Madmen and Specialists

If you’ve ever spent some time in a Ghanaian town, such as Kumasi, in Asante region, you will occasionally have seen people half-clothed in filthy rags, hair matted with the red-brown dust thrown up from the laterite earth, wandering the streets largely unmolested; talking, perhaps, to themselves; begging sometimes; or scratching through rubbish heaps looking for something to eat. When I was a child in Kumasi we were taught to fear these madmen and women, whom we called bodamfoo. When we were naughty we would be threatened with a visit from them. Indeed, there is an Asante proverb which runs: Obodamfoo se ne dam ko a, na nye ode hunahuna mmofra. (If the madman says his madness has gone, that doesn’t mean the thing he uses to frighten children.) Among adults, I think, it would be more accurate to describe the attitude to bodamfoo as one of mild contempt. The only other people I can think of who are regularly treated with a similar contempt are what we would call alcoholics (though these even children will mock). But (to quote another of our proverbs) Odehyee bo dam a, yefre no asaboro – if a royal goes mad, we call him a drunkard – because, obviously, it is worse to be a drunk than a lunatic.

Many of the bodamfoo die early as a result of their unsanitary lives; a few are locked up from time to time because they have threatened or hurt someone; others live permanently in asylums, where they are fed what the local branch of the Social Welfare Department has the money to pay for. I never heard of any receiving medical attention and certainly not psychiatric treatment. There is a fair amount of financial support in Kumasi these days for the very few mentally-ill children who get to be in the children’s home; but they are there because their families will not have them, not because they are being treated, and they depend on the charity of a few rich people, some of whom have had children with these problems themselves.

As for the less spectacular forms of mental distress – depression, anxiety – there are, perhaps, a few doctors and a few drugs, but these are available only to a small number of professional families. Most people would be more likely to go to a traditional or Christian priest or a Muslim malaam and seek solutions from the other world. There is, in short, plenty of psychiatric work going a-begging; and, what with all the other things we have to worry about, as the Ghanaian economy struggles along and life gets more expensive every day, improving mental health provision is not, it is fair to say, even a tiny blip on the radar of Ghanaian national political consciousness. This is surely true in most of post-colonial Africa.

The mental health of the native populations was not a central priority of British or French colonial governments in Africa, either. Psychiatry and Africans were each, in their own way, marginal to the preoccupations of the metropolitan bureaucracies: psychiatry was low-status medicine and Africans ... well. Put the two together and you had a recipe for neglect. As psychiatry was developing its modern therapeutic aspirations in Europe, the function of colonial asylums remained largely custodial. There was, for example, a mental asylum at Victoriaborg in the Gold Coast as early as 1888, but ‘with the exception of a brief period in 1929, when a specialist worked for a time at the Accra asylum, there was no psychiatrist in the Gold Coast until 1951.’ The first mental health clinic in Senegal – perhaps the most Westernised region of French West Africa – was not built until 1956. And in any of these colonies there were places for hundreds, at most, of the mentally-ill in populations of many millions. Only where there were significant European settler populations – in Algeria, Southern Rhodesia, Kenya and South Africa – did any very extensive mental health provision exist before the Second World War, and even in these places it was woefully inadequate. But the low status of psychiatry in Western medical practice generally suggests that the lack of human and material resources was not simply a colonial phenomenon: the same situation prevailed even in the Fifties in ‘any mental hospital in Birmingham, Lyon, Melbourne or Toronto’.

The late arrival of professional psychiatry in the colonies is less surprising when we remember that the move from custody to therapy in Britain was first officially advanced in a serious way only under the Mental Treatment Act of 1930. Not until after the Second World War, with the creation of the National Health Service, and the development of the Maudsley Hospital as a centre for the training of medical psychiatrists, did psychiatric treatment begin to be widely available; and the central models of mental health, until well after most of Africa was independent, continued to be those of neuropsychiatry. The neuropsychiatrists worked with a model of mental disease as a reflection of ’underlying biological abnormality’; they focused on chemical and physical assaults on the nervous system: insulin shock, metrazol, electroconvulsive therapy, lobotomy. This model alone, they thought, would enable them to advance along the sure path of science.

