in2mentalhealth

In January 2013, I had the opportunity to extent my stay in Kenya, after providing a MSF (Médecins Sans Frontières, Doctors Without Borders) mental health and basic counseling training for a group of Somali nurses in Nairobi. After these 2 weeks training I arranged a couple of visits and interviews with people working in, or using/surviving, mental health services in Kenya. I wanted to meet the people I knew for quite a while via internet (Facebook, Twitter, LinkedIn, my blog) and I wanted to satisfy my curiosity. I wanted to get some insight into the mechanisms and contexts in mental health care Kenya. Find positive vibes, plans and developments. Fostering hope, but also knowing where one must start and invest, in order to achieve improvements.

Country profile:
Kenya is a vast and beautiful country in East Africa. It’s one of the poorest countries in the world as well. Kenya has a land area of 580,000 km2 and a population of a little over 43 million with a life expectancy of 54 years.

Kenya is a clan or tribal society. There are an estimated 42 different communities, with Bantus (67%) and Nilotes (30%) in the majority. Most urban people speak Swahili and English, but there are people living in rural areas who speak only the language of their ethnic group. The country’s literacy level is 85%.
Most people in Kenya earn their money in the service sector or in agriculture and there are still nomadic pastoralist groups in Kenya. There is an increase in urban life and Nairobi has one of the 2 biggest slum areas in Africa, Kibera. This shanty town is believed to house between 170,000 and 1 million locals. By August 2012, the total number of refugees and asylum-seekers in Kenya, including some 55,000 in Nairobi, stood at more than 630,000. The UNHCR biggest camp in Kenya, Dadaab in the East, houses around 500,000 people, mostly Somali refugees.
Kenya is one of the leading African countries in internet access and mobile telephony, and in East and Central Africa the hub for Financial services. Nairobi is ‘the place to be’ for innovative technical developments and networking. There are also a lot of international NGOs with their region offices in Nairobi and there are a few universities. This makes Nairobi a city with this contrast: big slums, where most people live under a dollar a day, and a place where thousands of expats settle and enjoy the mild climate (1600 m altitude) behind high walls and fences, defending themselves against the poor fellow citizens.

In the recent history of Kenya the 2007 post-election riots and violence are most salient. The widespread violence and ethnic division after the disputed general election seemed a result of unemployment, economic disparities and widespread concerns about access to ancestral lands. On top of that were worsening border troubles with Sudan and Somalia. This election conflict resulted in almost 1,000 people killed and nearly 600,000 displaced, damage to physical assets, the loss of confidence among investors and tourists, and damage to social capital.
In March 2013 new national elections are planned and although everybody hopes that the lessons from the 2007 elections are learned, people fear renewed violence and months of unrest and disrupted life.

The mental health care in Kenya::
(Most information in this paragraph comes from a IJMHS open access report about Mental Health policy in Kenya, 2010, Integration of mental health into primary care in Kenya, article in World Psychiatry, 2010, and from the interviews).
The health service In Kenya is broadly structured into six levels; the national referral hospitals (level 6), provincial general hospitals, (level 5), district general hospitals (level 4), health centres (level 3), dispensaries (level 2) and volunteer community health workers (CHWs)(level 1).
Mental health care in Kenya is predominantly government funded, but remains extremely limited in terms of infrastructure, manpower and finances. Mental health specialist care is largely delivered at district level by psychiatric nurses running outpatient clinics, by psychiatric nurses at provincial levels running inpatient units and outpatient clinics, and by the national referral hospitals at Mathari, University of Nairobi, Gilgil hospital and Moi University. The total number of mental health hospital beds for the whole population was 1114 in 2009, with most provinces having only 1 bed per 200,000 population.
Kenya has its own self sustaining training program for psychiatrists at the University of Nairobi, producing around 6 new psychiatrists per year. The total number of psychiatrists grew from 16 in 2001, to approximately 80 in 2013. But psychiatrists can work in at the University (21), in a private practice 100% or 50% and an estimated 20 live and work outside the country.
Thus it can be seen that the majority of the psychiatrists are in Nairobi, and that the effective psychiatrist population ratio outside Nairobi is 1 psychiatrist per province of 3-5 million people.
In recent years Universities in Nairobi start offering a study psychology or psychology-counseling as well.
There are 500 trained psychiatric nurses in Kenya of whom only 250 are currently deployed in psychiatry, 70 are in Mathari National Hospital, leaving 180 in the districts and provinces, resulting in only less than 1 psychiatric nurse per district. Many psychiatric nurses have retired, died, left the country or work in NGOs, specially linked to HIV activities, and new applicants for mental health nurse training are dwindling.
Between 2005 and 2010 3,000 of the 5,000 primary health care staff in the public health system across Kenya were trained in basic mental health care, using a ‘sustainable general health system approach’. This was in a partnership between the Ministry of Health, the Kenya Psychiatric Association and the World Health Organization (WHO) Collaborating Centre, Institute of Psychiatry, Kings College London and funded by Nuffield Foundation. The International Journal of Mental Health Systems published an evaluation article about this project, 2013.
There is 1 medical social worker in each province but none at district level, and there are social workers in prisons, probation services, the children’s dept and the ministry of Social services.
Thus the specialist service for nearly all regions and districts is largely delivered by extremely overstretched mental health nurses, who have had hardly any access to continuing professional development throughout their careers. In the urban area’s like Nairobi this situation is much better.

