A pioneer of psy: The first Ugandan psychiatric nurse and her (different) tale of psychiatry in Uganda

Abstract

In Africa, the emergence of a “modern” mental health regime centered on psychiatry is often portrayed as a unidirectional intervention by “the West.” Analyses ranging from medical histories of colonial psychiatry to more recent studies of Global Mental Health focus mostly on the role of external actors and the ways their actions impact(ed) on local populations. Uncritical studies simply reduce the complexity of African therapeutic landscapes to a “treatment gap” and see the introduction of “science-based” mental health approaches as necessary “civilizing” missions. Critical studies emphasize the harms of psychiatric interventions and celebrate local healing practices instead. Both approaches are problematic: they ignore the many interconnections between highly dynamic treatment regimes that cannot be neatly designated as African or western, portray local populations as largely passive, and neglect the multiple ways in which psychiatry has been embraced, adapted, and disrupted by Africans themselves. This article challenges simplistic depictions of “western” psychiatry in Africa by providing a portrait of Rwashana Selina, the first Ugandan psychiatric nurse who—after being sent to the UK in the 1950s for training—became a central figure in Ugandan psychiatry. Based on interview material, I recount her life story and discuss her formative role in the development of psychiatric care in the colonial and postcolonial era. Rwashana's tale of Ugandan psychiatry emphasizes co-operation, mutual acknowledgments and pluralistic leadership and thus breaks with typical images of and dichotomies between white doctors and supposedly inferior African medical staff.

Keywords

Africa history nurse psychiatry Uganda

Introduction

I first heard of Rwashana Selina¹ in 2015 while conducting fieldwork on the emergence of what Nikolas Rose (1999) has called “psy”—that is, the various institutions, practices, and discourses that constitute psychological and psychiatric expertise—in Uganda.² I was interviewing the Director of Butabika, the national Psychiatric Referral Hospital, about the history and present state of the Hospital. “If you want to know about the history of this place, and of psychiatry in Uganda, you better talk to Rwashana,” he said, after admitting that the archival records were scarce and probably in a dismal state. He explained: “She retired a few years ago, but was a psychiatric nurse here for a very long time. You should really talk to her.” Somewhat surprised that the best historian of Ugandan psychiatry might be a psychiatric nurse, and not sure what to expect, I called Madame Rwashana the next day and she invited me to her home for a talk.

In this article, I tell the fascinating life story of Rwashana Selina (henceforth Rwashana) as she described it to me. Her account challenges common depictions of “western” psychiatry in Africa and the actors that have driven it. It suggests that psychiatry as it has come to be practiced in Uganda was developed through co-operation, mutual acknowledgments, and pluralistic leadership and that a key actor in this process was in many ways quite the opposite of the figures typically depicted in descriptions of biomedicine in Africa: not a foreign white, or elite African, male doctor but a Ugandan female nurse from a relatively poor, non-urban background.

In Africa,³ the emergence of a “modern” mental health regime centered on psychiatry is often portrayed as a unidirectional intervention by “the West.”⁴ Analyses ranging from medical histories of colonial psychiatry (e.g., McCulloch, 1995) to more recent studies of Global Mental Health focus mostly on external actors and how their actions impact(ed) on local populations. As Cooper argues, uncritical studies reduce the complexity of African therapeutic landscapes to a “treatment gap” and see the introduction of “science-based” mental health approaches as necessary “civilizing” missions. Critical studies emphasize the harms of psychiatric interventions and celebrate local healing practices instead (Cooper, 2016a, 2016b). Both approaches are problematic: they ignore the many interconnections between highly dynamic treatment regimes that cannot be neatly pigeonholed as African or western. Furthermore, they portray local populations as largely passive, neglecting the multiple ways in which Africans have embraced, adapted, and disrupted psychiatry.