In this absorbing book, Jock McCulloch, the author of a study of the psychiatric and social theory of Frantz Fanon, turns his attention to the development of the small field of colonial ethnopsychiatry, concentrating largely on the British colonics of Kenya, Nyasaland and the Rhodesias, North and South, and on the related work of mental hospitals in South Africa. Ethnopsychiatry was almost entirely the theoretical preoccupation of the small group of European men who worked in the colonial mental health services; its aim was to uncover and, where possible, to develop treatment for what was distinctive in the maladies of ‘the African mind’.

Foucault and others have shown the multiple ways in which culture shapes the experience of mental illness and our responses to it, and it is now axiomatic that an understanding of the patient’s social context – of the conceptual and normative world he or she inhabits – is a necessary condition for making sense of mental disease. The ethnopsychiatrists were ill-equipped to work in such a culturally nuanced way with black Africans. Modern social and cultural anthropology grew up alongside ethnopsychiatry and there was only a small pre-existing body of scholarly knowledge of African cultures for the colonial psychiatrists to draw on. They had, by and large, very little knowledge of anthropology, and no training in its methods and ideas. Ethnopsychiatry was, as McCulloch says, ‘very much a self-enclosed enterprise’.

The effects of the professional isolation of ethnopsychiatry, within medicine and from anthropology, were exacerbated by the fact that the most extensive facilities were in the settler colonies, and the ethnopsychiatrists were members of the settler communities there. While they did not take much notice of the theories of the anthropologists, they absorbed a good deal of the speculations of the white settlers, and the result is that their responses to the various distressed Africans who came their way provide a Rorschach test of settler attitudes to Africans. Ethnopsychiatry may tell us very little about the mental life of Africans, mad or sane, but it reveals a good deal about the attitudes and the lives of the colonials.

McCulloch has studied the records of the Mathari Mental Hospital, built in 1910, in Nairobi, which had facilities for two European and eight African patients, thus permitting a few of the mentally-ill to be moved out of the prisons where they had been housed until then. (Mathari remained under the supervision of the prison medical officer for most of the next twenty years.) Until Mathari was built, ‘European lunatics were sent to South Africa for treatment and a fee of five shillings per day was payable by the British Government’ for each of them. But Mathari was never really considered a suitable place for Europeans and most ‘European lunatics’ continued to be shipped home to England by their families or to South Africa by the Government.

Most of the Europeans at Mathari in the early years suffered from alcoholism; of the 31 admitted in 1921, one died from delirium tremens. Fifty-seven Africans were admitted in the same year, and those deemed incurable remained there until their deaths. But the records make it plain that the priority, so far as treatment went, lay with Europeans. ‘The asylum files ... are filled with stories of European alcoholics who had brought ruin upon themselves and their families. There are no parallel records regarding the lives and families of the African inmates.’

One of Mathari’s European alcoholics was, for a period, the most colourful colonial psychiatrist ever to practise in British Africa: he was not a patient, however, but the senior member of staff. Dr James Cobb, who was appointed senior medical officer in 1937, had had experience in British mental hospitals. A friend of the Prince of Wales, he was well-connected in English society, which mattered a great deal in the snobbish world of the settler colonies. Given the malady that afflicted most of the Europeans in his care, Cobb’s appointment was an almost literal instance of putting a lunatic in charge of the asylum: his own alcoholism was acute. He was also, as McCulloch puts it, ‘homosexual and thoroughly eccentric’ and he was apparently depressive, having once been treated in hospital in England after an attempt at suicide. When drunk, he entertained his guests by showing off the inmates; and he kept a Great Dane and two lions in the hospital compound, making ‘no attempt to hide from the patients or staff the nature of his attachment to the lions’. (McCulloch’s description of Cobb as homosexual suggests that the attachment was to a male lion; having raised the issue, McCulloch is coy about the details – which is mildly irritating, though he does tell us that Cobb was believed by his successor to have been ‘having sex with one of the animals’. Actually, it suggests something rather odd in our thinking about sexuality that a man who sodomises a lion should be described as homosexual; but I digress.)