1. Users and Survivors of Psychiatry Kenya (USPKenya)

I had the opportunity to visit a two-weekly peer support group meeting of the USPKenya, Saturday 26th January. Eighteen ‘experts by experience’ and caretakers came together in a hired room in the heart of the Nairobi city centre. In a quiet, gentle and respectful atmosphere they talked about their ups and downs, ways of coping with the mental problems, work, side effects of medicines, going off medication, experiences with psychiatrists, feelings of hopelessness, but also about getting to terms with their mental condition and hope. Some of them are attending the USPKenya meetings for years now, but for some of them this was their first encounter with the support group.
Users and Survivors of Psychiatry Kenya is a Non-Governmental Organization (NGO) founded in 2007. It is a membership organization whose major objective is to promote and advocate for the rights of Persons with Psychosocial Disabilities. Their first newsletter is just issued and they are on Twitter and Facebook. They are affiliated with the World Network of Users and Survivors of Psychiatry and represented on the board of the Pan African Network of People with Psychosocial Disabilities.
The USPKenya and the support groups are peer managed and peer led. They have support groups running in Nairobi, Karatina (Nyeri County), Kikuyu (Kiambu County) and currently setting up more in Nakuru and Eldoret Counties.
USPKenya likes to enhance mental health awareness within the country and beyond by providing correct information and by empowering persons with mental health conditions and their care givers to find their voice and advocate for their rights. They participated in a couple of national and international projects like EMPOWER (Empowering people affected by Mental disorders to PromOte a Wider Engagement with Research), iFred (International Foundation on Research and Education on Depression), amongst others. Currently they participate in ‘Comprehensive rights and empowerment for Persons with Psychosocial Disabilities in Kenya’, a project that seeks to improve the capacity of people living with psychosocial disability in Kenya, to understand and claim their rights as contained in the UN-CRPD (Convention on the Rights of Persons with Disabilities) and the Constitution of Kenya (CoK). Project is funded by the Open Society Foundation through its Disability Rights Initiative (DRI).
In the future USPKenya would like to extent their funding and activities. They have on their wish list for example an own venue or clubhouse in the city with possibilities for daytime or even income generating activities, specially for the members without a job. They would like to have their small movie, which is in the pipeline, broadcasted on the national television. They would like to have the Kenyan legislation changed according to international standards. They would like to join, and share experiences with other peer support groups in the World, etc. But Kanyi Gikonyo (CEO) and Michael Njenga (Head of Programs) are spending all their time (far more then 40 hours a week) voluntary on USPKenya and much will depend on support and commitment of other members or other persons.

2. Psychological services in the Outspan Hospital in Nyeri
Sunday 27 January I had a drink with the passionate and very friendly colleague-psychologist Elizabeth Wangari (on Twitter). She studied psychology at the United States International University in Nairobi and is currently working at the Outspan private Hospital in Nyeri, a 2 two hours drive from Nairobi.

