Some good may yet come out of it as the Chime affair draws attention to, pours much-needed light on and raises troubling questions about the issue of mental health in Nigeria. There is also an urgent need to revive the Mental Health Bill, which began its life in the National Assembly a decade ago. Cheluchi Onyemelikwe-onuobia explains…
The recent stories, reported in various media, surrounding Mrs. Clara Chime and her husband, the governor of Enugu State, have brought the opinions that I shared in my first article in THISDAY LAWYER in March this year where I wrote about reviving the mental health bill. As a professional and advocate who specialises in health law and has professional and personal interests in mental health, human rights, and domestic violence, I have found myself seeking to follow, mine, understand the undercurrents of both factual and sensationalised accounts of the case. As usual the comments and opinions of different persons including the National Human Rights Commission have been just as important and fascinating to me as the actual and alleged facts surrounding the case, not least because it is often an accurate barometer of our humanity or lack thereof.
These comments have addressed the issues of the appropriateness of otherwise of Mrs. Chime’s reaching out to the media and the National Human Rights Commission, the surprise that a medical situation like a mental health crisis could happen to someone in a privileged and public position, and following from that that medical help was not sought from specialists abroad as the Governor had recently benefited from, the alleged denial of access and more recently custody of their child, the political mileage that political adversaries may seek to milk from the situation, the alleged abuse that may allegedly have been the root of the mental health crisis, the alleged seclusion allegedly ordered by an alleged medical practitioner, and more recently, the forcible (by some accounts) return of Ms Chime to her family of origin (described in this particular paper as “bundling home”). These issues underscore public concern with issues such domestic abuse, mental health, human rights, privilege and power.
My intention in this article is not to rehash or dissect that particular case into pieces. I have no interest whatsoever in stirring the pit for salacious details. The reason is not as others say because it is a family or private matter. We often use the term “private matter” or “family matter” to cover up the grossest abuses. Anybody who has any knowledge of domestic violence or child abuse and other related issues, especially in relation to law enforcement, would find that phrase familiar and unappealing. Certainly illness – any illness – can, and for the most part should be a private matter. But given that press conferences have been given by both the Governor and Mrs. Chime, information released to the media by affected parties severally, the point about private matters and disputes becomes largely moot. Furthermore, if issues of alleged violations of human rights have arisen and been brought to the attention of the public, we have firmly and most assuredly moved from the private to public domain.
I am not taking this particular case apart, including the issues that raise my ire like the allegation that she is being denied access to her child, for other reasons. For one thing, I am unsure that it is helpful to Mrs. Chime; for another, I am certain that there are facts we are not privy to, and without the full facts one is necessarily limited in how deep one can only delve. Having said this, it is not difficult to see how Clara Chime’s cry for help seemed absolutely necessary to her. Were there any other way, given the circumstances, she would likely have taken it. Hopefully, it will benefit her, if not right away as one hopes, then in the long run. My hope is that beneath the noisy din currently surrounding that issue relevant authorities, medical and legal experts who have access to Mrs. Chime will do their very best to ensure that she is safe, her human rights are not infringed upon, she does not suffer any form of victimisation going forward, and that she has access to her child, and to the best medical and social support possible.
What that case has done, and this is the focus of this article, is to draw attention and to pour much-needed light on the issue of mental health in Nigeria. While there are other relevant issues that would also benefit from important discussions, I will focus on the issue of mental health, a much neglected area of health in this country. Instead of further sensationalising this very important matter, I will try to draw from it arising issues, lessons, and implications for our understanding of the wider concerns that underpin mental health in this country. To that end I will attempt to address some of the questions that arise. Many of the allegations have saddened and troubled me. The alleged facts raise some questions for that lady’s situation and for mentally ill persons in Nigeria more generally. For instance, under what circumstances can a mentally ill person be legally restrained or detained in Nigeria? Who makes that call and when? Can mental illness be sufficient ground for denial of access to contact with other people, including one’s children or family members? Is it necessary at any point to seek legal and medical intervention to ensure that the rights of persons who are mentally ill are protected even as their state of mind is taken into account? Are there existing mechanisms and institutions for ensuring that the human rights of people with mental illness are not trampled upon? How do we as people see mental illness? How much does stigma prevent uptake of necessary care and treatment? How much does the stigma surrounding mental illness and mental health challenges affect not only uptake of treatment but also our humanity, our understanding of what it means to care for others and to uphold their dignity alongside their treatment? These are broad concerns that are in urgent need of address. Within limited space, it is difficult to be exhaustive and address all the arising issues in depth but I will attempt to address some of them below.
