Kenyan Psychiatrist

When you treat security casually, crime festers2014-06-24T21:56:00.002+03:00

By Lukoye Atwoli

Sunday Nation 22 June 2014

Observing the behaviour of  Kenyans  and  their so-called leaders, there is no doubt we have failed to learn from history. For several months  now,  we  have  unnecessarily lost many lives in events that demonstrate a lack of creativity in the running of public  affairs.  These  events have  particularly escalated  in recent weeks.

One  could  come  to several conclusions based on this observation. Firstly, one could argue that it  is  all a  mere  coincidence, and  that  the  road  crashes, chang’aa deaths, terrorist attacks,  increased  crime  and political  instability  have  just happened  to  cluster  together purely by  chance. That  is, of 

course, possible but it is highly improbable.

Secondly,  one  could  argue that  some  malevolent  force hell-bent  on  destroying  our country for some obscure reason has planned at least some of these events. This  is  indeed  the  line adopted by some in and out of government, especially after the attacks at the  coast  when the government claimed there was a political angle to it all. 

The  President  laid  the blame for the current troubles squarely at the feet of “reckless” politicians who were inciting the people. Unfortunately,  all  indications  are  that  this  is  also highly  improbable,  and  that any politicians even  remotely associated with these attacks are either opportunists or bystanders in the wrong place at the wrong time.

A more plausible explanation is that these events are an indication of ineptitude in the arms of government responsible for maintaining  security, law and order. No matter the source of these atrocious happenings, it falls on the government to neutralise the threats before they materialise instead of waiting for people to be killed and then looking for targets to blame.

Social  psychologists  have long ago demonstrated a  link between disorder and crime. In what is now known as the Broken Window Theory, it has been shown that neighbourhoods and property that is left in a state of disrepair soon attracts vandals and criminals of all shades. Wilson and Kelling, in a seminal paper on this topic, argued that “untended” behaviour leads to the breakdown of community controls and order. They demonstrated how an abandoned  piece of  property in  a nice  neighbourhood can cause changes in the behaviour of residents, and eventually lead to increased crime and general 

disorder.

This theory  easily  explains what is currently happening in the country, and could even predict what is in store for us. The security docket has not properly exerted itself in a professional manner in dealing with crime in this country. That  is  not  in  dispute,  no matter where  one stands politically. As  a  result,  many  “small” crimes  have  been  going  unpunished  while  our  police oﬃcers get  collectively tarred with claims of corruption and bribe taking.

Tolerance for “small” crimes such as assault, robberies and murders has increased so much that police spokespeople routinely refer to them as “normal” crimes. Consequently  the  country has slid into a general state of lawlessness,  and the  government’s brazen  assertion  that we are now responsible for our own security only worsens this perception. 

Because  of  our  tolerance for “Broken Windows” in our country,  terrorists and other criminals  are having  a  ﬁeld day. The sooner the government acknowledges this situation and takes ﬁrm action to deal with it the better for all of us. 

Dr Atwoli is a consultant psychiatrist and senior lecturer at Moi University’s School of Medicine.

lukoye@gmail.com

Want to see how nations burn? Visit social media

2014-06-17T21:47:00.002+03:00

By Lukoye Atwoli
Sunday Nation 15 June 2014

Kenyans on social media are a loud and boisterous bunch. Over the past few years they have distinguished themselves as a most combative collection of citizens, and nowadays it is not uncommon to learn of social media wars against other countries or individuals who are perceived to have slighted the motherland. National issues discussed on social media often take on the crimson hues of a violent confrontation, and ethnic organisation is never far from the picture.

Many have argued that the anonymity afforded by social media provides people with the perfect cover to slip into fantasy personae and role-play behaviours they would otherwise not engage in outside of the social media environment. Examples are cited of many otherwise timid people morphing into violent bullies online, driving young people to attempt such harmful acts as suicides and violence.

My view is a little different, though. I would argue that the anonymity of the Internet unmasks one’s real motivations, and allows them to act out their real impulses with little fear of immediate embarrassment or punishment. The result, therefore, is that one feels free to act without the constraints of social conventions and mores, and studying one’s online behaviour can often reveal more about their personality than the traditional assessment methods.

Of course this is a highly generalised view, and it would take a highly experienced analyst to uncover these issues, especially in cases where some people use the Internet to attempt to cover up what they consider to be their real selves. They open multiple proxy accounts and often have social media “conversations” with themselves in order to convince their audience that they are in fact separate individuals.

The long and short of it is that studying the behaviour of Kenyans online may actually be key in unravelling the mystery behind the interesting phenomenon in which most Kenyans openly profess love for their motherland while engaging in the most egregious war-mongering activity online.

Almost every open Kenyan discussion one comes across on many social media platforms degenerates into ethnic sparring and name-calling whenever the subject veers towards politics or social conduct. People known to be socially progressive and public-spirited often expose their tribal warrior blood when push comes to shove on the blogosphere.

And there is a pattern to these eruptions. In the run-up to the 2007 elections, social media chatter rose to a crescendo with tribal slurs and threats of annihilation, with plenty of mention of ethnic practices that were deemed to disqualify or qualify some candidates for national leadership. As the post-election violence escalated, the buzz on social media reached deafening heights, and it became impossible for any sane Kenyan to get in a word edgewise at any given time.

My engagement on social media today convinces me that we are approaching that point again. False and exaggerated accusations are being made against politicians on each side of the divide, aimed at casting them almost in the same light as wild animals. These accusations are then being transferred wholesale to their ethnic communities, and explanations are made based on tribal stereotypes. Eventually nothing can be heard but war cries and insults.

That is how nations burn. That is how genocides incubate. Social media is the spark that will eventually ignite the restive tinder-box that goes by the name Kenya.

We cannot say we were not warned this time.

Dr Atwoli is a consultant psychiatrist and senior lecturer at Moi University’s School of Medicine. lukoye@gmail.com

It’s time leaders did what they were chosen to do

2014-06-08T18:54:00.004+03:00

By Lukoye Atwoli
Sunday Nation 08 June 2014

In the past few weeks I have been travelling in the US on business related to research and collaborations between my institution and some American medical schools. As always, I have been keenly observing events on my trip and juxtaposing them against conditions back home. A useful observation I have made concerns our behaviour when we disagree on ideas.

Just like Kenyans, Americans bicker and quibble about everything from who should get state-supported health care to what should happen to the baby in a woman’s womb. And the arguments can get pretty acrimonious and public, sometimes raising tempers to the level of threats of violence in sections of the population.

But that is as far as the similarity extends.

The greatest difference lies in the reason why they engage in these arguments and conflict. To a large extent, the average American is proud of his country and its heritage. In every city one visits there will be a museum dedicated to the history of the city and the state, and the greater US. There are monuments everywhere you go commemorating the most seemingly innocuous achievements of the city’s inhabitants, and American heroes.

Every national holiday is an opportunity to remember and re-enact important historical moments in America’s journey since its founding. School-children recite that history with pride, and point out national monuments as though they were erected in their lifetimes. On the whole, Americans argue about their respective convictions on what is best for the US.

Contrast this with Kenyans. For the past 12 years or so, we have been poised on an ethno-political knife-edge requiring very delicate balancing to avoid outright civil war. Kenyans are almost equally divided into two factions on any national issue — those that support the government and those that don’t. Some members of these two factions have shifted back and forth, both among politicians and among the voting public, but the proportions have remained mostly undisturbed.

At any point in time, these two factions express the most vehement loathing for each other, and at least once in the past 10 years this has erupted into open armed civil conflict. Political arguments are turned into existential matters for the politicians’ tribesmates, and nobody remembers the greater good of the republic.

We have heard leaders and their followers say that they are ready to let the country burn if they cannot achieve their goals peacefully. We have heard politicians taunting each other about nusu mkate (half-loaf) governments, as if Kenya is bounty to be fought over, and the winner takes it all. Political power has become an end in itself, rather than an opportunity to serve.

The result is that we have elected people into positions of power who often act as if they have absolutely no clue what that office entails. People are coming into power without the slightest idea what they will do for the people who elected them. This is especially surprising given the amount of resources that are spent campaigning for public office.

I remain hopeful that in my lifetime I will see my country transform into a land where we argue about ideas we think are good for Kenya, and not for individual leaders’ fortunes. But it is difficult to sustain this hope given our current political landscape.

Dr Atwoli is a consultant psychiatrist and senior lecturer at Moi University’s School of Medicine. lukoye@gmail.com

Medical schools should teach, not make money

2014-06-04T05:07:00.002+03:00

By Lukoye Atwoli

Sunday Nation 01 June 2014

Recent demonstrations by medical students at one of our local universities exposed just the tip of the iceberg as far as problems in the training of medical personnel are concerned. The students were complaining about lack of facilities and staff to teach critical courses in their curriculum. This shouldn’t surprise anybody knowledgeable about medical education in this country.