The 150-bed Outspan Hospital is the only hospital that has a Department of Psychology in the whole Mount Kenya region. The Psychology Department came about due to the hospital’s need to give patients health care that is holistic in nature. Which means that the patients not only require physical care but their mental health also needed to be taken care of. The Department of Psychology was opened in August 2009 for both in-patients and out-patients and has outreach programs/talks on schools, corporate organizations and churches. The psychological services offered range from counseling patients with drug and substance abuse, VCT/HIV, trauma, grief, loss and bereavement, stress and anger management, family and marriage, youth and children, to psychological assessment and crisis interventions. In February 2013 they opened a 24/7 helpline with telephone number 0727251941.
The Department consists of 3 psychologists and a few interns. The psychologists ‘walk hand-in-hand’ with the medical staff, which means that they cooperate and complement each other in stead of a providing separate treatments.
One of the biggest challenges in the psychological care in this region of Kenya are the patients with an alcohol/drug abuse and dependence. Elizabeth estimates that 50% of the patients have a addiction or abuse history. A lot of them start drinking and using marihuana/bhangi at a very young age (e.g. 12 years old) and toxic self brewed alcohol is widely available.
Another challenge last year was a 3 months strike of nurses in the state hospitals. Since Outspan is a private hospital, staff was not on strike and there was a real influx of patients from the whole region. They could barely found room in the hospital to put these extra patients and they worked a lot of extra shifts and hours.
Plans for the future include more awareness programs in the community and on schools about alcohol/drugs. For instance teachers in secondary schools could detect adolescents who are trying alcohol and drugs and give brief interventions and referral to the hospital. Another plan is the opening of a rehabilitation centre next year for alcohol/drug abusers.

3. Mathari State Hospital Nairobi
Monday morning, 28 January, I find out that my Kenyan telephone was not working anymore (problems with registration), that the taxi was 40 minutes late (traffic jam), and when arriving at the Mathari hospital, that there was no electricity in the whole area, driving the pharmacist (worries about her fridge) and anesthetist (preparing an ECT treatment) to despair.
But in all this disorder and chaos I met psychiatrist dr. Catherine Syengo Mutisya. She seemed not impressed by the turmoil and took time to explain to me the current practical and treatment challenges and invited me to join her on her round this morning in the forensic department (or maximum security unit for law offenders with mental illness).
I really appreciate the opportunity she gave me to look around and write about the Mathari hospital, after so much negative (and one sided) attention the hospital received in a CNN documentary (Locked Up and Forgotten) in 2011 and in other media.

Dr. Syengo Mutisya is the Deputy Medical Superintendent of the Mathari Hospital (for the last five months), a director of the Nairobi Mental Health Services and Nairobi Parenting Clinic, and a consultant for a couple of other hospitals and universities. She is sometimes on the national television or radio or in newspapers with health talks and news on mental health.
Together with Catherine I crossed the extensive hospital terrain by car. I saw a few of the 14 wards (e.g. buildings with a big half sunny half shadow lawns, enclosed by a fence, patients walking and laying around), lots of trees and gardens, small buildings for offices and laboratories, few shops and even a mPESA sign (mobile money transfer agency).
In the forensic clinic 15 patients were waiting to be seen and assessed by Catherine. A few for medication, but most of them for a report for court: were they able to plea or not? Some new, others for the second time or more. For instance a man accused of having marihuana and not eating or drinking for a couple of days. A 20 year old girl who had injured a relative but was not talking and seems to live in her own world. A boy with epileptic seizures, and has been stealing property. A young man who escaped, but came back because he did not have any money to go back home. A woman from Uganda who looked sad and did not speak. Unclear if she could understand English or Swahili; not responding. Few very confused and disorientated patients. A man who was accused of murder, but seem not to have insight or knowledge about what is happening to him. A man who had been violent due to medical condition (delirium) and wants to go to court and plea himself free.
Although Catherine was running out of time, she kept patient and polite, going through all the 15 files and letters. Trying to understand all the individual patients, their stories and their struggles, deciding what would be the best next step.

The Mathari Hospital was established in 1904 as a small pox isolation centre and later became known as The Lunatic Asylum operating under the Lunacy Act which had been implemented by colonial Kenya. In 1924, it was renamed Mathari Mental Hospital. In 1978 the Maximum Security Unit was opened for law offenders with mental illness (200 beds) and in 2003 the only state owned rehabilitation centre for drug and substance abuse disorder treatment moved to the hospital with a bed capacity now of 35 for male and 10 for female. The hospital has grown to be a centre for integrated services that includes a paediatric and adolescent psychiatric clinic, diabetic clinic, general outpatient services, maternal and child health clinic (MCH), voluntary counseling and testing (VCT), laboratory, pharmacy, dental services, Comprehensive Care Clinic (CCC), mortuary, radiology, occupational therapy (OT), physiotherapy and a TB clinic.
The hospital currently has 400 members of staff and a total bed capacity of 700. The staff consists of 7 working psychiatrists, 70 trained psychiatric nurses, but no clinical psychologist or psychotherapist.
The hospital has huge debts (40 million KSh), accumulated over the past years, and is receiving about 6 million KSh a year (about 68.000$). Patient pay for treatment when they can or when they have a health insurance. Catherine estimates that 50% of the patients in the hospital are abandoned by their relatives and that a lot of patients with relatives are too poor to pay. The patients in the forensic ward are sent by court and don’t have to pay either. This means that far less then 50% of the patients will contribute to the hospitals finance, maybe 20%?
There is no psycho-therapeutic potential in the hospital and occupational therapy and rehabilitation services are very limited. They can’t offer the patients the new generation (and more costly) antidepressants (like SSRIs), anti-psychotic drugs (like Risperidon) and modern anesthetics (for ECT). Patients or caretakers have to buy them elsewhere.
So, yes maybe there are patients ‘locked up and forgotten’ in this hospital, and yes most of them are not getting the most effective and evidence based treatments which are available elsewhere. But that does not mean that they do not receive treatment and care at all. A more nuanced or neutral reporting would help the hospital more and could help de-stigmatize mental disorders nationwide as well. Helpful examples are e.g. Sitawa Wafula’s blog about the hospital ‘Shine Mathari Hospital’ or her blog about the CNN documentary Locked Up and Forgotten, and the 1.30min video with the news about the admission of Top-rated Kenyan female boxer Conjestina Achien.