In essence, studies of psychiatry, and of biomedicine in Africa more generally—even the critical ones—tell a rather singular tale (Mkhwanazi, 2016). They often have very similar storylines and a clearly designated “cast,” with the main roles assigned to foreign white biomedical doctors and their presumed local African counterparts—traditional or faith-based healers. There are exceptions, of course, which present a more complex and ambiguous picture with fewer stereotypical “heroes.” Wendland (2010), for instance, has dedicated a whole book about Malawian medical students to the question of whether “African biomedicine” is the oxymoron that many studies seem to suggest. Livingston (2012), although at first glance telling a rather typical tale of a white German doctor and “his” cancer ward in Botswana, conveys an amazingly rich, nuanced and complex picture of biomedicine in Africa in which Botswanan nurses play crucial roles. Furthermore, prominent figures like Thomas Lambo, the first African psychiatrist, or Frantz Fanon disrupt conventional images of psychiatry and psychiatrists in Africa (Bullard, 2005; Heaton, 2018).

Nevertheless, the widespread perception that biomedicine in Africa has always been, and continues to be, driven by outsiders (expatriate doctors, western NGOs, or international organizations like the WHO) remains largely unchallenged. Too seldom do we hear stories of people that fundamentally change our ways of thinking about it. This article seeks to tell such a story. It is not concerned with the question of whether psychiatry in Africa is a good or a bad thing, or whether it is different from western psychiatry. Rather, it relates an account that conveys a different image of African psychiatry and its central actors. In order to situate both Rwashana's descriptions of Ugandan psychiatry and my analysis, I first provide a brief summary of the literature on colonial and post-colonial psychiatry in Africa as well as a note on methodology.

The history of psychiatry in Africa

In recent years, there have been a number of important publications on colonial and post-colonial psychiatry in Africa (e.g., Bullard, 2005, 2007; Bell, 1991; Heaton, 2013; Jackson, 2005; Keller, 2007; Mahone, 2006, 2007; McCulloch, 1995; Parle, 2007; Pringle, 2013, 2019; Sadowsky, 1999). Hardly any work, however, addresses nursing (for a rare exception, see Marks, 2007). As these analyses from various parts of the continent show, there is no single history of psychiatry in Africa; but there are some similarities. Importantly, one can distinguish between the history of institutional psychiatric practice, which is the focus of this article, and the intellectual history of psychiatric theories (Vaughan, 2007).

Drawing on the abovementioned literature, and focusing on Uganda, I will summarize four overlapping phases in the history of psychiatry in Africa: 1) early colonial psychiatry from the mid-19th century to the 1940s; 2) late colonial and early post-colonial psychiatry from the 1940s to the early 1970s; 3) the decline of psychiatry from the 1970s to the 1990s; 4) the revival of psychiatry since the early 2000s.

The first mental asylums were established in Sierra Leone, Ghana, and the Cape Colony in the late 19th century, many of them initially for white settlers. However, by the early 20th century, many colonial states had designated, if limited, spaces for the “insane,” often in prisons or prison-like facilities, and usually segregated by race. Asylums were predominantly places of confinement for those who disrupted social life, particularly in the urban centers. They were often overcrowded and hardly any treatment was provided (McCulloch, 1995, p. 12ff.). In Uganda, the first “lunatic asylum” was set up in Hoima Prison in 1921. In 1935, Mulago Mental Hospital was opened and two decades later—due to overcrowding and other problems—replaced by Butabika, which remains the only psychiatric hospital in Uganda. The first trained psychiatrist in Uganda arrived from the UK in 1949 (Pringle, 2013, p. 39ff.).

During this early phase, a small number of colonial psychiatrists dominated research on mental illness and “abnormal” behavior of Africans. Their theories, locked into a discourse on racial difference and often closely tied to eugenics (Vaughan, 1991, p. 115; Mahone, 2007), promoted three key beliefs: that the African is similar to a lobotomized European (esp. Carothers, 1953); that mental illness in Africa is largely due to acculturation and reflects failed attempts by “primitive” Africans to cope with “modern” civilization; and that depression is rare in Africans due to their underdeveloped sense of individuality and moral conscience (Akyeampong, Hill, & Kleinman, 2015, p. 3f.). These psychiatric theories were used to justify colonial control, address problems of colonial governance, and suppress anti-colonial resistance, particularly in settler colonies. The early days of colonial psychiatry—both its practices, but especially its theories—have since come to be the focus of much critical research which reveals how closely the rise of modern psychiatry paralleled, and in some cases even helped to facilitate and justify, colonial rule (Mahone, 2006, 2007; McCulloch, 1995).