Many universities treat medical education as a cash cow rather than as an avenue for increasing the number of critical personnel in the health sector. Several times in the past, medical students have been admitted to “medical schools” only to find themselves idling on campus without teachers or material to learn.

The Medical Practitioners and Dentists’ Board, being responsible for regulating medical training in the country, has tough questions to answer in this regard unless they can demonstrate the problematic institutions are duplicitous in their dealings with the Board.

The Board is certainly aware of the shortage of doctors in this country, and any move to rectify this situation is definitely laudable. Unfortunately this shortage also affects availability of experts to train medical students in the various areas of medicine. Especially in the basic sciences that form the bedrock of medical training, there is an acute shortage of lecturers even in the more established medical schools.

This being the case, it is surprising that there is no sustained policy to focus on training of experts in these fields in order to ensure all medical schools are sufficiently served. The result is that in some cases the same individual is involved in teaching medical students at several universities, obviously to the detriment of quality teaching and all but obliterating any opportunities for research. With the proliferation of medical schools in all corners of this country this situation is sure to worsen.

CAREER PROGRESSION

Further complicating the issue is the involvement of universities in the training of certain paramedical cadres without clear career progression. For a long time in this country, the Kenya Medical Training College has been training a highly qualified cadre of paramedical personnel known as clinical officers.

These officers have helped ensure Kenyans in the most remote parts of the country have access to a clinician who can diagnose and manage common medical conditions. Beginning training at diploma level, they were able to further their training at higher diploma level specialising in one field of medical practice. Those that were so inclined could later join medical school and train to become doctors.

Some of our universities jumped into the fray and initiated the training of this cadre as they prepared medical curricula for future training of doctors. After a while, some bright chaps at these universities came up with the idea that they ought to train the same cadre at degree level, without a thought as to how they would fit in the highly regimented medical fraternity.

Many of the students enrolled in the courses believing they were being trained to become doctors. Unfortunately many of their dreams are ending in frustration when they find that many institutions do not know how to deploy them when they apply for jobs.

It is time we held candid discussions about the direction of medical training in this country because, after all, the arguments and tantrums, the lives and livelihoods of Kenyans are at stake.

Dr Atwoli is a consultant psychiatrist and senior lecturer at Moi University’s School of Medicine. lukoye@gmail.com

Doctors’ killing signifies a worrying trend

2014-06-04T04:41:00.000+03:00

By Lukoye Atwoli

Sunday Nation 25 May 2014

In the past few weeks, this country has lost several doctors due to various causes. The recent killings of doctors in Nakuru and Meru are particularly noteworthy because they poignantly illustrate the state of our nation.

Firstly, outside of medical circles, these killings have gone virtually unremarked and police have, as usual, chalked them down to “normal thuggery”. This reflects the general situation in this country, where we have accepted that we can lose such important members of our society and not be shocked. We are so preoccupied with ethnic sharing of the national cake that we are unable to appreciate the fact that the scarce health worker resource continues to be depleted in preventable ways.

Secondly, these killings demonstrate the difficult working conditions that many health workers are having to contend with as they serve the thankless populace. Many doctors are working extremely hard to save lives, often without anyone to relieve them when they are tired. They work long hours and have little time for their families or friends.

Unfortunately, when they burn out and decide to take a break, they are often accused of having abandoned their patients to go and “enjoy” themselves. And when they continue working despite their inevitable problems, they become error-prone and are crucified for every small mistake they make. When their luck finally runs out, they find armed thugs waiting for them when they come home after a long night at work. This once-glorified profession has lost its lustre, and now carries the risk of premature mortality and a lifetime of suffering.

Thirdly, the fact that these unfortunate deaths have not triggered talk of a crisis in the health sector clearly demonstrates that both the national and county governments are only paying lip-service to the health of their people. Measures have not been taken to protect health workers and ensure that they operate in a more conducive environment. The national government has all but abandoned health workers, leaving them at the mercy of county administrations that often don’t have the foggiest idea on how to manage a health workforce.

As a result, health workers are continually being threatened with the sack for a variety of ills, real and imagined. Every so often, a governor lashes out at these “thankless officers who are trying to avoid supervision” and promises citizens that he will make them work or fire them if they are lax in their duties. Many have resigned as a direct consequence of this intimidation, while others have, in the past, been “released to the national government” in an undisguised move to eliminate “foreign” professionals from some counties.

A Kiswahili saying aptly captures the current state of affairs: Usiwatukane wakunga na uzazi ungalipo (Do not insult midwives while women still give birth). As things stand, health professionals feel badly treated, insulted and abandoned by the political class while, on the other hand, citizens are demanding more and more from them.

Perhaps if we knew that everyone will at some point need to see a health professional, we would plan differently. Maybe we would allocate more funding to the health ministry, use the funds to train and hire more health workers, and procure equipment and supplies that would make their work more effective, and rewarding?

But maybe nobody cares!

Dr Atwoli is a consultant psychiatrist and senior lecturer at Moi University’s School of Medicine. lukoye@gmail.com

Let’s not interfere with MCAs’ oversight role

2014-06-04T04:31:00.000+03:00

Once again sorry for this delayed posting; I've been traveling quite a bit lately, but hopefully I should now be able to post more promptly. Here come a series of the latest articles...

By Lukoye Atwoli

Sunday Nation, 18 May 2014

The recent spate of impeachments and impasses at county assemblies pitting governors against members of county assemblies (MCAs) seem to be raising hackles in certain quarters. There are increasing murmurs suggesting that MCAs are being overzealous in their task of keeping the county executive on its toes. There is even talk of passing legislation to limit the county assemblies’ roles in the impeachment of governors.

The idea that MCAs wield the power to fire the county government terrifies many observers, and there are suggestions that this power will cause governors to try and please them with corrupt deals and money-wasting perks.

I disagree with the doomsayers.

One key reason Kenyans rejected the old constitution was that it had systematically concentrated all power in the hands of the president, who could delegate and use the powers at will. At some point, a little over 20 years ago, a former Attorney-General boldly declared to the National Assembly that “nobody, save the president, is above the law”.

The implication was that the president could do pretty much as he pleased, and all presidents under that constitution did exactly that. In that constitution, there was even a clause that indicated clearly that all public servants served at the pleasure of the president. He had power over life and death, and the many detentions without trial that dot our history are just a few of the demonstrations of that power.

It is in realisation of these dangers that Kenyans resolved to write a new constitution and, in a process spanning two decades, we eventually came up with our current charter. In the new constitution, we reduced and dispersed executive authority, to a large extent. We created multiple executive offices protected by the constitution, and introduced rights that could not be abrogated at will.

In the realisation that even the dispersed executive could go overboard and harm the very people it was supposed to serve, we built in a system of checks and balances that, if implemented, would be the envy of all civilised nations across the globe.

At the national level, we established a Senate with the power to send the President and his Cabinet packing should they contravene the constitution or any other written law. The National Assembly was vested with day-to-day oversight authority to ensure that the interests of the citizen are upheld in all government dealings. Above all, we established a Judiciary to arbitrate in cases of conflict between the different arms of government, and between law-abiding citizens as well.

At the county level, we established the office of governor to parallel that of the national president, and county assemblies to provide oversight and, if necessary, to impeach the governor and his executive should they behave in a manner contrary to the best interests of the citizens. To guard against frivolous motions of impeachment, we gave the Senate the final authority to decide the fate of impeached governors.

As far as oversight of executive authority is concerned, especially in the case of governors, the constitutional procedures have been scrupulously observed. We should let the law take its course because that is how we designed our system of governance. Interfering with the oversight functions can only send this country back to the dark old days of leadership by executive fiat, and this would be a sure recipe for chaos.

Dr Atwoli is a consultant psychiatrist and senior lecturer at Moi University’s School of Medicine. lukoye@gmail.com

Depression is never the patient’s fault

2014-05-13T12:16:00.004+03:00

By Lukoye Atwoli
Sunday Nation 11 May 2014

It is heartening that Kenyans are beginning to see the importance of mental health, and many are beginning to ask questions about how they can improve it. The media has been extremely helpful in this regard, with pieces in the print and electronic media tackling this difficult subject. In this regard, one could safely conclude that the citizens are ahead of their government.

As the government dithers and prevaricates, Kenyans continue to suffer from the debilitating effects of mental ill health. Suicides, homicides, road traffic ‘accidents’ and incidents arising from illicit alcohol use are just some of the outcomes that have become very prominent lately. In response, the government prefers to tackle only the symptoms.

Brewers and consumers of all kinds of alcohol are arrested and processed through the criminal justice system, while nothing is done to deal with the underlying causes. Suicide attempt is still a criminal offence under Kenyan law, although prosecutions and convictions are rare largely due to humane interventions by prosecutors and judicial officers. Interestingly, in the midst of this mental health crisis, the government saw it fit to disband the Division of Mental Health in the Ministry of Health despite clear legal provisions for it.