But what can be done to improve?
To generate more money staff could try to let more patients pay for treatment. For instance to let them chose between cheap old-group medication and the more expensive new generation medication and let them pay for the lather. To trace more relatives who could pay for treatment.
With improved treatment (which the hospital is doing through their on-going hospital reforms) and more positive attention in the media, the hospital could be a place where people send there relatives for treatment, not as a last resource, but because they understand that the Mathari hospital is a cure hospital, where people with severe mental disorders can recover or get stable enough to continue with their live outside the hospital. This could attract more people who can pay for their treatment.
The hospital staff will continue lobbying for more attention for mental health care and funding for the hospital. But because they are not optimistic about this road (government) they launched a Friends of Mathari to partner with other interested (private) parties or people.
And when you look at the Mathari hospital in a broader, nation wide, context, it would be even better to decentralize the care to smaller facilities in every county and more cooperation with, and implementation of, community based mental health and mental health service user and family groups. To prevent that people with mental disorders are far away from their relatives and prevent them from being ‘forgotten’.

4. Sitawa Wafula, mental health crusader (and more):
Wednesday 29 January. Sitawa Wafula is someone I had to meet in Nairobi, because she is a mental health activist and a social media adept like me. We know each other from Twitter. She is a lovely lady, a multi-artist with poetry as her main profession. Sitawa advocates, using all means and media, for more attention and awareness in mental health, epilepsy and for rape survivors, amongst other things. In 2010 she was appointed Mental Health Youth Ambassador because she was very vocal about her bipolar condition. She is an ‘experts by experience’ and does not shy to Tweet and blog when she is not feeling very well. She writes (see her blog), gives presentations, plays football when a youth wellness centre is opened in Kibera, is organizing ‘poetry, wine and everything’ evenings, etc.

So we met on a terrace and shared our ideas and opinions. First Sitawa explained me the developments around the new mental health bill in Kenya, replacing the outdated or non-operational Act of Parliament 1991, the ‘infamous’ chapter 248 Mental Health Act. Sitawa is part of the Mental Health Stakeholder’s Legislation Review committee. When this committee tried to review this old Act there was so much to be changed that constructing a whole new mental health bill seemed an easier procedure. In this new bill the current standards and conventions like the UN-CRPD (Convention on the Rights of Persons with Disabilities) and the Constitution of Kenya (CoK), have been incorporated. Now the Draft Mental Health Bill 2012 is ready, but the official endorsement has to wait until after the 4 March 2013 elections.
In Sitawa’s point of view, a lack of knowledge about mental health conditions and epilepsy is the main cause of stigma and exclusion in the Kenyan communities. On her wishing list are more people, or even celebrities, who dare to come forward with their mental disorders in public. More awareness campaigns and positive attention for facilities like the Mathari mental hospital. She sees the youth as the most important target group, because a lot of mental disorders start at this age and young people are the agents of change.
Sitawa likes to start a presentation with asking the people about their views and beliefs regarding mental illnesses, epilepsy, mental disability, addictions, other diseases and the more general community problems. Start with their assumptions and prejudices about the world around them, and then educate and explain about the differences and facts. Don’t make it all a too delicate and special topic either; mental health is part of daily life so are mental disorders. Or as she point it in one of her blogs: ‘I believe joint efforts among groups dealing with mental health, HIV/AIDs and Drug and Substance Abuse will go a long way in helping the world’.
Sitawa also administers One Mind ‘Lend your Voice campaign’, a youth-led mental health awareness campaign, and she has partnerships with different NGOs and peer support groups, like for instance KAWE, The Kenya Association for the Welfare of People with Epilepsy and BasicNeeds Kenya (see below). She would love to attend one of the big international mental health conferences, and I think she could give there an outstanding presentation as well, but she’s afraid that the costs will be an obstacle.

