Recently, we discussed what is going on in the continent. Meeting as scientists involved in mental health research, education, and care, we found ourselves confronted by many questions.
One of the questions tackled was on the kind of care that is acceptable for our people in the context of limited resources. This is because we have had to deal with assumptions that poor countries will remain poor forever, and will therefore never be able to provide services that meet standards set by rigorous research.
Our governments have accepted the thinking that they must generate ‘cheaper’ alternatives whose quality might fall short of what is acceptable, but which are ‘at least better than nothing’. This thinking has percolated through all sectors of our economy that address social needs, and in health it has resulted in the institutionalisation of temporary solutions built on uncertain evidence.
In Cape Town this past week, we considered the idea that one can train a lay person for a few days or weeks in a complicated psychological treatment and then deploy them to provide the service in areas where there are no mental health workers. In fact, some countries have gone as far as training alternative mental health workers even on the prescription of common medications used for the treatment of mental illnesses.
The problem with this approach is that it completely ignores the fact that treatment interventions are at the tail end of a process. This process begins with an understanding of normal body functioning, and goes through what happens in disease, ending up with what needs to be done to correct the abnormality. Training people using algorithms that focus primarily on the treatment process is potentially dangerous given the risk of wrong diagnosis and the failure to appreciate limits should things go wrong.
This same problem was applied to the practice of medicine when a decision was made that the country was poor, and would remain too poor to afford proper medical care with well-trained doctors, nurses and other important medical staff. In their place, the government decided to train alternative cadres for all those, using accelerated curricula that focussed mostly on the things that are to be done at the tail end of a clinical process. Over time, these programmes have now become an end in themselves, and some have morphed into degree programmes taking almost as long as the training in the professions they were meant to cover in the first place.
Several names have been coined for this phenomenon, the commonest of which are ‘task-shifting’ and ‘task-sharing’. More recently, we have come to understand it as the concept of “poor medicine for poor people’, and this is unconscionable for any ethical health worker.
The culmination of our meetings in Cape Town was the launch of the African Global Mental Health Institute, with the mandate to collate what is known and to generate new knowledge, on mental health.
We must end the notion that African lives are cheap and can be experimented on without consequences.
Lukoye Atwoli is Associate Professor of Psychiatry and Dean Emeritus, Moi University School of Medicine; [email protected]