Increased media coverage obviously cuts both ways. The media can serve to inform and educate the public about mental health, but occasionally some misleading information may be sneaked in, often by good-intentioned individuals. This can only be prevented by inclusion of experts who would then moderate the message and ensure that only accurate information is fed to the public.

A case in point is a recent programme discussing depression and suicide on one of our local TV stations, in which the moderator kept asking participants why they got depressed. In summing up the discussion, one of the panellists suggested that depression can be prevented and even managed by a simple change of attitude. It was in fact stated that ‘depression is a choice’, and that a depressed person can choose not to be depressed.

This is an unfortunate assertion that does more harm than good. Depression is a mood disorder characterised by a profoundly low or irritable mood most of the time over a significant period of time. Other features of depression include changes in sleep and appetite, impaired attention, concentration and memory, a sense of worthlessness and hopelessness, excessive and inappropriate feelings of guilt, slowing of thought and even developing ideas of suicide.

A normal person would never wish to feel depressed, because the pain and anguish associated with depression is so severe that it is often considered more debilitating than physical pain. A depressed individual will initially try all interventions available to them to deal with their depression. They will pray, try to be ‘strong’, use herbs and even try to adopt a positive attitude.

The fact that their depression persists and gets more and more severe is evidence that all these interventions have been unsuccessful, and they need professional help. Throwing the ball back into their court and suggesting that they are responsible for their illness only serves to make things worse, and can drive some to contemplate suicide. It exacerbates their feelings of guilt and may just push them over the edge.

People with depression need supportive family and friends, but above all, they need professional help.

Dr Atwoli is a consultant psychiatrist and senior lecturer at Moi University’s School of Medicine. lukoye@gmail.com

Science and religion not on equal footing

2014-05-05T14:27:00.000+03:00

By Lukoye Atwoli
Sunday Nation 04 May 2014

In the past few days, the media have uncharacteristically given lots of attention to the atheist idea and its proponents. A prominent atheist has been interviewed several times on various television stations, and newspapers have written about him and his lack of religious beliefs. As a result, many religious folk have reacted with consternation, arguing that it is wrong to give prominence to the idea that gods do not exist, and that humans are responsible for all decisions they make.

A key feature of all debates between atheists and theists is the idea that everyone must believe in something supernatural, and that if someone does not believe in a god or system of gods, they must then have another belief to replace that. Many think that all atheists have replaced gods with science, or the theory of evolution, to be specific.

As a result of this argument, we live with the misconception that religious ideas are competing at the same level as scientific ideas. In my opinion, it is important to make the distinction that these two systems cannot, by definition, operate at the same level of reasoning.

Whenever two people engage with differing points of view, no amount of passion will win the debate unless logical arguments are presented to support the views. It does not matter whether you are discussing who is the best person to elect as president, or if the sun will rise tomorrow, or indeed if it is right to kill another human being because he dresses differently. Logical arguments are persuasive and convince people to change whenever they encounter them.

Scientific arguments follow this rule to the letter. One can never make a persuasive scientific argument while presenting no logical support for it. In other words, whenever one makes a proposition they are required to provide the evidence. In science, one must lay bare their methods and results, and allow other interested scientists to try and prove the proposition wrong. In other words, science thrives on scepticism and constant questioning.

That is how we have been able to discover more ways of making life easier and more comfortable.

APPEARANCE OF LOGIC

On the other hand, religious arguments, while they start with the appearance of logic, end with the completely illogical assertion that there are some things that cannot be interrogated or known, except by some mysterious supreme being.

Faith – the idea that it is okay to believe that something is true on the basis that someone authoritative said it is so – is glorified in most religions, and questioning the deity is frowned upon. Doubting the deity is accompanied by threats of eternal damnation, and even earthly punishment.

It is difficult for one to elevate both these ideas to the same level, and argue that they can stand on the same pedestal and attempt to persuade humanity to accept them as equals. How can that be when the religious apologists attempt to use scientific arguments to prove their claims, and when that eventually comes to a cul de sac, they invoke the infallibility of their revelation or authorities?

As we discuss the issue of religion and its effects in our society, these are some of the issues we must take into consideration.

Dr Atwoli is a consultant psychiatrist and senior lecturer at Moi University’s School of Medicine. lukoye@gmail.com

It’s not too late to redeem health services

2014-05-03T11:34:00.001+03:00

By Lukoye Atwoli
Sunday Nation 27 April 2014

The Kenya Medical Association held its 42nd Annual Scientific Conference this past week where it came to light that health services are in dire straits. The Medical Board gave alarming statistics that showed a huge discrepancy between the number of doctors trained in Kenya, and those currently working in the country. Obviously there is an exodus of doctors and other health workers in search of the proverbial “greener pastures”.

Why is this happening?

Until a few years ago, the terms and conditions of service for doctors were unbelievably pathetic. Following the registration of the doctors’ union and a series of strikes, the government improved the pay packages for health workers and developed a retention policy. For the first time in many years, health workers started seeking change of employer from the private sector to the public sector. Many people in far-flung areas were for the first time in their lives able to see a doctor when unwell.

Then came the new Constitution that devolved a portion of health services to the counties. In a monumental misreading of the Constitution, the national government purported to have devolved the health sector “100 per cent”. As a result, many health workers found themselves in the employ of county governments that had other priorities.

In their first budgets, many county governments did not provide funding for health workers’ pay. As a result, there are still problems with remuneration of health workers. Many health policy decisions are being taken as afterthoughts, without regard to the fact that their impact often means that people could die.

A perception has been created that health workers are against devolution of health to the counties. This is an erroneous assertion aimed at painting health workers as spoilt brats who do not want to be supervised in their work. Many governors are pushing this argument, going as far as to claim that many of those asking for pay are “ghost workers”. Some have embarked on an ethnic audit of their health staff, and others have been encouraging doctors to emigrate to their “home counties”.

Finally, many doctors expect that when employed, their employer would eventually pay for them to undergo further studies in pursuit of specialisation. The national government has, to a large extent, facilitated this through a scholarship programme in the Ministry of Health. Unfortunately, this assurance is lacking in most county governments.

These are some of the issues that are driving doctors and other health workers away from public sector employment to the private sector and, more worryingly, to other countries. Right from the beginning, health workers have proposed solutions to deal with these and other emerging issues. These suggestions have been largely ignored by the powers that be.

Happily, political leaders at the national level are coming to the realisation that unless urgent steps are taken, people will continue to die and suffer from preventable causes. A parliamentary committee has been reported arguing for the formation of a national agency to deal with human resources for health in order to eliminate inequities and address the welfare of health workers and the public.

One hopes that those responsible for the health of Kenyans will take this initiative seriously, unless they are happy with the continued deterioration in the sector.

Dr Atwoli is a consultant psychiatrist and senior lecturer at Moi University’s School of Medicine. lukoye@gmail.com

Be humane in search for illegal aliens

2014-05-03T11:31:00.002+03:00

Apologies for delayed posting. But here goes:

Be Humane in search for illegal weapons

By Lukoye Atwoli
Sunday Nation 20 April 2014

There is no doubt at all in my mind that there are terrorists in our midst, hell-bent on causing chaos and inflicting suffering on our fellow citizens. Multiple explosions and shootings bear out this view, and only a person who does not live in Kenya would argue that there is no terror activity going on here.

What is not clear, however, is who the terrorists are. Traditionally, and in other countries, a shadowy terrorist group is always at hand to claim credit for terror attacks. For instance, Al-Qaeda took responsibility for the 1998 US Embassy bombings in Nairobi and Dar-es-Salaam. Similarly, Al-Shabaab claimed responsibility for the attack on the Westgate mall in Nairobi.

In the more recent attacks, it is curious that no group has claimed responsibility, even as we all blame Al-Shabaab. Be that as it may, we cannot take this terrorist activity lightly. Kenyans are paying a cadre of civil servants good money to sniff out the terrorists and ensure that the rest of us get a good night’s sleep without worrying about being attacked.

It is in this light that the government launched an operation to identify and deal with actual and potential terrorists living in our midst. The operation appeared to initially target Somalis in Eastleigh area of Nairobi and some suburbs in Mombasa. The police have since announced that the operation would spread to other regions of the country, and was aimed at catching criminals and foreigners residing in Kenya illegally.

Unfortunately, the perception that Somalis are being unfairly treated persists. At the beginning of the operation, social media was abuzz with activity. Most Somalis pointed out the absurdity of targeting a single community or religious group and meting out dehumanising treatment in the name of searching for terrorists. They gave heart-rending personal accounts of the treatment they or members of their families underwent in the hands of police.

SMALL SACRIFICE

Many non-Somali Kenyans appeared to fully support the raids, and opined that it was a small sacrifice to pay for enhanced security. That was only until they also bore the full brunt of the operation. Writing from a middle-class neighbourhood in Nairobi, a friend detailed how she woke up in the wee hours of the night to loud noises and bangs at her gate and doors, thinking that the house was being robbed.