Starting in the 1940s, after the downfall of the eugenics movement, the work of colonial psychiatrists with their racial theories about African brains and minds became the subject of profound criticism (most prominently by Fanon, 1961/2004) and was soon dismissed—although “cultural othering” continued. The new field of Transcultural Psychiatry emerged, which sought to assess the prevalence and manifestations of mental illness in Africa and around the world in relation to western psychiatric concepts and nosologies (see, e.g., German, 1972).

The immediate post-independence era also saw a relatively brief period of distinct attempts to initiate culturally-adapted forms of “Africanized” psychiatry, most prominently by Thomas Lambo in Nigeria and Henri Collomb in Senegal (Bullard, 2005; Heaton, 2013). New forms of treatment (ECT and, later, drugs) became widely available and most institutions by then had professional psychiatrists and nurses, most of whom, however, were expatriates. In the 1950s and 60s the need for African psychiatrists, who could better understand and respond to local manifestations of mental illness, became apparent and the first African doctors were sent to the UK for specialized training in psychiatry. In 1970, the Association of Psychiatrists in Africa was founded (Heaton, 2013, Chapter 2).

Uganda was at the forefront of these developments. Pringle (2013) refers to the period 1955–1972 as the “golden age” of Ugandan psychiatry. Makerere Medical School, then the leading institution for training African doctors, set up a psychiatry department in 1966 which co-operated closely with Butabika. Stephen Bosa, who would become Butabika's first Ugandan medical superintendent and an important figure in the development of Ugandan psychiatry, was sent for psychiatric training in the UK in the late 1950s. However, despite an increasing number of trained African medical staff, Ugandan psychiatry was dominated by a small group of engaged expatriate psychiatrists, most importantly Allan German. Despite amicable relationships between the foreign psychiatrists and the Ugandan staff, clear hierarchies remained (Pringle, 2013, p. 155ff.).

In the 1970s, psychiatry entered a phase of decline in many African states. Due to broader politico-economic dynamics (political conflicts, economic decline, structural adjustment programs, etc.), attempts to set up widely accessible psychiatric services and include these in the general medical system lost momentum and largely disappeared (Akyeampong et al., 2015). In Uganda, the golden age of psychiatry came to a rapid end after Idi Amin took power in 1971 (Pringle, 2013, p. 255ff.).

Only recently has interest in psychiatry revived in Africa. This renewed interest was driven in part by the Global Mental Health movement and related efforts by the WHO since the early/mid 2000s to increase psychiatric services in low-income countries (Akyeampong et al., 2015). An important field of research also emerged through the study of psycho-pathological implications and consequences of the HIV/AIDS epidemic. This included pioneering research in Uganda (e.g., Musisi & Kinyanda, 2009). The Ugandan Ministry of Health integrated mental health into general health care in 2000. There have been various attempts to decentralize and expand psychiatric care to regional health facilities as well as several reforms and renovations at Butabika. After its decline in the 1970s, there is once again an active Department of Psychiatry at Makerere, including leading female psychiatrists like Elialilia Okello and Catherine Obbo.

A note on methodology

The interview with Rwashana is one of 35 interviews I conducted with leading figures—psychologists, psychiatrists, and psychotherapists—in Uganda's mental health care landscape as part of a project on emerging forms of psychotherapy in Uganda in the contemporary era (see Note 2). Here, I focus solely on this one interview because it offers a rare and in some ways novel perspective on the past. It stands out from my other interviews, which mostly focused on the present and—even though I always inquired about the longer history of psy in Uganda—usually provided relatively vague, standardized accounts of the past (cf. Pringle, 2013, p. 266). I am not a historian and my own material on the history of psychiatry is comparatively limited. Thus, the aim of this article is not to give a detailed account of the complex history of Ugandan psychiatry (for a thorough historical analysis which complements this article in important ways, see Pringle, 2013, 2019)⁵ but to present an as yet untold story that conveys a unique image of African psychiatry and its central actors. It is important to bear in mind that interviews are always, to some extent, staged performances in which interviewees offer selective, subjective views and present themselves in a particular, sometimes heroic, light. Furthermore, memories of the past are sometimes clouded, contradictory, and are always shaped by the present. Thus, the narrative presented here should not be read as a “pure” account of the past. As will become apparent, it is infused with nostalgia and the desire to portray Butabika—a place Rwashana deeply cares for and that nowadays often receives negative publicity (e.g., MDAC, 2017)—in a positive light to a foreign anthropologist. The early days of Rwashana's career coincided with a particularly vibrant phase of Ugandan psychiatry in which the reforms undertaken there were recognized and admired across Africa (Pringle, 2019, pp. 18f., 141ff.). The enthusiasm of that “golden age” underlies her narrative and might overshadow her account of later, less glorious, periods—particularly the 1980s (Pringle, 2019, p. 184ff.). Nevertheless, Rwashana's narrative deserves to be heard in its own right and I present it here as she told it. Although I tried to follow up and contextualize the information she provided, I cannot verify all her claims, particularly regarding the situation of nursing at Butabika during her time, as there is hardly any data available. Finding more testimonies of nurses and patients from that era is a worthwhile endeavor for future research.