5. BasicNeeds Kenya:
On rainy Wednesday 30th January I met Joyce King’ori, country program manager of BasicNeeds Kenya at their office in Nairobi West.
BasicNeeds is an international NGO with projects in India, Sri Lanka, Ghana, Uganda, Tanzania, Kenya and Laos PDR, Vietnam and Nepal. Since 1999 they have helped over 88,000 people with mental illness or epilepsy, not to mention their caretakers, their families and their communities. They have a clear approach in their work, which is called the Model for Mental Health and Development. In this model BasicNeeds tackles mentally ill peoples’ illness, as well as their poverty. They help mentally ill people start to earn a living after they have been given access to regular, community-based treatment. They also work with communities to overcome stigma and abuse. People with mental illness and epilepsy use the power of their collective voice to advocate for their right to mental health services in their communities.
BasicNeeds is still extending their activities in Kenya by targeting existing groups, like for instance tea or coffee farmer groups, and help strengthening their fabric, their awareness on mental health issues and organize community mental health care. This can in a variety of ways. Mental health clinics may be held at existing health centers or dispensaries. Or community based organizations host the clinics at their own venues or community centers and take on the bulk of the organization of the clinics while (government) mental health professionals attend and provide diagnosing and treatment. Follow up support can then be given by the volunteer community heath workers (CHWs). Forming or joining self help groups not only provides therapy and support but allows participation in income generating activities, such as poultry and pig rearing, egg selling, farming dairy goats, soap making and the production of craft and bead products. Each new group elects officials, develops a constitution and registers with the appropriate local government ministry.
From a small pilot project in Kangemi informal settlements in Western part of Nairobi in 2005, BasicNeeds program currently has projects like this in 9 districts spread over four out of the eight provinces. These are Nairobi West, Kiambu West, Nyeri North, Nyeri South, Laikipia East, Laikipia North and Meru South. There are currently 120 self help support in Kenya with a total of 7000 members. The office in Nairobi runs with 7 paid staff.

Working in partnership with the government ministries of health and local government authorities, BasicNeeds also initiated a program of training for general health staff and traditional healers.
On Joyce’ wish list is first of all mental health facilities for children and the youth, because there is still nothing for these groups in Kenya. Together with Uganda BasicNeeds Kenya applied for a Grand Challenges Canada fund to address this need.
Another wish is reaching the very remote groups like the nomads and the people in the districts not yet covert.
Third: having more resources and capacity building in South Sudan. BasicNeeds is piloting in South Sudan (including a training for doctors), but due to the security situation and lack of infrastructure, scaling up goes too slow, regarding to Joyce.
The last (but not least) wish is more use of the new media in targeting and involving the youth. BasicNeeds Kenya is already using bulk SMS services for mothers (antenatal care) and farmers (about crops, rain, advices), but would like to have an internet-SMS platform for the youth as well. So that these young people can share stories and even can access counseling chat/talk services via there phone. BasicNeeds Kenya is running the One Mind, Lend Your Voice campaign and issued a ‘Mental Health (paper) Magazine for the Youth’ in July 2012, but an ongoing web-based magazine/network will fit better in this internet and smartphone era.
The thorough and well-tested principles and methods of BasicNeeds, together with Joyce’ ‘thinking outside the box’ give me a feeling that this is where community based mental health care is all about: To do more, and reach more people, with the same budget. By building on what exists, going to the people where they are and ‘power to the people’. Bravo!