In a panic, she called her friends and acquaintances asking them to get help. She later realised that the attackers were not robbers, but policemen conducting an operation to flush out suspected terrorists. Like most of her neighbours, she did not let them into her house. The only neighbour who did had his house ransacked and all rooms turned upside down. By the time the policemen left, most people in this neighbourhood had a very dim view of the police operation.

Is it impossible for our police officers to be more civil in carrying out these operations? Is there no other way of identifying potential terrorists and criminals without causing so much suffering to innocent citizens? Is ethnic profiling the only way of ensuring our national security and enhancing cohesion? How long will these operations last, and how shall we measure their effectiveness?

These are just some of the questions we must deal with, even as we pursue these miscreants.

Dr Atwoli is a consultant psychiatrist and senior lecturer at Moi University’s School of Medicine. lukoye@gmail.com

‘Healing’ crusade poses serious health risk

2014-04-17T12:15:00.001+03:00

By Lukoye Atwoli
Sunday Nation 13 April 2014

Kenyans are a highly religious people. This is borne out not only by their open declarations of religious affiliation, but also by their often overzealous demonstration of religious fervour whenever they are called upon to do so. This, in itself, is not a bad thing. It might even be a good thing, especially in circumstances when this religious zeal is directed at activities aimed at improving the lot of needy individuals or humanity at large.

Unfortunately, due to the nature of religious belief, occasional tragedies occur. There are multiple examples of this, and it is pointless to rehash them here. The reason they occur is that the average religious person takes the message from their holy book or their cleric literally. Many proclaim that their clerics are messengers of their deity, and the holy book is the unquestionable transcription of the deity’s words. Sometimes the outcome of this blind obedience is serious harm and even death, but even these are explained away as the doings of an inscrutable deity.

Over the long Easter weekend, one such cleric will descend upon Eldoret with the professed mission of spreading the message of repentance and holiness. As has been the practice in previous crusades of a similar nature, it is expected that many will ferry their sick relatives from far and wide, and present them to this preacher who is also fabled to be a faith healer.

ABANDONED MEDICATION

Those of us taking care of thousands of Kenyans with chronic conditions will be waiting for the inevitable outcomes with dread. We know many patients who have already abandoned their medications and clinic follow-ups in anticipation of healing at the crusade, and dozens more who will attend the crusade and abandon their treatment.

We dread the reports we shall get when we follow-up patients with chronic conditions like HIV, cancer, diabetes and mental illnesses to their homes. We fear we will be told some of them died after being convinced they were healed at the crusade thus stopping their life-preserving treatments. We fear we will find them at home, wasting away while believing fully that they have either been healed, or that healing is on the way.

We dread the events we shall continue to encounter in the clinics of the Moi Teaching and Referral Hospital, weeks and months after the four-day crusade. Many patients will show up in deplorable health and, when asked what happened, they will say that they thought they had received healing at the Easter crusade. Many more will suffer irreversible damage due to chronic illness, and will return to the hospital only at the urging of worried family members.

Why do we raise the red flag at this point, before the crusade happens? Because we believe it is still within the powers of the organisers of the crusade to do something about it and ensure that no lives are lost, and no one goes home in worse health.

The organisers and preachers should announce to their faithful that nobody should stop taking their medication or stop attending their regular clinics, in anticipation of healing. That simple message will save dozens of lives, and ensure continuing good health for countless others, which one would expect is a good thing for the organisers of the crusade.

Dr Atwoli is a consultant psychiatrist and senior lecturer at Moi University’s School of Medicine. lukoye@gmail.com

Jubilee one year on: Analysis of health pledges in Jubilee Manifesto

2014-04-11T16:06:00.001+03:00

Free maternity keeps Uhuru and Ruto health pledge (I didn't do the headline!)
By Lukoye Atwoli
Daily Nation, Wednesday 09 April 2014

Soon after his inauguration, President Kenyatta declared that all maternity care would be offered free of charge in public facilities. Many commentators equated this pronouncement to President Kibaki’s free primary education pledge that was made so early in his term that many thought it would fail. One may suppose that President Kenyatta made his “free maternity care” pledge in this same spirit, and hoped that things would come together somehow and make it work.

To some extent, this has happened in many parts of the country, and the government says that hospital deliveries have registered a significant rise from 40 per cent to 66 per cent. However, there have been hiccups in some parts of the country where, due to limited financing, some counties have decided to start charging for some of the services.

To some extent, the fortunes of the health sector under the Jubilee government may be encapsulated in the success or failure of the free maternity care initiative. In the Jubilee manifesto, party leader Charity Ngilu, now a Cabinet Secretary, indicated that she joined the Jubilee coalition on the basis that it would “ensure that all Kenyans get quality and affordable healthcare.” This then became a key plank in the new government’s agenda, perhaps explaining the President’s haste in providing solutions for the sector.

The coalition identified bureaucracy and corruption as major impediments to improving health services, and further argued that the National Hospital Insurance Fund (NHIF) is “bloated and corrupt”. Brain-drain involving health practitioners, especially doctors, was mentioned as well. The coalition indicated that their first focus would be on preventive health, and universal healthcare was to be rolled out through local primary healthcare centres. Finally, the coalition’s stated intention was to make Kenya an international medical hub with an increase in medical tourism by adopting the “successful Indian model”.

Several specific pledges were made in the manifesto as the method by which the coalition would reach their healthcare goals. The coalition pledged to increase health financing from 6 per cent to 15 per cent of the budgeted expenditure, perhaps to bring the country into compliance with the Abuja Declaration target.

The number of physical facilities were to be increased, bringing a health facility to within five miles of every home, and many previous provincial hospitals were to be upgraded and equipped to the status of referral hospitals. Diagnostic centres for all conceivable illnesses were to be set up, and free mosquito nets would be distributed to all families in need.

Better nutrition was to be encouraged, and medical research, including on indigenous medicine was to be promoted under the Jubilee coalition government. E-health and private sector participation was also to be encouraged and promoted, and pay packages for doctors and other health workers were to be improved.

One year down the line, an evaluation of the Jubilee pledges comes up with perhaps one major success story.

Free maternity care is now government policy, and many facilities across the country are not charging mothers to deliver or get other services related to childbirth. This is a huge plus especially in rural and poor settings where mothers preferred to deliver at home, assisted by local midwives or other women, than go to hospital and have to pay what they considered to be exorbitant rates.

On the whole, however, it is difficult to find much to write home about what this government has done with regards to healthcare. Healthcare financing continues to be meagre, and in the last budget, the national government allocated 2.1 per cent of expenditure to health. It is not known what the counties collectively allocated to health, but the few that were analysed had allocated less than 3 per cent of their budgets to health as well.

The government started out on a bad footing when they appointed both a Cabinet Secretary and a Principal Secretary who were not healthcare professionals, going against the pledge made by Deputy President William Ruto in the Manifesto. This had the effect of delaying any serious initiatives in the sector, given that the two senior officials required a crash course in the sector and how it works.

One of the key handicaps faced by this government is that the manifesto did not take into consideration the changed healthcare environment, with the constitutional shift of primary healthcare and some curative services to the counties. Without a mechanism of ensuring cooperation of the county governments, it is therefore difficult to operationalise many of the pledges concerning healthcare at the county level.

Today, strikes in the sector are an everyday occurrence, and recent reports indicate that many doctors are leaving the civil service to go abroad or into private practice as a result of problems with their terms and conditions of service in the counties. The legislative and policy framework has not done any better. Four years since the coming of a new Constitution, health is the only sector that has not been re-formatted legislatively to conform to the law. The Health Bill has remained in draft form for a long time, and stakeholder involvement in its drafting and progress has been reluctant and limited.

As far as the health sector is concerned, the Jubilee coalition rates a very modest score.

Dr Atwoli is a senior lecturer, Moi University School of Medicine and national secretary-elect, Kenya Medical Association.

Is it time to regulate religious teachings?

2014-04-09T12:02:00.004+03:00

By Lukoye Atwoli
Sunday Nation 06 April 2014

Kenya seems to be in the throes of a major social convulsion and time has come for us to confront certain demons that represent a major threat to our continued survival. Lately, a new monster that had remained largely under the surface has emerged, in the manner of “religious extremism”. This has been blamed for incidents of “radicalisation” of youth, and even some of the terrorist attacks that are becoming common.

However, this term is, in my view, misleading. As part of some research I have done in the past, I have asked dozens of religious practitioners what constitutes an extremist or fundamentalist. Even within the same religion, different responses are given. For instance, some argue that an extremist is one who takes a literal interpretation of their religious book or teachings, and behaves accordingly.

Others contend that extremists “misinterpret” religious teachings and use them to harm others. The problem with this argument is that it assumes that everyone, including non-adherents, understand what teachings are actually being misinterpreted. When pressed, those with this opinion argue that no religion teaches intolerance or hate, and none condones murder of “innocent” people.