Rwashana Selina's life story

I will first give an overview of Rwashana's life story before singling out several aspects for further analysis. Throughout the text, I quote extensively from the interview, sometimes slightly editing the language. The interview was conducted at Rwashana's home on the outskirts of Kampala, approximately two kilometers from Butabika, in September 2015. This is what I wrote in my field notes:

Rwashana welcomes me heartily into her home, a small brick house in a middleclass neighborhood. She is wearing a colorful kitenge dress, she is tall and looks younger than 75, her age at the time of our interview. I sense that she is a proud and strong woman. It feels easy to connect with her right from the start. Her English is excellent, and I don't have to ask any questions to get her started on the interview. “My names are Rwashana Selina, I am married, 51 years in the marriage, we have seven children, and we have 23 grandchildren”, she introduces herself as I turn on my recorder. She briefly talks about her children, three of whom have degrees in psychiatry or clinical psychology. Then she goes on to tell me about her life-long career in Ugandan psychiatry.

She was born around 1940 in Western Uganda, near Mbarara. Her father had died before her birth; her mother remarried and had more children. Rwashana, who was raised by her aunt, was the only one of three sisters to finish primary school and go on to secondary school on a bursary. After graduating, she left the village to attend nursing school in Kampala. She recounts:

I only had three dresses—one for peeling matooke [type of banana and important staple food], one for school, and one for church. I had no underwear and no bras so I made them myself from cloth that my aunties sent. Then, I bought my first pair of shoes, in the village we never wore shoes. Those days, the floors at Mulago [National Referral Hospital] were always well-polished and shiny, not like today, and I nearly slipped the first time I tried to walk there with my shoes.

Rwashana's first ever contact with psychiatry was through her sister who was working with psychiatric patients at Mulago as a nursing assistant. Rwashana initially had no interest in psychiatry but soon changed her mind: “I had no interest as such, to take up psychiatry, but at the nurses hostel at Mulago, I kept on talking with the fellow nurses, and we said: ‘but psychiatry is a virgin area, someone could go and adventure there.’ So I picked interest.”

She applied for a scholarship and, in 1961, went to Britain to study psychiatric nursing at Baxley Hospital in Kent. The psychiatry department at Makerere Medical School had not yet been created and a course for mental health nurses would only be established in 1969. After three years of training, Rwashana returned to now independent Uganda in 1964 and started working at Butabika:

I was the first woman to have taken psychiatry, I was the one who could speak the vernacular language. Europeans were the people who were around by then: the matron, the deputy matron, the nursing sisters. I was the first [Ugandan] nursing sister to work with them, they welcomed me very well, the environment was so ok.

Uganda had gained independence in 1962 and was now under the regime of Milton Obote, which was fast spiraling into political crisis. Although compared to other countries at the time of independence, Uganda had several well-trained African doctors at Mulago (Iliffe, 2002, p. 136ff.), the psychiatrists and psychiatric nurses at Butabika were all expatriates, except for the medical superintendent Dr. Bosa (see above). The hospital had a bed capacity of 960 and patients were brought in from all over the country, though the majority came from nearby regions, and often stayed for long periods. Rwashana describes the conditions and staff relations at the hospital as good, although she mentions food shortages due to the increasing political turmoil. She soon took on an influential role in helping to prevent conflicts and misunderstandings: due to her ability to translate between expatriate staff and Ugandan patients, and her ability to establish rapport with the patients:

I could hear the patients talking, I could hear the staff how they reacted to patients, sometimes [both sides] would not be very nice … But when I came, they had a problem. [She explains how she could understand, and would reproach, both sides for negative speech and behavior]. I started working with the patients, tried to change things here and there. Staff used to eat patients' food, but when I came in I sensed that and made it stop. This made me very popular, because I entered into their world [laughs]. But it was ok, later on we worked very well with everybody, and still during Amin's time.