6. The Africa Mental Health Foundation:
On Thursday 31 January I started with visiting the Africa Mental Health Foundation (AMHF) near the Uhuru park, in a quite and nice (oasis with a amazing bunch of trees) 3-storeyed building. I had the change to speak with Dr. David M. Ndetei and Elizabeth Ombati. Dr. Ndetei is psychiatrist, Professor at the University of Nairobi and founder and director of the AMHF. He is the driving force behind a lot of research and publications and gifted international speaker and networker, for instance ‘There is Hope For Mental Health in Kenya’, a talk at the University of California, Berkeley on October 18th 2012. Elizabeth Ombati is ‘expert by experience’, a youth mental health advocate, and the communication officer for AMHF. She is journalist/writer by profession and is active on Twitter. The AMHF has Twitter and Facebook accounts too.
The concept of AMHF was concretized in 2000, but in the first years it was more a concept then a official foundation. The AMHF, with help of volunteers, has been providing mental services on a few high profile incidents such as the Nairobi American Embassy Bomb Blast, a Kenya Airways plane crash and a fire tragedy in which 67 school children were burnt to death in 2002. In 2004 the foundation was officially established and with the previous experiences they were able to mount a similar mental health response in a slum area in Kenya following the political clashes after the 2007 general elections.
Now the AMHF is a resource centre with 17 staff members, available to ‘anybody with an interest in mental health’, mostly students from public and private universities who come to access materials in their collection or meet with a person with certain expertise whether local or foreign. Their main objectives are: 1. Mental health research and dissemination of findings. 2. Develop innovative practices for mental health services in the context of prevailing socio-cultural and economic factors in Africa 3. Capacity building on mental health and mental health research 4. Advocacy on mental health and the rights of persons with psychosocial disabilities’ influencing policy.
The AMHF offers free services to the needy who cannot afford services as well, and in one of the offices AMHF is hosting the Samaritans Kenya. Samaritans (or Befrienders as the service is called in some countries) provides a listening service and emotional support to those in distress, despair and feeling suicidal. The 70 volunteers are available 7×24 hours and receive special training in listening skills to help in responding to vulnerable community members.
The foundation is publishing books, like the African Textbook of Clinical Psychiatry (together with AMREF), the A-Z of Mental Health (the most sold), Contemporary Psychiatry in Africa and is working on The History of Mental Health Kenya, using the archives in Kenya.
The foundation has an elearning portal (accessible after sending a letter with CV) and opportunities for support for Post-PhD, PhD and Masters Students and independent researchers in Mental Health and Substance Use Related Research in Kenya.
Recently the AMHF received funding from the Grand Challenges Canada (GCC) (‘Bold Ideas for Humanity’) for two projects: Screening for alcohol and depression in Kenya (The Computer-Based Drug and Alcohol Training Assessment in Kenya (e-DATA-K) and Promoting mental health in Kenyan children (The Kenya Integrated Intervention Model for Dialogue and Screening to Promote Children’s Mental Wellbeing (KIDS). The KIDS intervention has been tried successfully in Australia. It is not only children in this method who are involved but the education managers, teachers and parents as well. The trainings focus on recognizing mental health conditions and putting preventive measures; the whole idea being to enable children to develop their full potential. This is the first time this model is being tried in Africa.
Under the e-DATA-K project, AMHF wants to develop innovative ways of training clinical officers, nurses and lay health workers on how to recognize issues related to alcohol and depression. It will be carried out in Makueni and Machakos counties in Eastern Province. The E-DATA-K is an mhealth project. The diagnosing and reporting will take place locally with mobile phones and the data processing will be carried out from a central place.
On the wish list of the AMHF are: more funding like the GCC (they applied again in the latest GCC, with deadline 4 February 2013). More national and international partnerships. More ehealth and mhealth projects in order to reach more people and people in the districts with no psychiatrist or formal mental health care. More cooperation with, and training of, non specialist mental health providers like faith/traditional healers and community health workers or local health facility staff.
As the AMHF seeks opportunities to expand mental health services in remote and rural areas, they also focus on less privileged communities in Nairobi. They were involved in the founding of the psycho-trauma services in the Tawakal clinic in Eastleigh and in the Woodley clinic near the Kibera slums. See below.