The psychiatrist who passed on the gossip about these leonine adventures (which led to Cobb’s forced retirement in August 1938) was Dr John Colin Carothers, the central figure in this study. McCulloch came to know Carothers while working on this book and the retired psychiatrist provided him with access to much material as well as allowing himself to be interviewed. We may assume that much of McCulloch’s information about Carothers’s theories and motivation came from the man himself. Carothers was born in 1903 in Simonstown, the naval port on the Cape in South Africa, to an English engineer ‘who worked for the Admiralty at various ports throughout the British Empire’. He was educated in England and studied medicine at St Thomas’s before applying for a job in the colonial medical service in Kenya, to which he was appointed in 1929, on a salary of £600 a year. Part of Carothers’s reason for applying for this job was that he saw Africa, the continent of his birth, as home. He moved regularly over the next decade, apparently because he wanted to have as wide an experience of the country as possible. In 1933, at the age of 30, Carothers married: he met his future wife while she was staying with his boss. They enjoyed the social life of rural colonials, ‘mixing with the “best people” in the European community. In the smaller towns, there was always golf, tennis and parties.’ By the late Thirties, Carothers and his wife were living in the town of Kavirondo in the north-west of Kenya, and, in August 1938, 11 years after he had first embarked for Kenya, he requested and received permission to settle there. ‘Then, within a matter of weeks, he received a telegram ordering him to report to Mathari, where he was to serve as acting senior medical officer.’ Cobb’s sudden and embarrassing departure had left the colonial authorities little time to find a replacement.

The only trained psychiatrist in Kenya was Dr H.L. Gordon, Cobb’s predecessor at Mathari, whose retirement due to ill health had led to the short, unhappy period of Cobb’s incumbency. Gordon was the author of a 1934 paper in the Journal of Mental Science, whose thesis was that Africans were so different from Europeans that the major challenge facing the psychiatrist ‘was distinguishing between normal and abnormal behaviour’. He believed that schizophrenia in Africa was restricted to Europeans and Europeanised Africans and he claimed never to have seen either paranoia or manic depressive illness. In 1935 he presented a paper arguing that ‘the evidence today is against our Natives being as well equipped in the frontal brain as the average European’ – a view that was supported by studies he had himself encouraged. These had been carried out by the pathologist, F. W. Vint, who found that the brains of Africans were, on average, about 10 per cent smaller than European ones. It is, perhaps, as well that Carothers had only one such professional mentor to rely on.

Carothers settled down to the life of a psychiatric autodidact (he had, after all, no special training in psychiatry), reading the textbooks, but finding that little of what he observed among the Africans at Mathari fitted the standard profiles. Nevertheless, he took to the work. He was about to set off to study psychiatry in England when the war interrupted his plans – later, he was able to spend six months at the Maudsley Hospital and acquire a diploma. He retired early, in 1951, becoming a psychiatric specialist at St James’s Hospital in Portsmouth. Colin Carothers had spent more than half his career at Mathari without any substantial psychiatric training. He learned his psychiatry on the job.

In the years after his retirement from Mathari, Carothers wrote extensively about mental health and disease in Africa, receiving a commission from the WHO in 1952 to write a ‘monograph on mental health in Africa’. The British Government asked him for a report on the psychology of Mau Mau in 1954 and for one on mental health services in Nigeria in 1955. ‘Carothers’s influence,’ McCulloch writes, ‘was such that Frantz Fanon was moved to include an attack upon him in The Wretched of the Earth.’ Carothers’s major work, The African Mind in Health and Disease, published in 1953, was the summation of all he had learned in over a decade of research and more than twenty years in clinical practice. McCulloch’s summary suggests how much he had simply lent medical authority to the settler’s vision of the native.