In 1971, Idi Amin took power in a military coup and soon established a regime of terror. Rwashana mentions the Amin years several times in the interview, every time lowering her voice as if still afraid. The Amin era was a crucial turning point for her career and Ugandan psychiatry more generally. All the European doctors and nurses and even some Ugandan staff at Butabika fled the country, and she was called on to take charge—first organizing and overseeing the nursing on all the wards, and later, so she recounts, of the whole hospital. The staff that remained at Butabika, mostly nurses or unskilled nursing assistants, had little psychiatric training. Nor did the doctors that were sent periodically from Entebbe, and later from Libya, to check on the patients. Thus, Rwashana not only helped to manage the hospital; she also had a say in medical decisions. This is how she tells the story:⁶

One morning, Professor German, the first professor of psychiatry at Makerere, and Dr. Bosa, and other people [had a meeting] … They called me into the board room and said: “we have to hand you over the nursing side; the matron is going, the deputy is going, the white sisters are all going.” So they handed me over the female and male side. By then we had 967 beds—with all those patients! … We had a training school for nurses, at the enrolled level, by that time it was minded by a European doctor and a nurse, but all of them went on one day, can you imagine? Because of Amin. …[Later] I was handed over the keys, by then, we had no medical superintendent. A doctor was delegated from Entebbe where the Ministry of Health was to come once a week to see what was going on in the hospital. So the whole hospital was almost on me [laughs]. But then I was strong and able to move here and there, be in charge of the patients' care … I was the managing director. But I thank God, the doctor who came once a week just asked what had been happening, the hospital secretaries were all African, so they were there, and we continued working like that. Later Amin got some doctors from Libya … but these doctors were not competent in their psychiatric treatment. The good thing was: they would write treatment, I would come, cross out theirs and put mine. But none of them ever refused or said why is this dark nurse is doing all this. I think they knew they didn't know much, so we continued in that situation.

During the Amin era⁷ she received a scholarship and returned to the UK for a one-year management degree at the Royal College of Nursing in London, which prepared her for a long career in nursing administration. She returned to Butabika and initially continued working with the patients. Gradually, things improved and new doctors were posted to the hospital. They were Ugandan general doctors, not psychiatrists, but their degrees included some basic psychiatric knowledge and practical training. The European doctors who had left under Amin never returned.

During the Obote II era (1980–1986), Rwashana continued working at the Hospital but became increasingly active in medical politics and nursing education. She was on the committee of the nursing council and lobbied for the inclusion of a psychiatric component in the nursing curriculum. From 1985 to 1995 she was the President of the Ugandan Association of Nurses and Midwives. Not least due to her relentless efforts, a school of nursing was set up near Butabika with the specific purpose of training psychiatric nurses:

We were able to influence the nursing council to put a psychiatric component in the curriculum, and I feel proud of that! Because the nurses, midwives, did not have any idea about psychiatry, our patients would suffer very much. … We fought very much to get these things in place, I remember when I used to go to the Ministry for a meeting, and I would say ‘”I want blankets, I want bed sheets, I want [this and that] for my patients.”… It would be a struggle, and each time they would say “there she comes,” because they knew I would bring something about psychiatry, which nobody knew about. They would say “ah, your patients.” But I am glad now.

Rwashana's larger vision was to increase knowledge and recognition of psychiatry, both among medical professionals and in the general population, and to reduce the stigma associated with mental illness. She remained committed to this mission even after her retirement from Butabika.⁸ She narrates:

By the time I retired I was in the Ministry of Health, in health education. I said to myself: “I will never leave the Ministry unless I have put a chair in the headquarters.”… I wanted to come there and introduce [a mental health component] in health education. Dr. Kitumba⁹ by then was the coordinator. … Health education [was for the whole] of Uganda, so that if mental health could go there, it would get everywhere. I was given opportunity to go in that office. [She recounts how they started broadcasting radio programs on mental health, and how she and others from Butabika travelled around the country to educate staff at the regional hospitals].¹⁰ … [I only retired after I had] found someone who would carry out my vision, when everything I wanted was in place.