7. Counselling in the Tawakal Medical Centre in Eastleigh:

The very friendly Dr. Abdikadir Warsame (the man on the picture) co-founder of the psychotrauma clinic in the Tawakal Medical Centre, was so kind to take me from the AMHF office to his clinic in Eastleigh. There I met co-founder Dr. Maimuna and the other staff members, including 4 young volunteer counselors-psychology students. The students study psychology, because they saw their people suffering, but did not know how to help. They find out that there was a ‘discipline called psychology’ that covers the questions and solutions they were so keen to find. So they signed up for the courses and are carrying out their job in this clinic. That is what one could call a ‘choice made with the heart’! The young women were cleaver, funny and very eager to master their profession and the world.
Tawakal Medical Clinic in the heart of Eastleigh, Nairobi East. Eastleigh has a population of about 350,000 with the majority being of Somali ethnicity. The 20 years during war and instability in Somali has greatly affected that country’s people and a majority have moved to foreign countries with many living in Kenya. In Eastleigh the people are not safe as well; violence and insecurity are rampant and the neighborhood is regarded as one of the most unsafe of Nairobi. There are youth gangs, clan extremists and an estimated 8 gun groups. In the second half of 2012 close to 10 grenade attacks were carried out in less than two months. It’s still unclear now who were behind it. And the extremist movement Al Shabaab tries to recruit young men for their combat in Somalia. On top of that is the tense relationship between the Nairobi police and the Somali population in Eastleigh, sometimes escalating in violence (in November 2012 for instance 42 police officers were killed in an ambush in Eastleigh) which adds to the feeling of insecurity amongst the population.
As the counselors explain, the last couple of months people in Eastleigh are hiding at home and you see far less children and women in the streets then a half year ago. This means less patients in the clinics and more hidden suffering and isolation. Along with the decrease in patient numbers the clinic is facing more relapses in mental health conditions.
Dr. Warsame and Dr. Maimuna were already working for their community for years, before they went back to the University in Nairobi to study about mental health. They went seeking specialized knowledge, help and research after they had discovered that most of the patients appeared medical healthy yet they still would complain of multiple pains. Their treatment of that time seemed not effective enough for these symptoms.
so, they discovered that most of the patients were suffering from psycho-somatic complaints like the ‘hapa hapa’ [here and there] syndrome. A syndrome that has been coined from a Tanzanian psychological condition that affects mostly refugees, due to their exposure to wars and attacks in their homelands. In the hapa hapa syndrome patients complain of pains in virtually all parts of their bodies. They tend to get irritated easily, are always ready to fight with no room for compromise, and also suffer from sleeping disorders, a situation that further explains their indulgence in khat chewing, cigarette smoking, and now alcohol abuse. They started the cooperation with the AMHF and launched the psycho-trauma clinic in Tawakal medical centre. On board now are the four counselors, an occupational therapist and a community health worker. They run weekly support groups (now 15 groups of 16 women each!), provide individual counseling and, if necessary, do home visits. The team selected a group of trainers from within the locals, who were then taken through a five-week long intensive training program in basic counseling. After training, the first group of 30 youthful graduates was in December 2012 presented with counseling certificates. The program aims to equip 240 counselors.
Dr. Abdulkadir explains further that mental health is stigmatized in the Somali population. If they would tell someone that he/she is having a mental illness, the person will disappear. They do a lot of counseling, but they rather call it ‘education’ or ‘support’ and they often tell the patients that they are not mentally ill but there is a problem in their head.
Every day new patients come to the center and there is a lot of mouth to mouth advertisement. Even refugees in for instance Sweden and Denmark call for counseling! As Dr. Abdulkadir explains: ‘The Somali people have gone through a lot of emotional turmoil because of the war, and even when they go to foreign countries, it is difficult to find people with whom to share their anguish, hopes and desires’. That is the reason that they receive such long-distance phone calls from various foreign countries offering therapy through the phone.
On the wish list of the Tawakal psycho-trauma center are: 1. Reaching the vulnerable young men in the community. 2. Scaling up their services like a cascade: training more counselors and starting more groups. 3. And most and for all: to have peace in Somalia and Eastleigh; preventing more people suffer from this anguish and terror.

8. The Peter C. Alderman Foundation trauma counseling partnership with the Woodley Clinic in Kibera:
The Woodley Clinic, owned by the City Council of Nairobi, is just on the edge of one of the biggest slums in Africa, Kibera. Although inside the clinic you don’t see anything of this dense populated slum, most patients come from Kibera and bring their problems and challenges of poverty, malnutrition, HIV, substance abuses, rape, trauma, etc, with them.
On this Thursday late afternoon I visited this clinic in company of Elizabeth Ombati, communication officer of the AMHF. Because it was after the clinics’ rush hours (which are approximately from 10am-2pm), Mrs. Immacolata Nyaga (‘Mama Nyanga’) was able to take some time to show us around and tell us with proud the Woodley trauma project story. Mrs. Nyaga is the only, and very experienced clinical psychologist in the centre and the one in charge.
Although the Woodley clinic, type dispensary, offered medical services like antenatal care, family planning, growth monitoring and promotion, HIV counseling and testing, immunization, prevention of mother to child transmission of HIV, youth friendly services, etc., for quite a long time, the trauma counseling services started in 2007 after the election violence. Especially rape survivors were in need of psycho-social support, and the staff of the clinic added counseling sessions to their basic packet of services. After funding from the in New York City based Peter C. Alderman Foundation (PCAF) in May 2012, they could start a formal trauma counseling project with a psycho-trauma nurse who is learning on the job. Mrs. Nyaga shows us the figures of cases and sessions in one of the (paper) registers. Like 8 new reported trauma cases in the last 3 weeks. Along individual counseling the clinic offers education/awareness group sessions in the clinic and in the community.
The PCAF has partnered with the AMHF and the Kenyan Ministry of Medical Services to provide trauma care at the Woodley Clinic with a plan to expand mental health services in Kibera through the use of community health workers.
The general mission of the PCAF is ‘to heal the emotional wounds of victims of terrorism and mass violence by training indigenous health workers and establishing trauma treatment systems in post-conflict countries around the globe’. From it’s launch in 2001, they have reached over 100,000 people suffering from depression and post-traumatic stress disorder resulting from terrorism and mass violence by their Foundation-trained doctors and Foundation-run clinics. They issue the open access African Journal of Traumatic Stress (AJTS), a peer reviewed journal, and organized 5 Annual PCAF Pan-African Psycho-trauma Conferences, the last one in Tanzania.
On the wish list of Mama Nyaga is first of all more professional staff in order to be able to do more and expand the activities in the community itself, like more groups and more education. Second to transfer this model of trauma counseling to other clinics in the city and country; to serve more vulnerable and traumatized communities and people.