Carothers acknowledged that Africans did have some strengths, such as loyalty, self-confidence, sociability and forgiveness, and that their culture fostered an aptitude for dance and music. However, in summarising the African temperament Carothers lost sight of those frail virtues: ‘The African accordingly has been described as conventional; highly dependent upon physical and emotional stimulation; lacking in spontaneity, foresight, tenacity, judgment and humility; inapt for sound abstraction and for logic; given to phantasy and fabrication; and in general unstable, impulsive, unreliable, irresponsible and living in the present without reflection or ambition or regard for the rights of people living outside his own circle.’

It is clear why Fanon felt there was a case to answer. Not surprisingly, when Carothers turned to Mau Mau, he saw a psychopathology of the Kikuyu and, as McCulloch explains, he argued that Africans were known to have

a facility for dissociation which enabled them to live incompatible lives simultaneously and to reconcile contradictions in behaviour which for Europeans would be inconceivable. This facility was characteristic of the Mau Mau; many of the rebels could, he said, be classified as psychopathic criminals. For this reason, Carothers feared that even if screened carefully many of the Kikuyu rebels could never again be trusted and that the seeds of evil might be dormant within the tribe for many years.

One is tempted to remark that the psychopathology here is paranoia, and Carothers its victim.

McCulloch sees that the problem is not how late psychiatry came to the colonies but why it came at all, and so he asks the right question about the adventures of the ethnopsychiatrists: why on earth did they bother? Ethno-psychiatry was practised only on a minuscule scale; even if it had been effective, it would have dealt with only the minutest fraction of the psychiatric problems of the ‘natives’. There was no reason to suppose that the available knowledge was sufficient to cure even those few who came within its ambit and there is little evidence that the mental health of the natives figured much in the ruminations of the policy-makers in Paris and London.

McCulloch considers and rejects an attempt to apply to colonial psychiatry Foucault’s model of the ‘great confinement’ which sees the emergence of psychiatry in Europe as an emanation of new technologies of power. This view, he argues, ignores the manifestly good intentions of those who set up institutions like Mathari. ‘In the absence of such intentions it is impossible to explain the willingness of colonial governments to spend so much money on institutions which brought so few benefits.’ His alternative is that the creation of psychiatric institutions in the colonies served three major interests: they gave a new kind of power to the doctors; they gave the settlers somewhere to place their most embarrassing relatives; and they were ‘evidence of the civic virtue of settler societies, symbolising their ability to construct a state which mimicked the grand configurations of the metropoles’. Judged by these aims, ethnopsychiatry must be said to have been a (modest) success.

Whatever our contemporary assessment of the merits of the older forms of neuropsychiatric therapy or of the newer ones made possible by the modern psychiatric pharmacopoeia, it is clear enough that, in the mid-century, the rate of success in dealing with the more severe psychiatric problems was low, and that much of the treatment was based on theories flimsier than would now be required for practice on human subjects. Even if they had had more resources and staff, it is unlikely that the ethnopsychiatrists would have had much luck as healers: they lacked the basic cultural knowledge. Some, perhaps most, of the patients who passed through the clinics would probably have been better off wandering the streets of their own communities – provided they posed no physical threat to others – than warehoused in colonial asylums. Of course, there is no reason to think they would have been welcomed back by the families that had, in many cases, kicked them out in the first place; or that they would not have been the victims of the unkindnesses daily meted out to the mentally-ill around the planet. Anyone who wants to add the colonial mental hospital to the long bill of indictment against colonialism, however, would do well to ask how these people would have been treated by their own societies; and should ponder, too, the fate of the mentally-ill in post-colonial Africa.