Rwashana's passion for her work and dedication to psychiatry did not end after she left the Ministry, and she started engaging in voluntary work. Together with other psychiatric professionals, she founded “Hope after Rape” in 1994 and was President of the NGO from 1995 to 2005. Increasingly, she turned to spiritual work and Pentecostalism, which she was actively and proudly pursuing at the time of our interview—and in which she still managed to include aspects of her psychiatric vocation. She told me:

Now I am a pastor. [She says she is a home-based pastor and not aligned with one specific church.] … I do counseling for people who are going to get married, some churches send me people. And we have an altar of prayer here, every Tuesday. … [Just now] I was preparing a lecture about depression for these pastors, to waken them up, because not every patient they get is spiritual [some may also have medical conditions]. [laughs]

Reflections

There are many things that stand out in Rwashana's life story which disrupt conventional representations of psychiatry in Africa. Here, I focus on three images: of foreign doctors and nurses; of African psychiatric hospitals; and of African female nurses.

Images of foreign doctors and nurses

The European doctors and nurses working at Butabika in the late colonial and early post-colonial periods are mere background actors in Rwashana's narrative. She describes them as welcoming and open towards her, as skillful people dedicated to their work, but also as somewhat naïve and helpless due to their inability to properly communicate with patients. In her words:

[The relationship between Ugandan patients and white doctors] was good. But [there were issues] with the translation, because the doctor would not know what the person had said, so patients could tell them what they felt like. … Doctors were highly influenced by patients: if they saw a patient who was speaking English and he would say “I am now very well and I can go home”, they would quickly right a discharge form [laughs] … I would go there and say “doctor, let me tell you, I wish you knew how that man behaves.” Because he was speaking English, and he was fluent, …the doctors would think this patient is very well.

She recalls how most patients, and even the Ugandan nurses at the time, had such poor English that even she would sometimes struggle to understand them. She returns to the issue of language and translation at different points in the interview, and emphasizes the importance of communication for the successful diagnosis and treatment of patients, and for establishing rapport with them: “The most important is language, if you know their language you are able to penetrate [interact] with them.” European doctors clearly lacked this important skill. And this compromised their otherwise powerful position and image—at the hospital, but also in Rwashana's narrative.

A lack of local language skills and cultural knowledge among foreign medical staff (and administrators), commonly raised as a problem in the literature on colonial psychiatry (e.g., Mahone, 2006; Vaughan, 1991), heavily impacted their ability to accurately diagnose and treat people with mental illness, and to distinguish between normal and abnormal behavior. Although this became increasingly recognized in the period leading up to independence, there was still a great reluctance to give authority to African doctors (Mahone, 2007; Pringle, 2013, p. 152ff.). In this context, nurses, especially trained ones, had a crucial role as intermediaries between doctors and patients (cf. Marks, 2007). However, given Uganda's linguistic and cultural diversity, and given that most staff came from nearby areas and were Luganda speakers (see below), communication would not have been easy with all patients, especially those coming from non-Bantu speaking regions in the North and East.

At no point does Rwashana allude to underlying racial tensions, which are a common feature of descriptions of psychiatry in Africa during the early colonial era (e.g., Jackson, 2005; Keller, 2007; McCulloch, 1995). When I asked her whether she encountered racism in her early years at Butabika, she replied:

It wasn't much, because racism to whom? Except tribalism, we would talk about tribalism, because we would know that these patients are from North, these are from the West … patients fighting each other, that would be a problem, even a staff. But there was a general rule that nursing assistants cannot be recruited unless they come from the region of five miles around [therefore most of the staff were from similar regional and ethnic backgrounds].¹¹

It is important to acknowledge that the heyday of “racist” colonial psychiatry was before the 1940s, although even in the post-colonial period African medical staff were by no means regarded as equals. Furthermore, in contrast to settler colonies like South Africa, Algeria, Zimbabwe or Kenya, where racial tensions between Africans and Europeans prevailed or increased after the 1940s, these were less prevalent in Uganda in the 1950s and 60s. In fact, systemic racism in Uganda is mostly associated with the Amin era during which predominantly Asians, but also other foreigners, were expelled. Ugandan post-colonial history, however, is rife with highly politicized ethnic tensions which, as noted by Rwashana, were also felt at Butabika and led to conflicts between Ugandan patients and staff from different parts of the country.