Other organizations in mental health Kenya, but not interviewed:
–Kenya Psychiatrists Association
–The Schizophrenia Foundation of Kenya (SFK)(via the WFSAD)
–The Kenya Society for the Mentally Handicapped
–Caritas Kenya
–The Kenya Association for the Welfare of People with Epilepsy (KAWE)
–Alzheimer’s Association of Kenya (AAK)(via the AMHF)
– The Cool Waters Publishers and Consulting firm, website currently off line director is Susan Catherine Keter.
–AMREF in Kenya
–Normal Difference Mental Health Kenya
–Open Minds Kenya
–Oasis Africa Institute of Leadership and Professional Psychology

Conclusions:
When you compare the mental health capacity and care in Kenya now with say 15 years ago, the improvements seem enormous. As if there was nothing, except the big hospital and probably traditional/faith healers taking care of people with mental disturbances. And now there is ‘something of everything’. There is happening a lot nowadays and although it is yet far from enough it gives hope and will encourage more people to join the movements in this health field. It can be in seeking a career in mental health, in doing research, in joining peer support groups, blogging or speaking out about mental health on the national media, helping to improve mental health legislation, or just in helping a relative or neighbor with his/her struggle or mental health condition.
It seems that a plan build on a conventional/Western model of mental health care, with mental health care delivered by specialized professionals like psychiatrists, psychologists and psychiatric nurses, is deemed to fail. Even with the current increase of students and trainings, serving 43 million people with this model will take a century or more.
It seems that a plan build on hope that government or international funding will increase enough to expand the mental health care as it is now, is not realistic as well.
Or you could say: more people must be reached with the same resources and amount of mental health specialists. One must build on what is already in place and integrate mental health care, support and awareness campaigns, in existing groups, communities and organizations.
So, a shift in thinking seems necessary and one can see that there is already a movement in Kenya in the right direction. More innovation and thinking outside the box. More elearning and mhealth projects and research, more empowering of service users and their caretakers, and more trained general health care staff and CHWs.

In trying to get more international funding for projects and training one could try to look outside the ‘not so popular’ mental health sector and seek a connection with the non communicable diseases or apply for human rights funds, children funds, grants for innovation like the Grand Challenges Canada, try crowd funding, etc. A few organizations mentioned above are already trying these roads.
Or, inside Kenya, one could try to organize income generating activities for people with mental conditions and their caretakers.
But still, more money will not be the solution where one should rely on too much.

Conditions and treatment in the Mathari Mental Hospital are still under international standards, and in the near future there will be a next scandal, video or debate about this institute, I’m sure. But until there is an alternative for this asylum and care, this hospital seems a necessity in this country. Were else can people go with their confused or aggressive relatives? If a community based mental health care in is place and/or care is more decentralized, there will be less tendency to bring disturbed people to Mathari and leave them behind. Only then this hospital can downsize or transfer itself to a specialist hospital for brief specialized admission and treatment.

To warp up with 8 key points for the future of mental health care in Kenya:
1. Information and awareness is key
2. Support for people with mental conditions and caretakers is key
3. Innovation is key; thinking outside the box
4. Working together and transcending sectors is key
5. Integration into the communities is key
6. Good legislation is key
7. Youth and children are key
8. Passion is key

Roos Korste, psychologist, international trainer, blogger

Acknowledgements: I would like to thank all the persons mentioned above, who took the time and effort to provide me with the necessary information. I hope, in due time, I can do something in return.