Unfortunately, a plain reading of the holy texts of the religions that are dominant in Kenya reveals a different picture. Many passages condone the killing of those that are regarded as non-believers, and condemn to death and eternal suffering those that deny the existence of the deity to whom the book refers. Although there are many other passages describing “upright” behaviour and being available to help other human beings in need, it is difficult for an ordinary adherent to determine what is to be done and what is to be avoided on the authority of the holy book.

From a secular perspective, one is left in the difficult position of determining what conforms to religious teaching and what does not. When someone argues that the holy book teaches one thing or the other, it is difficult to contradict them, even if other sections of the same holy book teach quite the opposite.

What is known is that no religion teaches their adherents to be “lukewarm” or to pick and choose what to believe and what to leave out. Both Christianity and Islam hold their holy books to be comprehensive and infallible. They are considered to be either direct utterances of the deity, or material written under the direct guidance of the deity.

If we are to accept that religious extremists or fundamentalists either misinterpret or distort religious texts, then it follows that one cannot gain complete religious insight from a plain reading of the religious texts. It follows also that for one to fully understand the teachings of a particular religion, there is more learning to be had outside of a plain reading of the religious text.

NO HINDRANCE

This begs the question why then religious preachers are so poorly regulated. Almost anyone in this country can start a sect and be allowed the freedom to propagate their teachings without let or hindrance. Perhaps religious institutions should be regulated in much the same way the various professions are regulated, in order to ensure that their teachings do not run afoul of the aspirations of our nation as enshrined on the Constitution.

The alternative is to contend with continued religious “radicalisation”.

Dr Atwoli is a consultant psychiatrist and senior lecturer at Moi University’s School of Medicine. lukoye@gmail.com

Wage bill debate sets stage for law review

2014-04-01T09:21:00.001+03:00

By Dr Lukoye Atwoli
Sunday Nation 23 March 2014

Finally, and as predicted, the motive behind the recent wage bill ‘conversation’ is becoming clear. Already there are moves in Parliament to reduce the number of elected representatives ostensibly because someone has determined that they are a major contributor to the allegedly ‘ballooning wage bill’.

Apparently we must get rid of women members of the National Assembly, nominated Members of Parliament, members of the county assembly and even reduce the number of counties in order to reduce recurrent expenditure.

An interesting observation about this whole charade is that it is obviously being led by people who have always been opposed to the new Constitution. They have now repackaged themselves into protectors of our national expenditure, and are proposing moves meant to improve our economic position. Their real goal, as is now becoming evident, is to subvert the currently established constitutional order and revert to the authoritarian model in which all authority vested in the president, who was considered for all intents and purposes to be above the law.

This whole venture is extremely dishonest. Over the last three years or so, health workers have engaged the government in dialogue aimed at rationalising the national health workforce in order to improve service delivery to Kenyans. To this end, they have repeatedly suggested the need to have a health service commission that would register, recruit and deploy all health workers in the country, based on needs identified by the counties. (READ: Team set up to cut costs starts work)

The stock response from the government has been that such a move would require a constitutional amendment allegedly because the Constitution has vested all public human resources in defined constitutional commissions, and the health service commission is not one of them. Further, the Cabinet Secretary for Health is on record claiming, fallaciously one must add, that all health services have been devolved under the Constitution.

BREAKNECK SPEED

The point of this example is that the political establishment has determined that it is next to impossible to enact legislation addressing key human resource concerns in the health sector, but is now attempting to legislate far-reaching changes in the constitutionally provided structure of government.

Predictably, these bills will move at breakneck speed through the Houses of Parliament as long as they enjoy the support of the ‘owners of government’. (EDITORIAL: Government wastage has become appalling) Politicians have indicated that even if it takes a referendum to enact the changes they are interested in, then that is the route they will take.

All this action is being taken, of course, in the interest of reducing the wage bill. One wonders if anyone else can see the ludicrous chain of reasoning behind such moves.

As has been argued before, more immediate measures can be taken to control expenditure, including cutting fraud, waste and abuse in government offices. Streamlining procurement procedures and consistently punishing corrupt officials will definitely yield dividends that will see the economy grow sustainably. More importantly, though, taking measures to increase our national income and productivity will be the key drivers of economic growth. Cutting public workers’ pay will not.

It would therefore serve our legislators well to focus on keeping the Executive on its toes, instead of wasting time singing the Executive’s chorus whenever they are called upon to do so. All this bickering is only serving to reduce investor confidence in the state, and no amount of wage bill cuts will bring this back.

Dr Atwoli is a consultant psychiatrist and senior lecturer at Moi University’s School of Medicine. lukoye@gmail.com

Marriage Bill harms rights of the mentally ill

2014-04-01T09:15:00.003+03:00

By Lukoye Atwoli
Sunday Nation 30 March 2014

Two things caught my eye this past week, and both are worthy of comment. First, our National Assembly passed a Marriage Bill that has elicited all manner of comment, ranging from polygamy to gay marriage. Unfortunately, combing through the Bill, one comes across several instances of senselessly discriminatory clauses, chiefly against people with mental illnesses.

For instance, the effect of Clause 12(a)(ii) of the Bill is to prohibit people with chronic mental illnesses characterised by recurrent episodes from getting married. Similarly, Clauses 66(6)(g) and 73(1)(g) make such mental illnesses legitimate reasons for voiding or annulling a marriage.

The net effect of the Marriage Bill as debated and passed in Parliament is to ensure that a diagnosis of a chronic mental illness would mean that the individual cannot legally get married. It also means that even if one is already married, if they are found to have had a chronic mental illness with a chronic recurrent course, their spouses could legally petition for the marriage to be annulled.

The problem with this bill, as with all legislation that purports to use mental illness as a reason to restrict people’s rights, is that the originators clearly do not have an understanding of what constitutes mental illness.

CONDEMNED TO A LOVELESS LIFE

Current research evidence suggests that between 10 and 25 per cent of our population suffers from a serious mental illness. The import of the Marriage Bill is that this large segment of our population would be condemned to a loveless life in which any attempt at a long-term relationship would be null and void.

Before he assents to it, the president must subject this bill to thorough scrutiny by mental health professionals in order to cure it of these discriminatory and unconstitutional provisions. However, if he agrees with the intent of the bill, which is to prevent the mentally ill from contracting legal marriages, he must demand a clause that requires that everyone of marriageable age undergo periodic psychiatric evaluations that shall determine whether they can get married, or if already married, whether the marriage may continue to be recognised under the law.

This, of course, means that he will have to budget for the training and recruitment of a huge number of mental health specialists in the coming years to help implement these provisions. Perhaps this is not such a bad thing after all!

The second issue that caught my attention were media reports alleging that Catholic Cardinal John Njue had raised misgivings about a tetanus vaccine aimed at preventing maternal and child illness and deaths related to childbirth. He allegedly termed the mass immunisation campaign “fishy”, and urged his followers to further interrogate this vaccine.

The cardinal, when he speaks, is assumed to be speaking for the Catholic Church. Devout followers of the Church are expected to hang onto his every word, and look up to him for spiritual guidance. When he suggests that a vaccine may be dangerous, at least some of his followers will take him seriously and start refusing it. The result will be potential illness and deaths that would have been prevented by the vaccination.

Before making such potentially harmful statements, religious leaders would be well advised to seek competent guidance from experts in the field, many of whom may be found among the faithful of the church.

Dr Atwoli is a consultant psychiatrist and senior lecturer at Moi University’s School of Medicine. lukoye@gmail.com

‘Ballooning wage bill’ the latest national fad

2014-03-17T16:15:00.001+03:00

By Lukoye Atwoli
Sunday Nation 16 March 2014

As is the fashion in this country, the attention of all and sundry is now riveted on the latest fad, the ‘ballooning wage bill’. We have now forgotten about the issues surrounding the standard gauge railway, which was given the green light to proceed despite serious misgivings about its cost and viability. We are no longer talking about the starving people in the north. We have moved beyond our outrage after the Auditor-General reported that over Sh300 billion in government expenditure could not be accounted for.

As we now embark on long-winded discussions on the ‘ballooning wage bill’, we are still planning to spend billions of shillings to pay what the government calls ‘ghost workers’. We are going to spend billions to pay the parallel county governments under control of the national government, also known as the ‘provincial administration’ despite the envisaged scrapping of this system by the Constitution.

In each county, several people are doing the job of one person. For instance, in the health sector, each county has a member of the executive committee in charge of health, effectively the county minister for health. Under each of these individuals, there are chief officers in charge of health, effectively the county principal secretaries for health. They control a multitude of staff under them responsible for county health functions.

PARALLEL FUNCTIONS

Interestingly, the national government has also deployed county directors of medical services and directors of public health to each county, under whom there are district (sub-county) medical officers of health. In many instances, these officers have a parallel bureaucracy under them, effectively duplicating the roles and functions of the county-appointed officers. This confusing structure is duplicated across all the purportedly devolved functions.