In summary, Rwashana's story of the European doctors at Butabika in the 1960s differs from common portrayals: despite the importance of their early presence, they were not the only significant actors that drove the development of Ugandan psychiatry. In this regard, her narrative provides an important additional perspective to the majority of the work in which expatriate, male doctors are credited as the main protagonists of African psychiatry.

Images of African psychiatric hospitals

Rwashana's descriptions of Butabika Hospital clearly reflect her deep affection for the place and are markedly different from common depictions of African psychiatric institutions as dark, dirty, and dismal places where patients are drugged, mistreated, and warehoused rather than cared for.¹² Certainly, her portrayal has its blind spots: while she hints at shortages of staff, food, and other essential resources at different parts of the interview, the challenges that she and her colleagues must have faced throughout much of Butabika's history were probably far greater than she mentions (cf. Pringle, 2019).

Butabika today is no idyllic haven—and presumably never was—but a last resort for those who cannot afford other forms of mental health care. It is understaffed and under-resourced and much of the therapeutic work is done by unpaid psychiatry and psychology students. One often sees highly drugged and sedated patients, sometimes naked, running around the premises. The food is minimal in both quality and quantity and the wards are overcrowded. Nevertheless, the staff I met there (the director, psychologists, psychiatrists, service users, and student trainees) were extremely dedicated to their work and their patients, and thus I encountered some of the spirit of the place that Rwashana describes. While it is important not to sugarcoat the state of many of Africa's psychiatric hospitals, which is amply documented, her narrative highlights aspects of those institutions and their staff which are, perhaps, underreported in the literature.

Rwashana emphasizes several times how patients were looked after well and with great dedication by the nurses, especially in earlier days when the nurse/assistant nurse–patient ratio was better.¹³ Before the drive to decentralize and deinstitutionalize psychiatric care in the early 2000s, patients, especially those from upcountry, would often stay for several weeks at the hospital, thus enabling closer relations between them and the staff. Rwashana recounts:

Particularly those who came from upcountry … some of them could stay up to four months. After you felt that the patients were starting to improve, you first had to communicate to Gulu [town in Northern Uganda], find out if there is a relative who can come. If not, you had to arrange someone who speaks the same language to go with this patient home, to explain to those people how this patient is going to be cared for, that he is no longer dangerous, that he is on drugs. Those are the scenarios we used to have, so we would take these patients home with an escort … But our establishment used to have a good number of staff compared to today, now it is so limited, in all hospitals, not just psychiatry. Then we had a good number of untrained nurses, and when I came I tried to get the books and start training them, translating from English to Luganda, so that they could know how to manage these patients. They were very eager to learn. Patients were well looked after.

Although the number of skilled psychiatric professionals (both doctors and nurses) was lower than today during most of the time that Rwashana worked at Butabika, government hospitals were generally better staffed, something that changed quite dramatically with the beginning of Amin's regime and, later, with the introduction of structural adjustment programs in the 1980s (cf. Pfeiffer & Chapman, 2010).

We had nursing assistants, not trained nurses, but those untrained nursing assistants, and they were many. You could do a shift and put at least 12 at night in one ward, which would make it easy, because if there was any case they would manage to handle the patients. But now you go into Butabika wards, you find two or three nurses at night. … It is all reduced. … I think the structural adjustment [was when they were cutting down numbers]. I also think when they saw that trained nurses were coming up, they started reducing. But the number of trained nurses is not really enough. … That is why I am saying, Butabika, the government institutions, are not properly staffed.

However, Rwashana also acknowledged positive contemporary developments such as the establishment of special wards and general medical services on the hospital grounds.

They are doing very well, we have, they have alcoholic centers, drugs centers, all those used to be in the general wards during our time. … There are new developments. … Butabika is very, has always been nice, and patients respect nurses, and respect other staff.

Overall, while it may be important to criticize the current state of psychiatric institutions in Uganda and Africa more broadly as a way of calling for attention and resources to improve them, it is equally important to acknowledge what these institutions, and especially the people who work there, are achieving under far from ideal conditions. Rwashana's affectionate, if nostalgic, portrayal of Butabika forces us to see beyond the bleak image of African psychiatric hospitals and reminds us of the humanity that can also be found in such places.