The first issue I would like to address is stigma. If current estimates are right about twenty to thirty per cent of 160 million Nigerians suffer from mental health challenges. That is a significant number. These challenges range anywhere from stress-induced illnesses to depression, from bipolar disease to borderline personality disorder and schizophrenia, with varying degrees of seriousness. In older persons, dementia may be brought on by organic changes in the brain, and some of the symptoms may be psychiatric in manifestation. In many people, mental health challenges are transient and situational, that is, any challenges are brought on by the circumstances and disappear once they get treatment. In some other people, it can be a chronic illness. With twenty to thirty per cent of us suffering some form of mental health challenge at one time or another, the chances are very high that we would know someone who has, has had, or will have a mental health challenge whether it is a bout of depression after the death of a loved one or a particularly stressful situation, a bout of transient psychosis, or a continuing mental health challenge.
In view of the significant numbers of people who suffer from mental illnesses, how do we view mental health and mental illness? If you were to ask a typical Nigerian her or his picture of mental health – they would describe a woman sitting on the corner of a street eating rubbish, or a man carrying a bag of empty bottles walking down the street and speaking to himself. They would very likely not describe a person who is suffering from depression, on anti-depressants, and who has succeeded in eliminating the suicidal thoughts which often used to plague him, nor would they describe others who continue to receive care and manage their illness effectively. The pictures that abound now create an atmosphere of stigma, painting the mentally ill as vulnerable and dangerous, and mental illness as a chronic illness that is the worst possible illness that can afflict a human. Even among and outside health care professionals, including mental health professionals, stigma remains a huge issue.
Yet many who have had experience with mental illness or mental health challenges either as sufferers or family members or friends know different. I know good and kind people, productive, highly educated, and successful people who have had mental illness or continue to deal with mental illness. I know that it is possible to recover, to manage some illnesses effectively, to live a full, productive life.
As a result of the stigma still attached to mental health issues in this country, mental health challenges, both transient and chronic, are viewed as was attributed to one lawyer, speaking about Mrs. Chime’s alleged illness and quoted on the pages of a credible newspaper as “public odium.” Why should an illness of any sort be labelled in this fashion? Some, including family members, have felt the need to state emphatically that Mrs. Chime has no form of mental illness, and even more importantly, that mental illness does not run in their family. I ask: What if she did? Why should this be the end of the world? I am aware of the environment in which we live, the outdated attitudes and views to mental health matters, and thus sympathise with what they are seeking to do. But these attitudes are unhelpful, and are a result of the deep-rooted stigma that afflicts this country, and they do not help mentally ill persons, not do they allow us progress as a country and a society.
Stigma manifests itself in all sorts of discrimination – from the personal (marriage, relationships) to external matters like employment and appointments. Indeed, when mental health is mentioned in our legislation, generally speaking, it is not to provide for human rights coverage, it is generally to exclude on the grounds of “insanity.” If we continue to live in a society where mental health issues and challenges are hidden because of the perceived stigma which may extend to all sorts of discrimination, personal and societal, we do not achieve a society in which mental health challenges become non-existent. What we accomplish is a driving underground of people with mental health challenges, which is to no one’s benefit. Uptake of treatment will remain low, causing people to suffer needlessly. Public education will remain non-existent, causing people to make the sorts of comments I have had to read on social media and in the pages of credible newspapers.
As a society, we need to start viewing mental illness as an illness, like diabetes, cancer, malaria, and so on. We also need to draw the necessary distinctions between mental breakdowns, chronic mental illnesses, and mental challenges that are or can be successfully controlled and managed. Very few people would wish any illness, mental or otherwise upon themselves, and our attitude and stance towards mental illness should be just the same as we would have for other illnesses. Someone might urge, “do not hold your breath,” but we must continue to use opportunities like this to state the obvious, to seek to change thinking and attitudes, to compel people in our country to adopt humane, caring, non-discriminatory attitudes.
