mental health’ These perceptions also reflect the desperate times A crude and homogenised version of Western almost everybody is living through: widespread psychiatry may well operate across the continent in poverty and food insecurity, with the formal employ - in-patient settings and elsewhere, regardless of context. ment rate standing at around three per cent, and pub - As mentioned above, this is a pathologising system, lic services barely functioning. relying heavily on polypharmacy. It plays out in a con - The manufacture of a chronic psychiatric patient tinent whose central dynamic is poverty and hunger. Is These factors, in combination with the overuse of the this culture of psychiatry, which is passing to the next diagnosis of schizophrenia, contribute to the manufac - generation of African doctors, fit for purpose? ture of a chronic psychiatric patient, whose place in Medical school curricula should legitimate the the world is lost as their stay in Ingutsheni lengthens. part played by indigenous forms of knowledge, get - Yet in the 1970s the World Health Organisation ting students to see that socio-culturally shaped un - (WHO) international pilot study of schizophrenia derstandings are not merely incidental, but at the (which assumed a unitary condition worldwide) heart of the illness experience. There is no one ‘schiz - found that psychosis in non-Western countries (Nige - ophrenia’, and no one ‘psychology’. ria, India, Columbia) seemed to have a better outlook As the Ingutsheni cases demonstrate, these issues than in the West (USA, Denmark). create real consequences for patients and their fami - In Africa there are more cases of short-term, re - lies across Africa. Framing the question of what kind active psychosis or other stress-driven presentations of in-patient psychiatry would best suit Africa’s re - which should not be called ‘schizophrenia’. alities is the WHO-supported drive to encourage the At Ingutsheni, fourth-year medical students clerk ‘scaling up’ of Western-style mental health services patients (examine them and record their details) and worldwide. present them to me and another lecturer in clinical African governments are urged to invest in such seminars. Medical training is a formal engagement services, yet they have pitifully little money even for with modernity and the students know implicitly that physical healthcare – in Zimbabwe per capita expen - indigenous knowledge is outside modernity’s limits. diture on health is one of the lowest in Africa. Moreover, what wider costs may accrue when non- As a consequence, they tend to discount patients’ Western mentalities carrying culturally embedded and references to African interpretations of adversity – time-honoured forms of understanding and redress are which emphasise external agency via bad spirits or displaced by imported approaches based on a ‘techni - ancestors – and to remedies such as the use of tradi - cal’ view of mind which is assumed to be universal? tional healers. These are understood to be outside the framework of proper psychiatric assessment. Derek Summerfield is an honorary senior lecturer at For example, in one case, the patient’s predomi - London's Institute of Psychiatry and a member of the nant complaint was that ‘my ancestors want me to Executive Committee of Transcultural Special Inter - suffer’. This is a culturally unremarkable attribution est Group at the Royal College of Psychiatry. This for adversity in Zimbabwe (as generic here as ‘it was article is based on his paper What kind of in-patient God's will’ might be elsewhere). But the student psychiatry for Africa? Report from Zimbabwe, pub - understood that there was no place for this in the (im - lished on line by Cambridge University Press: 06 ported) psychiatric textbooks. Instead she interpreted January 2020 the complaint as evidence of formal mental illness, a References paranoid psychosis, as the textbooks – not written Jackson, L. Surfacing Up: Psychiatry and Social Order in Colo - with Africans in mind – seemed to dictate. Similarly, nial Rhodesia 1908–68 . Cornell University Press, 2005. Cross - RefGoogle Scholar stand-alone ‘hearing voices’ largely reflect a culture- Jablensky, A, Sartorius, N. What did the WHO studies really bound idiom of distress in Africans and not mental find? Schizophr Bull 2008; 34 :253–5.CrossRef Google Schol - illness. But in Ingutsheni, and doubtless elsewhere in arPubMed Africa (and, I have found, in the NHS too), auditory Summerfield, D. How scientifically valid is the knowledge base hallucinations alone in socially distressed people are of global mental health? BMJ 2008; 336: 992–4. CrossRef - assessed as denoting active psychosis requiring Google ScholarPubMed Summerfield, D. Afterword: against ‘global mental health’ . antipsychotics. This is what happens when cultural Transcult Psychiatry 2012; 49: 1–12.CrossRef Google Scholar 2 Book Review Blue Remembered Sky : Jill Boswell on Charlie Comins’s memoir of growing up at Ingutsheni psychiatric hospital in the 1950s In this complex and absorbing book, the author they seek out the house sets herself several tasks that may not at first servants: ‘It made no dif - glance seem readily related. ference that we couldn’t We start with what might be her first therapy session understand a word they with her counsellor, Sandi, and ends with her final were saying, for they never one. This suggests that the process of self-discovery shooed us away .’ has for the author been closely bound up with explo - Comins has stringent ration of many other lives in the Zimbabwe – or criticisms of the regimes at Rhodesia – of her past life. the Ingutsheni hospital, Much of the book concerns Comins’ childhood in her coming to realise that white colonial family in Bulawayo, where they lived for many patients there were 16 years in the grounds of Ingutsheni psychiatric hospi - treated with harsh anti- tal, where her psychiatrist father, Lionel, worked.