Images of African female nurses

Julia [expressing admiration]: “You did so many things in this field…”

Rwashana: “Not much, but I loved nursing so much.”

Julia: “It is probably a profession you need to love, otherwise you cannot do it very well.”

Rwashana: “Yes, and having a forceful personality, it helps me too.”

Lastly, Rwashana's life story challenges the conventional image of (African) nurses, and African women more generally, as subordinate and marginal actors. At different points in the interview, Rwashana describes her persistence, even in difficult or unpleasant situations, and how she never gave up fighting for her patients, for the nursing profession, and for destigmatizing mental illness and psychiatry.

When I ask how she dealt with the stigma that was and still is attached not only to people with mental illness, but also to those working in psychiatric professions, she told me:

Stigma was very high, people could not understand how someone could go and study mental illness and be with those mental patients. For me, even at home, to encourage people to call them mental patients not mad people, it gave me problems. My husband would tell any visitor: “If you want any peace in this house, don't call these people mad! Madame wants you to say they are patients.” And then I went and explained why I want them to be called patients, why they are patients. People had stigma, very big stigma, as I said even right up to the Ministry of Health.

Even from the brief time that I spent with Rwashana, I got a sense of her energy, passion, and authority. I could image her as a young woman, deciding to venture out into the world and into a professional field where she could make an impact. I could imagine her with her patients and with doctors or politicians. Even today, she still passes by the hospital regularly to check that things are going ok. “It is my home. I go there, they respect me, and if I see anything which is not good, I ring Dr. Basangwa [the director] and say ‘ah ah, I am coming to see: how about this?’”

In this final quote Rwashana asserts her important role in the development of Ugandan psychiatry and Butabika, in particular:

By 7am I used to be in the hospital, every morning. By the time the doctor came, I had made my round throughout the whole hospital so I would give a report on whatever was happening; nobody could tell me [anything]. Because I had been in every ward, seen how the patients slept, read the reports, signed the reports. I was even named Butabika [laughs]. I was named Butabika because I knew everything and I could defend my patients and my staff in all aspects.

Conclusion

This article challenges simplistic depictions of “western” psychiatry in Africa by providing a portrait of Rwashana Selina, the first Ugandan psychiatric nurse, who—after being sent to the UK in the 1960s for training—became a central figure in Ugandan psychiatry. Instead of (yet another) story on the lacks and gaps of “African biomedicine,” she provides a more complex, multifaceted, and dynamic history of psychiatry in Uganda in which agency, willpower, and a relentless dedication to patients and professionalism stand out. Instead of a focus on (foreign) doctors, she provides the rare perspective of a local nurse who engaged with the very different life worlds—of patients, local and foreign doctors and nurses, politicians and health administrators—that make up Ugandan psychiatry. In order to complexify the discourses on psychiatry and biomedicine in Africa we need to hear more tales like these. Finding the people who can tell them is a crucial desideratum for the future of medical anthropology and cross-cultural psychiatry in Africa.

Footnotes

Acknowledgments

I am very grateful to Rwashana Selina for telling me her life story and allowing me to publish it in this form. I would also like to thank all the other participants in my research for sharing their perspectives on contemporary developments in the Ugandan mental health sector. I greatly appreciate the critical comments and helpful suggestions by three anonymous reviewers on earlier versions of this text. And I thank Jovan Maud for his sagacious advice throughout all stages of the writing and publishing process.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: parts of the research for this article were funded by the Fritz-Thyssen-Foundation and the Volkswagen Foundation.

ORCID iD

Julia Vorhölter

Notes

Julia Vorhölter holds a PhD in anthropology from Göttingen University, Germany, where she works as a lecturer and post-doc researcher at the Institute of Social and Cultural Anthropology. Her regional focus is Sub-Saharan Africa, especially Uganda, where she has been carrying out fieldwork both for her PhD and her current post-doc project. In her PhD thesis, she analyzed the situation of youth in Northern Uganda in the aftermath of the war between the Lord’s Resistance Army and the Ugandan Government and their positioning in discourses on socio-cultural change and the post-war future. Her more recent work focuses on contemporary discourses on mental health/illness and emerging forms of psychotherapy in Uganda.

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