So our national government has assembled all the experts in economic affairs, and correctly diagnosed the problem behind our slow economic growth and difficulties meeting our recurrent obligations. The problem, of course, is the ‘ballooning wage bill’! Different percentages are cited, all in an attempt to demonstrate that we are paying our workers way more than they deserve, leading to inadequate funding of development projects and over-reliance on aid from the bitterly-hated West.

And our government, after correctly diagnosing the problem, has come up with the very best solution possible under the circumstances. We must reign in the ‘ballooning wage bill’ if we are to survive imminent economic collapse.

This is because we are unable to shepherd the economy to grow in ‘double digits’ as naively promised during the campaigns, while paying our lowly workers as much as we are currently doing. It has proved difficult to rein in the corruption that costs our economy hundreds of billions of shillings annually, because we are paying our workers way too much.

We cannot deliver on the health, security, infrastructure and education promises to our population, and at the same time pay the health workers the salaries they demand. In fact, according to the brilliant economists advising our government, we may need to retrench some of those workers in order to improve efficiency in service delivery.

According to the government, making the private sector the preferred employer for our top brains is the top priority. The first step, of course, is to institute a pay cut across the board and tame the ‘ballooning wage bill’.

Brilliant, revolutionary stuff, if you ask me!

Dr Atwoli is a consultant psychiatrist and senior lecturer at Moi University’s School of Medicine. lukoye@gmail.com

Voters sold their right to health for Sh20

2014-03-11T16:11:00.004+03:00

By Lukoye Atwoli
Sunday Nation 09 March 2014

Kenya’s health sector is in a shambles. Hundreds of health workers have now worked for over two months without pay because the national and county governments cannot agree on who is responsible for them. Shortages of medicines and important supplies are rife, even as governors try to outdo each other in ‘flagging off’ lorryloads of medications in their counties. As a result, ordinary Kenyans are suffering.

A few weeks ago, a middle-aged man from my village suddenly collapsed and had to be rushed to hospital. The local hospital could not manage his condition because he needed intensive care facilities that were not available. The nearest referral facility was over a hundred kilometers away in another county, but the family organised quickly to transport him there.

When they got to the hospital, all the intensive care unit (ICU) beds were occupied, and they were informed that the next available ICU beds were at a nearby private hospital. The relatives agreed to have him admitted at the private hospital where after more than a week in the unit, and despite the best efforts of the team managing him, the patient died.

This is when the problems began for the family. Intensive care is very expensive business, and the family was asked to raise over a million shillings to clear the hospital bill. This poor family could only raise a fraction of the cost and had to beg the hospital to release the body for burial. This took a while to happen, and in the meantime the family looked around for someone to take responsibility for their conundrum. Of course doctors and other health workers bore the brunt of their criticism.

TURN AGAINST HEALTH WORKERS

This is not a scenario unique to my village, or indeed to any one part of our country. This is a story every ordinary family of Kenyans has had to live through at some point. Unfortunately, when it happens, we turn against the very same health workers who have struggled in very difficult circumstances to save lives, and accuse them of all manner of ills.

In my discussion with the bereaved family, it struck me that they all could not make the important connection between their own choices and the fate that befell them. I asked them if they had informed any of their elected representatives about their problem. They informed me that the politicians had done their duty before elections, and owed the electorate nothing. Their twenty and fifty-shilling handouts had bought these villagers’ votes, and there was no use approaching them to solve such ‘small’ problems as the health of their constituents, among others.

Flabbergasted, I attempted to demonstrate that if they had voted based on policies and not because of clan, family and handout considerations, perhaps their local hospital would have been better equipped to save their relative’s life. Perhaps the county referral facility would have had well-equipped ICU facilities, with adequate beds to help all those in need.

Perhaps they would have had functioning ambulance services that would have arrived a few minutes after the patient collapsed, and carried out onsite procedures that would have prevented further damage and improved his prognosis. If they had used their vote better, perhaps their relative would not have collapsed in the first place.

I do not know if I managed to convince them, but I hope I did.

Dr Atwoli is a consultant psychiatrist and senior lecturer at Moi University’s School of Medicine. lukoye@gmail.com

Anti-gay law: Lots of smoke and no light

2014-03-03T16:30:00.000+03:00

By Lukoye Atwoli
Sunday Nation 02 March 2014

The Ugandan parliament recently passed legislation outlawing “homosexuality” in the country. The law provides for life imprisonment for anyone committing or promoting the “offence of homosexuality”, among many other penalties and prohibitions.

It has been argued that the fact that the Ugandan parliament passed this law and the president assented to it is sad, but does not merit more than just passing comment from anyone who is not Ugandan or directly affected by it. (READ: Kerry calls Museveni over anti-gay law) This is fair enough on the face of it although, in such a digitally connected world, it is difficult to isolate a country and argue for internal self-determination on laws such as this that criminalise behaviour that responsible scientists in the field do not consider abnormal or even harmful.

More pertinent, though, is the fact that the Ugandan action is part of a wave of intolerance being propagated across the continent by forces intent on forcing their own particular brand of morality on African countries. Nigeria recently passed similar legislation, and efforts are gathering pace in Kenya to introduce similar legislation in our parliament. This is the reason I think it is important to make the following points so that when the legislative debate gets here, nobody will argue that we did not raise any opposition to it.

I have encountered, on social media and elsewhere, arguments that opponents of homosexuality are disgusted by the behaviour, or that it is somehow un-African and un-Christian. Many of those supporting such legislation use these arguments to back their viewpoints. We have, before this legislation was even contemplated, discussed all these points with vigour and often agreed to disagree.

However, in order to fully appreciate this matter, it is useful to understand what “homosexual” means. First, it is a form of sexual orientation referring to someone who is sexually attracted to persons of the same sex. Second, it is a form of social identity, whereby an individual identifies with people of homosexual orientation, and perhaps also refers to themselves as being homosexual. Third, it is a form of sexual behaviour involving intercourse or other sexual activity between individuals of the same sex. (READ: Uganda newspaper names 200 'homos' after anti-gay law signed)

SAME SEX

It is important to appreciate that a person may meet one, two or all three definitions of homosexual. For instance, one may have homosexual orientation but never identify themselves as homosexual or engage in homosexual behaviour. Similarly, one may engage in homosexual behaviour without identifying themselves as being homosexual or even while having primary sexual interest in members of the opposite sex.

It is instructive that these “anti-gay” laws are often informed by the third definition only, and criminalise the behaviour on the assumption that this will end the orientation and social identities. Unfortunately mountains of research on this topic suggest that such moves are futile, and homosexuality cannot be “cured” by such moves.

It is also true that the arguments about homosexuality being “disgusting, un-African or un-Christian” are also informed by visualisations of homosexual behaviour, often between males. While I can understand some people’s disgust with this kind of behaviour, it is difficult for me to link this disgust with the law-making process.

We simply do not go out and legislate against behaviours solely because they disgust us. How then is homosexuality different? Surely even the “crime” of homosexuality needs a victim?

Dr Atwoli is a consultant psychiatrist and senior lecturer at Moi University’s School of Medicine. lukoye@gmail.com

Mental health philanthropy is good, but …

2014-02-25T09:19:00.001+03:00

By Lukoye Atwoli
Sunday Nation 23 February 2014

Two weeks ago in this column, we discussed the need for a high profile advocate for mental health in this country. I was at the point of despair, having given over and over again the reasons why it is important and even profitable to invest in mental health. Despite these noises, the Ministry of Health had gone ahead and illegally disbanded the division of mental health, at a time when such a division should have expanded to address the mental health challenges of Kenyans.

A few days after the article was published, I spoke with the Cabinet Secretary for Health, who assured me that the government was aware of the challenges facing the sector, and was doing something about it. As it turns out, First Lady Margaret Kenyatta did visit Mathari Hospital accompanied by benefactors from the Safaricom Foundation who donated Sh50 million to help rehabilitate the facility.

The donated funds will go towards renovation of some wards and purchase the necessary equipment and necessities to improve patient care. One must necessarily thank Safaricom Foundation and the First Lady for taking the initiative to highlight the plight of the mentally ill and their carers. One also hopes that Mrs Kenyatta has, through this kind gesture, accepted to be the voice of the mentally ill and look out for their best interests.

Unfortunately, however, the Mathari situation is emblematic of our treatment of the mentally ill in our country, in our homes, and in our social circles. We do not plan for their needs, and instead “out source” them to charitable individuals and organisations. Most activities aimed at improving the mental health of Kenyans are funded by donors and private individuals.

I hope that with the involvement of the First Lady and the well-heeled donor fraternity, the government’s conscience will be sufficiently pricked, encouraging those responsible to take mental health more seriously. If I had my way, I would ensure that a few steps with huge gains are implemented immediately to obviate the need for Safaricom Foundation to make a similar visit this time next year.

MENTAL HEALTH ACT

The Ministry of Health would move to fully implement the Mental Health Act’s provisions on funding of mental health services and creation of a board to advise the government in this area. The Division of Mental Health would be revitalised and facilitated to enable it to handle emerging mental health problems, including suicide, homicide, road crashes and substance use, such as alcohol related problems.

