Abstract
The histories of transculturalism and decolonization within psychiatry have evolved and intertwined such that they are nearly inextricable. Indeed, you would be hard-pressed to find a piece on one without reference to the other. This begs the question: what fresh understandings of transcultural psychiatry could be enjoyed if scholars determined whether transculturalism was somehow essential to psychiatry’s decolonization? To that end, readers are in a fortunate position, as this review examines two recent works concerned with the decolonization of African psychiatry, one in which transculturalism was fully employed and one in which it was not. Pringle details the decolonization of psychiatry in Uganda characterized by a rejection of transculturalism, while Kilroy-Marac focuses on the Fann Clinic in Senegal and the work of Henry Collomb, a central figure of African psychiatric transculturalism.
Pringle begins her book by detailing the events and machinations leading to the 1935 opening of Mulago Hill, Uganda’s first dedicated psychiatric facility. Attitudes to the African mind and the failures of Africanization are also treated. Within these chapters, the key theme of Pringle’s work emerges: psychiatry’s failure to instil its own relevance within the country. One is presented with a fact unsurprising and certainly not unique to Uganda or Mulago Hill: the indigenous did not regard the facility favourably. More modern attitudes to mental health served as the impetus for such a facility, prompting demands for specialist care beyond the mere imprisonment that had existed previously and a desire to avoid having mentally ill individuals roaming the streets. In Nigeria, both sentiments echoed uncannily with a similar public push for compassion and the maintenance of public order (Keller, 2001). Pringle asserts that Ugandans mistrusted Mulago as a place of permanent confinement, considering it a last resort. In the best cases, Mulago was used along with traditional healing techniques. In other cases, Ugandans used it only when family members became too violent or difficult to care for within the home. Mulago had many inadequacies which undoubtedly perpetuated these sentiments; however, let us not forget the milieu in which Mulago existed. Considering that institutions that preceded Mulago Hill, like so many colonial psychiatric institutions in Africa before it, were little more than internment camps, the local reluctance to accept Mulago was perhaps understandable.
Pringle goes on to expound the idea of mental illness in Uganda as a spiritual pathology, the natural consequence of this being that mental health was regarded as the purview of the herbalist or spiritual healer rather than the psychiatrist. The herbalist was ‘the first line of defence’, as Pringle puts it (p. 42). These beliefs have analogues appearing in West African countries such as Senegal and Nigeria (Zempleni, 1969). It is here that Pringle adds to the existing dialogue surrounding the difficulties of administering western psychiatry in newly post-colonial Africa by explaining that there existed a fundamental mismatch in colonial Uganda (and other African countries) between the indigenous people’s and psychiatrists’ conceptions of mental illness. The difficult reconciliation of African and western views on the aetiology and therefore treatment of mental illness are plain to see here.
Pringle rejects any idea that Africanization, in the form it was employed in Uganda, was particularly useful for psychiatry. During the 1960s and 1970s there existed an Africanization movement borne out of a motivation, during the decolonization process, to ensure institutions had leadership after European withdrawal. However, Pringle laments the relative cultural detachment of these newly trained Ugandan psychiatrists. They were drawn largely from a certain substratum of society, were trained by western doctrine and, in most cases, under western doctors. According to Pringle, professional qualifications necessitated the undertaking of postgraduate exams set and taken in the West. These Ugandan doctors were, for all intents and purposes, western doctors. Pringle argues that, as a consequence of this culturally insensitive training, these Ugandan psychiatrists harboured the same incompatible conceptions of mental illness as their European counterparts. This is borne out in her descriptions of their responses to the phenomenon of mass hysteria. Local explanations were ignored in favour of detribalization theory proffered by both White and Black doctors. A more culturally sensitive explanation, as Pringle suggests, is that changing social structure and ways of life, coupled with the political upset of the time, could have fuelled such a pathology. Insofar as bridging the cultural gap between the patient and the psychiatrist is concerned, the Africanization project that subsumed psychiatry during this period was a largely unsuccessful one.
