Breaking the shackles

Ghana is slowly developing its mental health care to protect human rights. Yet sensationalist journalism, including in the progressive media, continues to portray the treatment of mental health in the country as backward and abusive.

Photo by Etornam Ahiator on Unsplash

In February 2020, the British newspaper The Guardian published an article entitled “The scandal of Ghana’s shackled sick.” The article portrayed a grim picture of Ghana as a “mental health void.” There were, according to the journalist, only a “handful” of community mental health nurses in the country and medical facilities were “empty of psychiatric understanding.” The journalist met one of these nurses, Stephen Asante, who had set up an NGO, visiting families and healers, and working to free people with mental illness from their chains. However, there were problems with the supply of pharmaceuticals. “Since we ran out of medication, the only thing on offer is the chain,” he was quoted as saying.

The journalist and photographer were accompanying Human Rights Watch on a research trip to Ghana, the results of which were included in a report “Living in Chains,” which documents the shackling of people with mental health conditions in homes, healing centres, and hospitals, predominantly in Africa and Asia. Such reports on human rights and mental health in Ghana have become ubiquitous over the years. A 2012 report by Human Rights Watch depicting chaining and other human rights abuses in prayer camps, shrines, and hospitals cast Ghana in the spotlight of global mental health and was widely used to support calls for investment and research.

The Guardian article was accompanied by a series of carefully composed portraits depicting people chained to trees or locked behind iron grills, often alone. The overwhelming impression is of stasis, emptiness, and lack. These are familiar tropes of Africa: the place without history or innovation, where nothing changes; of starving bodies, deprivation and backwardness, awaiting rescue from outside of course. The images of chained Black bodies recall those deployed to argue for the abolition of the slave trade, the Black African on his knees, raising his shackled wrists in supplication—“Am I not a man and a brother?” In Lose Your Mother: A Journey Along the Atlantic Slave Route, the American writer and academic, Saidiya Hartman argues that these images reinforce the dynamics of the master slave relationship—the African must beg for his freedom, which rests in the hands of a powerful White saviour to bestow. The resonance with slavery is obvious but unmentioned (or unmentionable)—the chains and shackles that bind people with mental illness today are almost exact replicas of those used to forcibly capture and kidnap millions of Africans.

Such images, then as now, are designed to provoke shock and outrage. Yet psychiatrist and anthropologist Arthur Kleinman has cautioned against this “dismay of images.” While aiming to elicit compassion, they result in a particular kind of othering. The desperation of the “shackled sick” and the heroism of the lone mental health nurse construct a “tragedy” that hides as much as it reveals. In focusing the “foreign gaze” on chained African bodies within a landscape of scarcity and neglect, The Guardian article obscures significant advances in mental health care provision in Ghana, as well as the everyday struggles of health workers and families to provide care. Such gains have emerged from concerted advocacy by local actors over several decades, as well as the unheralded labor of ordinary mental health workers in hospitals and clinics across the country. They have been made in the face of decades of global indifference to the complex needs of people with enduring mental health conditions and retrenchment of public sector funding under neoliberal reforms promoted by donor governments of the former colonizing powers.

In an aside, the Guardian journalist mentioned that Stephen Asante was working “out of a hospital in Tamale,” a city in the northern region of Ghana, the only reference to the role of the country’s public health system in mental health. In fact, Asante is one of a rising number of mental health nurses trained and employed by Ghana’s health service, and posted around the country as part of a push to increase the reach of community-based mental health care. Indeed, compared to many countries globally, and certainly within sub-Saharan Africa, Ghana has a comparatively long history of community mental health care. From 1973, with the support of the World Health Organization and a British psychiatric nurse, mental health nurses were trained in community psychiatry and posted to community clinics. Political unrest, economic decline, and structural adjustment policies put a break on public expenditure and competing health priorities during the following two decades  prevented any significant expansion of the program. Most community mental health nurses remained clustered in urban centres, predominantly in the south of the country. However, over the last decade there has been a visible expansion of community mental health care in Ghana with ambitious plans to bring treatment “to the doorstep” of family homes and foster collaboration with traditional and faith healers to prevent chaining and other human rights abuses.

There are now over 2,000 community-based mental health workers employed by the health service, compared to less than 200 when I began research in Ghana 15 years ago. Another 2,000 work in the three public psychiatric hospitals in the south. Ghana has committed to opening a mental health unit at every hospital and clinic in the country, and is well on the way to achieving this goal. While the number of psychiatrists has also increased (now numbering 39, rather than the 13 inaccurately reported in The Guardian article), they are concentrated in inpatient services in the south. It is therefore mental health nurses like Asante who conduct the vast majority of community-based treatment of people with mental illness.

A few months after The Guardian article was published, I made contact with Asante. Like many Ghanaian mental health workers, he demonstrates deep commitment and compassion and an impressive ability to innovate and work around challenges, such as a lack of transport and reliable supplies of medication, in order to reach families in need. In a more recent Guardian article, Asante elaborated on the circumstances of the family who were providing care for Baba, one of the men depicted in chains. In this article, rather than abandonment or abuse, the emphasis was on poverty, and perhaps surprisingly, love. As Asante’s  piece made clear, chaining is not a necessary consequence of spiritual beliefs, stigma nor even the scarcity of services, but arises from the intersection of poverty, marginalization, and under-resourced health systems. Love, without the means through which to provide care, turned to hopelessness and neglect. As Asante recognized, meaningful and successful treatment required funds to purchase medicines, food, and supplies, alongside support and encouragement to enable Baba to resume his role in family life.

The chaining of people with mental health conditions around the world is of course something that we would all want to end. But when we see these images it is important to remember that in seeking to shed light on “hidden” atrocities, they cast other aspects into shadow. These may be the very histories we need to see in order to recognize what Seye Abimbola, professor of global health, calls “organic” change, arising through internal processes, policies, and dynamics, albeit, as in Ghana, in collaboration with international funders. Organic change—incremental, locally led, and embedded in local structures—is more likely to be sustained than the limelight-hugging, time-limited interventions of global humanitarian campaigns. Global media can play a vital role in making this kind of change visible, countering common media portrayals of Africa as helpless, backwards, and brutalized.

Further Reading

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