It has been alleged that Mrs. Chime was compelled to be detained and secluded on the instructions of the medical team treating her. Comments have been made in different forums about the wisdom, humanity, medical need, and human rights implications of doing so. I am well aware that there are circumstances in which a person who is mentally ill can be involuntarily detained against their will. But human rights principles require that certain measures be taken to ensure that any involuntary restraint in the context of mental health be done within certain, defined, parameters. The UN Principles for the Protection of Persons with Mental Illness and the Improvement of Mental Health Care 1991 and the Guidelines made thereunder provide clear guidance in the context of mental health as do several World Health Organisation documents. The Constitution of Nigeria also provides certain rights which are as applicable to mentally ill persons as they are to other citizens of this country. Generally speaking, involuntary detention should only occur when the person is likely to harm themselves or another person. Unfortunately, as I pointed out in my first article in this paper, it is not clear that many psychiatrists and others in the medical profession in Nigeria either truly understand this or apply this appropriately. The result is wariness in recognising psychiatrists and other medical personnel as acting ethically and in line with the best interests of the patient and the society when they make certain judgement calls regarding treatment of mentally ill persons.
Ideally, we should have a body, not just the National Human Rights Commission, but a body comprising persons with the due expertise in mental health, mental health law, human rights law who can receive and deal with appeals in such cases. Without the right expertise, the National Human Rights Commission is handicapped in providing effective assistance to those who seek its help. As allegedly occurred in this case, the National Human Rights Commission, conducted its initial investigations in the Chime case without a medical team, underscoring the need to consider a separate body to handle mental health and human rights issues such as arose in the instant case. Such a body would, amongst other things, investigate allegations of violations, and would conduct trainings in the human rights aspects of mental health from time to time for psychiatrists, other health care professionals and legal professionals involved in mental health care and mental health advocacy in this country.
To establish such a body, amongst other important requirements, we need comprehensive mental health legislation. As I stated in the article I wrote in this newspaper in March, there is an urgent need to revive the Mental Health Bill, which began its life in the National Assembly a decade ago! This legislation would address basic legal protections for the mentally ill and disabled and legal requirements that provide for fair processes and procedures. It would address issues like when a person can be involuntarily committed to a mental health facility, the situations under which seclusion at home or in the community is necessitated, the criteria for such involuntary commitment, who can make such commitment, how and when such a commitment can be brought to an end. It should address how custody matters are determined where a person is deemed to have a mental health challenge.
Further, as I stated in my last mental health piece, such will establish clearly the rights of persons with mental illness, set out penalties for violating such rights, including rights implicated in involuntary commitment and seclusion. The process of enacting the legislation will provide a forum and opportunity to address stigma, improve public education, and engage in important discussion about the desperately needed improvements that need to occur in our mental health system.
This brings me to the issue of mental health services in Nigeria. Aside from stigma, a lack of mental health legislation, there is also the matter of our poor mental health services. In discussions of health in Nigeria, mental health services are often ignored. In short, where HIV/AIDS, cancer, polio, and maternal mortality are heard about, mental health is still struggling to make its voice heard in Nigeria. As the WHO-AIMS Report pointed out, we have too few psychiatrists for the people that need them, too few of the other mental health care professionals, too few facilities, and inadequate equipment and drugs.
Finally, much of what has been alleged and stated factually in the Chime case goes on all the time in other places. There are places in this country where mentally ill persons are chained and left outside in all conditions of the weather, and then beaten up from time to time in order to “heal” them, where mentally ill persons are beaten by their spouses to exorcise the evil spirits, where some unscrupulous mental health professionals give out diagnoses without due investigation.
The three angles that I have written about in this article will help address some of the continuing issues – paying greater heed to our humanity, becoming educated about mental health issues and eliminating stigma would pay great dividends in improving mental health care. We must hear and heed the cry of mental health and the mentally ill in our country. We must try to take steps – enacting legislation, changing our attitudes to mental illness, spending more on mental health as part of the health sector, and calling to book those who violate the rights of others. We must challenge the status quo and call mental illness an illness like any other.
Let the Chime case be an impetus to take the right steps rather than just another sensational, titillating story.
Dr. Onyemelikwe- onuobia, a lawyer, is Lead Consultant, Health, Ethics and Law Consulting and Executive Director, Centre for Health Ethics law and Development