Pringle cannot help but echo the sentiments of the international community at that time, when she argues that a severe shortage of manpower, coupled with a lack of resources for African nation-building, inevitably placed limitations on existing psychiatric institutions and prevented the creation of new ones. In 1975 the World Health Organization (WHO) released reports detailing these challenges. In an effort to bridge the cultural gap between western psychiatry and African patients and alleviate manpower shortages, the WHO has continually recommended training African medical assistants and police officers, decentralizing psychiatry and incorporating it into general health care (Gureje and Alem, 2000). Perhaps unsurprisingly, these measures proved difficult to implement against an unmoving Ugandan government, focused principally on the economy. This was not uncommon in post-colonial African states. Such polities preferred devoting limited resources to matters that stakeholders considered more urgent.
Katie Kilroy-Marac presents a piece of primary research adding to the discourse of the oft-mentioned Fann clinic in Senegal. She tells the story from its inception under the tutelage of Henry Collomb to the present day. The piece is interspersed with accounts of the experiences she has had with the people she met and illustrates their attitudes toward the clinic.
According to Kilroy-Marac, Fann began in the context of decolonization and bore all the characteristics of a psychiatric institution of its time, notwithstanding the typical accompanying limitations. Kilroy-Marac details the genesis and subsequent reorganization of Fann under Collomb in 1959. He modelled Fann on his edict that western psychiatry had to be adapted to Senegal, a culturally relativist approach which necessitated the complete overhaul of therapeutic practices at Fann in order to throw off western psychiatric hegemony (Bullard, 2005). In order to achieve this, Collomb and his team at Fann actively sought out local interpretations of psychiatric illness, employed the services of traditional healers, and inaugurated pénc sessions as therapeutic interventions. There was a keen focus on the family unit, unrestricted visiting hours, and even encouraging a family member (un accompagnant) to reside at Fann for the duration of the patient’s stay. The Senegalese government supported Fann as it reconciled conveniently with President Léopold Sédar Senghor’s views of the importance of Black culture and his promotion of ‘negritude’. Staff felt satisfied that patient outcomes were better, particularly due to the accompagnant policy described in Kilroy-Marac’s work. It led to shorter inpatient stays, fewer relapses and better compliance with follow-up appointments for those patients who took part. Fann, however, did not exist in a vacuum, and critics were vocal. Particular criticism was made of the fact that, in a typical treatment plan, traditional methods were employed far less often than western treatments such as narcoleptic drugs and electroconvulsive therapy.
The works of Pringle and Kilroy-Marac are not overly ambitious in scope. Pringle concerns herself only with the story of psychiatry in decolonizing Uganda. Similarly, Kilroy-Marac’s work is a refreshing and robust treatment of the history of the Fann clinic from 1959 to the present day. Happily, this allows for a more complete history than could have been achieved if larger subjects had been studied. The natural consequence of this, revealed in Kilroy-Marac’s work in particular, is a rather blinkered view of African decolonization, with only a few brief references to other countries and contexts. Pringle avoids this with her enlightening treatment (in Chapter 6) of the common challenges for African psychiatrists. Her book aims to describe the obstacles facing psychiatry in Uganda, and also in some other countries. Pringle notes the relative reticence of the indigenous people to solicit western psychiatric intervention, and the lack of governmental and monetary support for the specialty. In her explanations of the response to these challenges, namely the introduction of Africanization, the inevitable weaknesses of an Africanization devoid of cultural relativism are laid bare. However, Kilroy-Marac’s work on Senegal’s Fann clinic reveals an entirely different picture of Africanization, one with cultural relativism as its central doctrine. Collomb, as she puts it, ‘sought both to understand local exegeses of mental illness and to integrate these into the clinical experience at Fann’ (p. 75).
Taken together, these two books provide fuller understandings of the challenges of psychiatry in Africa than either could have achieved alone. Particular attention should be paid to Kilroy-Marac’s use of ‘memory work’; it is as innovative as it is enlightening. She does not try to set the numerous primary accounts she has recorded as objective sources of historical fact, a task that would be very difficult to justify; rather, she sets up memory and remembrance as phenomena one can examine in an effort to further understand the political, cultural and post-colonial interplays surrounding the Fann clinic and its practitioners. We can all benefit from the continued development of this style of historical enquiry. Through the works of Pringle and Kilroy-Marac, we have exemplary studies into post-colonial psychiatric practices in Uganda and Senegal, making them valuable additions to psychiatric and colonial historiographies. Anyone interested can derive value from these works, which are sufficiently accessible to be of use in any undergraduate setting, yet Kilroy-Marac’s use of ‘memory work’ also makes it a stimulating book for those who are more experienced.