A vote for mental health services would be created in the Health Ministry budget in order to adequately fund mental health services, including mental health research, health promotion, prevention of mental illnesses and treatment services for the mentally ill. All government programmes and policies would be examined for their mental health impact, and those that pose a risk to the mental health of the population would be refined to reduce or eliminate this risk.

Doing these things does not constitute a favour to Kenyans. It is a right guaranteed to all those residing in this fair republic by the supreme law of the land, under the right to health. It is a responsibility bestowed upon our elected governments, and cannot be ceded to well-meaning philanthropists.

Dr Atwoli is a consultant psychiatrist and senior lecturer at Moi University’s School of Medicine. lukoye@gmail.com

‘Secular’ hypocrisy on show in Kisumu

2014-02-20T09:09:00.002+03:00

By Lukoye Atwoli
Sunday Nation 16 February 2014

Last week I was forcefully reminded by a friend of mine that Kenya is a secular state that is proud of its freedoms enshrined in our hallowed constitution. This happened in the context of the riots and demonstrations that beset the lakeside city of Kisumu over what the demonstrators argued was an attempt to erect a satanic monument in the centre of the city.

According to news reports, a group of businessmen who happened to subscribe to the Sikh faith had commissioned a monument to commemorate a hundred years of the community’s presence in Kisumu. The county government allegedly approved the project and the businessmen commissioned a local sculptor with instructions about the message they intended to convey.

It is in fact said that the construction of the monument continued openly, and nobody took any notice of it until a band of religious zealots linked its presence to some environmental phenomena going on in Kisumu at the time. They quickly determined that the monument was satanic and had to be demolished before fire and brimstone rained on the city.

They organised protests and demonstrations, culminating in a very public “lynching” of the figure. The Sikh businessmen eventually removed the image “in order to avoid further trouble”. The ensuing debates took on a shrill tone, with some commentators equating the Sikh religion with devil-worship, and others tarring all Kenyans of Asian origin with the same “devil-worshipping” brush.

SECULAR STATE

This is the genesis of the assertion that Kenya is a decidedly secular state, and no religious symbols must be allowed to occupy public spaces.

Those that hold this position are a variegated collection, so it would be unfair to accuse all of them of the same sin, so to speak. There are those who have always held this position, and are against any display of religious symbols or rituals in public spaces. They are against prayers during public functions, religious services or symbols on public property or display of the same by public officers.

A second section of this group, though, only discovered their indignation at the desecration of Kenya’s secular nature when the “satanic” symbol was hoisted in the “Christian” city of Kisumu. This is the hypocritical bunch that organise religious ceremonies in public schools, open public functions with prayers, teach religious studies in schools (often no more than proselytising ventures), and have no apologies peppering official speeches with praises for their deity. They remain oblivious of the feelings of others, and their secular sensitivities are only aroused when a competing faith gains prominence with some assistance from officialdom.

We must make up our minds in this country on whether we are a truly secular state, in which case religious symbols and rituals should be banned from all public spaces, or a multi-religious society in which all religions are given equal space in the eyes of the state. The second option is difficult to maintain given the multiplicity of religious claims, many often contradicting others, that would inundate the state under those circumstances. The default, then, is for us to bolster our secular credentials and ban all religious expression in public spaces and functions.

In conclusion, one must note that the sponsors of the Kisumu sculpture have vehemently denied any religious connection to the work, making its take-down all the more ridiculous.

Dr Atwoli is a consultant psychiatrist and senior lecturer at Moi University’s School of Medicine. lukoye@gmail.com

Mental health needs high-profile advocate

2014-02-20T09:04:00.001+03:00

By Lukoye Atwoli
Sunday Nation 09 February 2014

There has been a flurry of prominent and influential personalities selecting and supporting causes they hold dear to themselves and to Kenyans at large. They have taken up roles in advocacy and support of these causes, organising activities and raising funds for them. For instance, the President and his Deputy have taken agriculture very seriously and have invested heavily in programmes aimed at bolstering food security in our country.

The Deputy President’s wife has taken women’s empowerment to the next level, with her most prominent activity being in support of women’s groups across the country. And just last week, the First Lady launched preparations for a half-marathon in support of programmes to improve maternal and child care. She has also been involved in raising funds and awareness for HIV/Aids initiatives, and supporting orphaned or abandoned children.

In short, the top leadership in our country is involved in charitable initiatives aimed at empowering Kenyans of all walks of life. All these causes are equally worthy, and have far-reaching impacts on this country’s socio-economic situation.

But one thing is missing.

In my opinion, the most vulnerable members of our society, male or female, rich or poor, young or old, are those suffering from mental disorders. Wherever they are to be found, they are ridiculed, discriminated against, ignored, hidden or abused most savagely. So, for instance, people with HIV/Aids and mental illness have worse outcomes than those without mental illness.

It is in realising this that about 10 months ago I attempted to recruit such a high-profile personality through an open letter published on this page. I wrote the letter to the then newly-elected President Uhuru Kenyatta while he was still celebrating his victory in last year’s General Election.

In that letter, I challenged President Kenyatta to make his presidency count for health and, more specifically, for mental health. I pointed out the challenges facing the health sector as well as the consequences of neglecting the mental health of our people. I indicated to him that a decision to invest in health and mental health would make it much easier to address other sectors of our economy.

Unfortunately, most of the things I said then clearly still need to be repeated, which is why I am constrained to make this appeal again. I am looking for a high-profile Kenyan to take up an advocacy role for mental health in Kenya. If it pleases the President or any other similarly well-connected person, I would like to invite them to take up the cause of improving the lot of Kenyans suffering from mental disorders.

Any little thing done in support of this cause will go a long way in improving the lot of all Kenyans, not just those that are mentally ill. Such an advocate could team up with mental health advocates and give talks, participate in walks and marathons, help raise funds and try to influence the decision-makers at the heart of this government in favour of better mental health for all Kenyans.

Currently mental health workers, advocates and patients have few friends, and are considered queer, weird, or even misplaced whenever they appear anywhere in public. A high-profile advocate will help to change this situation, and improve the quality of life for these vulnerable individuals.

Dr Atwoli is a consultant psychiatrist and senior lecturer at Moi University’s School of Medicine. lukoye@gmail.com

Mentally ill deserve equal job opportunities

2014-02-20T09:00:00.004+03:00

By Lukoye Atwoli
Sunday Nation 02 February 2014

Last week there were numerous newspaper reports about a mentally ill doctor being nominated and interviewed for a top post in a county government. While most reports were factual and reported events as they actually happened, some were outright sensational and insulting both to the candidate and mentally ill people in general.

One newspaper headlined the story using the term “mad doctor”, while another referred to a previous case in which the doctor was alleged to have killed someone during an episode of illness. Almost all the stories had an incredulous tone, expressing surprise that a mentally ill individual could be nominated for such a post in a county government.

But what are the facts?

Mental illness can only be diagnosed by a qualified professional after taking a detailed history of the patient, and a physical and mental state examination. In many cases, investigations have to be carried out to establish the exact cause of the symptoms and, in some instances, physical causes are identified and treated, eliminating the mental illness totally.

Many people with mental illnesses are unaware of this fact, and continue to suffer from serious symptoms without knowing that they can be assisted to live a happier, healthier life. These “silent sufferers” are to be found at all echelons of society, from the poorest community to the most affluent groups. It follows, therefore, that even at the top levels of our many governments it is possible that some leaders are mentally ill but are unaware of this fact.

Most people think that mental illness is so obvious that it is easy to identify an individual suffering from such an illness. Unfortunately this is not the case. Mental illnesses run the entire gamut of human experience, from mild forms of anxiety disorders through moderately severe depressive episodes to the more obvious psychotic episodes that many identify with the term “madman”. It is, therefore, unfair to target an individual and label them negatively simply because they suffered a severe episode of mental illness and displayed their symptoms in public.

Obviously we need to articulate a policy on employment for people with mental illnesses. Such a policy must be careful to avoid falling short of the constitutional injunction against discrimination on the basis of one’s health status. Such a policy may prescribe, for instance, that a person suffering from mental illness is entitled to equal opportunity when seeking employment based on their ability and experience.

The only caveat that may be employed is that such a person must produce evidence of continued treatment and follow-up by a mental health specialist in order to ensure that their mental illness does not interfere with their work. This would mean that even after employment, should an employee develop a mental illness, they would be entitled to receive treatment and continue working once the treating physician gives the green light. Assuming that one is unable to work by virtue of having a mental illness is abusive, discriminatory and downright inhuman.

Should we decide that people with mental illnesses should not occupy certain posts in government or elsewhere, we must begin by conducting a mental status evaluation of everyone in those positions to ensure that they do not have a mental illness that interferes with the execution of their duties.

Only after doing this would we be justified to lock out any fresh applicants with mental illness.

Dr Atwoli is a consultant psychiatrist and senior lecturer at Moi University’s School of Medicine. lukoye@gmail.com

Why it is healthy to encourage dissent

2014-02-20T08:55:00.000+03:00

By Lukoye Atwoli
Sunday Nation 26 January 2014

In Kenya, there is always a scandal involving huge sums of taxpayer money going on. There is no doubt in my mind that this has been happening every year since independence, and perhaps even before. It is also very clear to me that if this were not the case, our country would be soaring in the league of developed countries, lending money to our poorer neighbours and helping others make good choices that would make them prosper like us.

Does this failure make Kenyans a strange breed among humans? I would argue that it does not. Human beings are by nature selfish and accumulative, and the few who overcome these base instincts are knighted and sainted, depending on the circumstances. Most of those that actively seek and attain positions of power do so for purely selfish reasons, despite the clothes of altruism they wear for public consumption.

Even for those who seem to “have it all” before they go for leadership positions, Abraham Maslow created a hierarchy of needs at whose apex he placed the most selfish need of all, self-actualisation. This selfish and accumulative need is a by-product of the survival imperative that has been with us since our ancient predecessors rose to their feet and began their journey across the then unexplored world. We needed to survive first, before we could be of any use to anyone else.

TRADE-OFF

Evolutionary psychologists argue that even apparent acts of altruism are often driven by a completely unconscious trade-off for future gain or survival. That is an attribute that is common among all things that are considered “living”, and humans are no exception.

How then do some countries prosper while others lag behind, mired in obscene corruption and impoverishment of the majority in favour of a privileged minority? Working on the assumption that all people are selfish and, given a chance, they would mortgage the entire country for their personal gain, prosperous countries ensure that no single individual has unfettered powers or the opportunity to make such decisions.

They ensure that every decision a person in power makes is second-guessed and discussed endlessly and often negatively. And whenever evidence emerges that this person has misused state resources or attempted to fleece the nation, the punishment is swift and unrelenting. They lose office and lose face, and spend a huge amount of resources to rehabilitate themselves, serving as an abject lesson to their successors and others in power.

This is the story of any country we look up to, any society we consider “successful”. And this is the reason Kenya seems to have stagnated and even retrogressed in some areas. The dominant voice in public discourse in this country is the silencing voice of Big Brother.

Whenever anyone expresses doubts about a decision by senior government officials, they are reminded to be patriotic, and often asked what a “nobody” like them has done for this country. They are asked to mind their own business, and in the past, we have even been asked, “Whose goat has he stolen?”

If we intend to prosper as a republic, we must encourage dissent, and urge our leaders to deal with the issues raised by the dissenters, however obnoxious, rather than demonising the dissenters themselves. A nation of meek sheep cannot roar like a pride of lions, no matter how loud they bleat!

Dr Atwoli is a consultant psychiatrist and senior lecturer at Moi University’s School of Medicine. lukoye@gmail.com

Insurance ‘exclusions’ a breach of the law

2014-01-21T18:16:00.002+03:00

By Lukoye Atwoli
Sunday Nation 19 January 2014

People with mental illnesses tend to be poorer than those in good mental health for several reasons. First, poverty appears to increase the risk of several mental illnesses, especially the more severe, debilitating ones. This is because the social environment plays an important role in determining an individual’s mental health, apart from their physical and psychological condition.

Second, mental illnesses inevitably interfere with an individual’s ability to attend to their daily activities, reducing their potential to earn an income and achieve prosperity. Obviously, then, poverty and mental illness create a vicious cycle that obviates the need to attempt to discover which of them came first.

Eventually, in order to address either condition, one must deal with the other. Thus in treating mental illnesses, measures must be taken to ensure continued productivity of the patient and, similarly, poverty eradication must build in measures to address mental ill-health.

In Kenya, most people pay for their health care out of pocket, and only a tiny minority can afford medical insurance. This is more so for those suffering from mental disorders. Getting a chronic illness, such as a mental disorder, is therefore often a ticket to poverty for most Kenyans.

EXCLUSION CLAUSE

Unfortunately, it is now emerging that even having medical insurance is not enough for many people with mental illnesses. Many insurers are getting into the habit of using the flimsiest of excuses to exclude payment for the treatment of mental illness. The commonest excuse is that there is a mental illness exclusion clause in the policy.

Other insurers, who purport to cover mental illnesses as well, often refuse to pay for treatment of specific conditions. The most commonly encountered “exclusions” are alcohol and substance abuse and suicidal behaviour. It is time we put an end to this inhumane behaviour that causes so much suffering for families that are already distressed.

Section 46 of the Mental Health Act, Cap 248 of the Laws of Kenya, provides that “no insurance company shall make any insurance policy providing insurance against sickness, which excludes or restricts the treatment of persons suffering from mental disorder.” Part two of this section makes it an offence to make such an insurance policy.

What this means is that every person in Kenya who has any insurance against any sickness is covered for treatment of mental illness. No insurance policy can reverse this. Therefore all those purported “exclusions” are in breach of the law, and any insurer who engages in such behaviour can be sued and compelled to pay for the treatment of mental illness.

LEGITIMATE EXCLUSIONS

As to the argument that alcohol and other substance-related disorders can be legitimate exclusions, this is what Section 2 of the Mental Health Act has to say:

“Person suffering from mental disorder” means a person who has been found to be so suffering under this Act and includes a person diagnosed as a psychopathic person with mental illness, and person suffering from mental impairment due to alcohol or substance abuse (emphasis mine).

In other words, alcohol and substance abuse (and related disorders) are rightfully considered as mental disorders for the purposes of Section 46, and no insurer can refuse to cover them for any reason whatsoever.

Unless insurers stop this discriminatory behaviour, they must prepare for the flurry of litigation that will inevitably come as Kenyans increasingly become aware of their rights!

Dr Atwoli is a consultant psychiatrist and senior lecturer at Moi University’s School of Medicine. lukoye@gmail.com

Enough of blaming others for our mistakes

2014-01-13T15:59:00.002+03:00

By Lukoye Atwoli
Sunday Nation 12 January 2014

Observing social discourse in Kenya, one notices a subtle shift in explaining the distribution of poverty and under-development in certain areas and among individuals. In the past, within relatively homogenous groups of Kenyans, the discussion invariably veered towards “marginalisation” by the dominant tribe(s) in government.

One community, or coalition of communities, would be labelled as oppressors of the majority, and all members of this group would be accused of all sorts of ills that resulted in most others sinking into poverty and want.

Among the so-called “oppressors,” however, the explanation for the opulence in their midst would be put down to hard work and innovative entrepreneurship. They would argue that they worked as individuals to build their wealth, and that those who enjoyed any favours from the State were in the minority and often transcended the tribe barrier.

They would cite examples of people from other tribes who have been engaged in large-scale looting of State resources, and were extremely wealthy, while their own communities remained largely dirt-poor.

REPETITION OF INCOMPLETE NARRATIVES

This group was also more likely to explain the high poverty levels in the rest of the country as being a product of laziness, excessive politicking, or lack of the entrepreneurial spirit.

Both these groups exemplify how insulating operating in an echo chamber can be. Repetition of these obviously incomplete narratives turned them into some sort of fact, gradually growing into self-fulfilling prophecies. Many otherwise able-bodied youth would resort to begging or extortion, or other more serious criminality, arguing that due to “marginalisation”, they were unlikely to make it legitimately in this country.

Almost all members of the “marginalised” group would be astounded whenever one expressed a contrary opinion placing the larger share of the blame on the complainers themselves. On the other hand, the wealthy “oppressors” would be shocked to learn that there are genuinely hard-working Kenyans who had been shafted by the system, whose property had been looted, and whose opportunities had been shrunk by operation of the largely ethnic-based system of cronyism.

The long and short of this piece is to demonstrate how things have changed today. A new coalition of “complainers” is emerging, and it has succeeded in resurrecting an old ghost to aid its cause. Today, the colonialist and his neo-colonialist ally are the main cause of our problems, and any indigene who thinks otherwise is dismissed as their lackey simply doing the bidding of his “foreign masters”.

Growing up in the 80s and 90s at the peak of Nyayo’s power, one was made acutely aware of the actual meaning of such terms. Being called a subversive under the influence of foreign powers always meant the withdrawal of the privileges of citizenship, and existence at “president’s pleasure”.

Critically examining the re-emergence of this phenomenon leads one to only one conclusion: We are constantly looking around us for scapegoats that can explain our failures in life, and we are averse to taking responsibility for the negative consequences of our actions.

In 2014, one can only hope that we shall discard this time-wasting habit, examine our own actions and resolve to make better decisions and accept the concomitant results. In order to develop this lovely country of ours, we must leave the West (or the “other” tribe) out of it!

We determine our own destiny!

Dr Atwoli is a consultant psychiatrist and senior lecturer at Moi University’s School of Medicine. lukoye@gmail.com