6 March 2013

Nigeria’s lunatic laws and evil spirits: what place for human rights?

Traditional and spiritual healers deliver the bulk of mental health ‘services’ in Nigeria, Africa’s most populous country. They profit from the populist belief that madness is caused by demonic possession. As a result people labelled as mad are hyper-stigmatised and families urgently want to rid the devil from their afflicted relative. Within this delusional belief system, beatings, lashings, burnings and rapes drive out the evil spirits. The colonial lunacy law provides precisely zero protections against arbitrary internment, chemical and physical restraints, and non-consensual electroshock in psychiatric hospitals. The tiny amount of psychiatrists are hospital-based and overstretched. Mental health services are largely absent from primary healthcare, save in some EU-funded pilot projects. Both the psychiatric and the traditional healing industries are unregulated, unmonitored and susceptible to corruption. Ill-treatment is carried out with impunity because perpetrators are never punished.

Nigeria is big, populous and poor. Its 162 million people live in a land-mass nearly four times the size of the UK. Nearly two thirds of the population live on under $1.25 per day, according to the 2011 UN Human Development Index.

This is the context in which I spent three days in humid and car-jammed Lagos, the second city of Nigeria. With Krassimir Kanev, esteemed colleague from the Bulgarian Helsinki Committee, I was co-delivered a two-day workshop to NGOs and lawyers on how to combat torture and ill-treatment against people with disabilities. On day three I participated in a roundtable with disability activists, representatives from the prison service, the attorney general’s office, the ministry of justice and others. The workshop was part of an EU-funded project coordinated by the London-based Equal Rights Trust in conjunction with the Legal Defence and Assistance Project, a Nigerian NGO.

Participants of the workshop gave numerous examples of how people with disabilities are discriminated against in various settings, including by their own families at home, in healthcare facilities, on the streets, in police lock-ups and in prisons. In this piece I want to share my thoughts on the duel challenges of traditional beliefs to madness and a defective mental health system.


Widely-held beliefs

Workshop participants were unanimous in their view that even educated people in Nigeria believe that madness is caused by the devil (I use the term ‘mad’ rather than using illness or disability terms to avoid either the suggestion that madness is viewed by the average Nigerian as a medical defect or a social phenomenon). People who have mad thoughts or exhibit mad behaviour are thought to be possessed by evil spirits, and thus the cure is to ensure that the spirits leave the possessed person’s body. Spiritual healers therefore beat the affected person to drive out the evil spirit, or shackle the person and deprive them of food or water. The fact that this practice involves inflicting physical and mental violence on another human being is seen, at best, as a minor inconvenience.

A 2008 article in the African Journal of Psychiatry gives some examples of how traditional healers treat people in Nigeria, claiming that in one church 40% of the ‘treatment’ for mental illness constitutes beating. Beatings are expensive: families spend significant amounts of money on the services of traditional healers.

I heard in Lagos stories of five year old children with disability who was believed to be a witch, a popular belief pedalled (and cured – for money!) by the church for many children, not just those with disabilities or behavioural problems. If the child’s parents are convinced that their child is demonised the child is abandoned by their family and at risk of being beaten, starved and killed by the community. For more on this epidemic of child abuse, watch this video and read this article.


Service deficiencies

Services for people with psycho-social disabilities in Nigeria are few and far between. A psychiatrist at the main hospital in Lagos told workshop participants that the country has around 160 psychiatrists, roughly one psychiatrist for a million potential patients (WHO data from 2011 doesn’t give the actual number but says there are 0.06 psychiatrists for every 100,000 people, and data from 2005 puts it at 0.09). Primary healthcare services do not deliver mental health care, despite a policy from 1991 which sets out that they should. According to a 2006 World Health Organization report 91% of mental health expenditure is directed to hospitals. From what I know from workshop participants, these hospitals ain’t pleasant places.

Such establishments are not inspected by any independent body, despite Nigeria’s commitments under Article 16(3) of the UN Convention on the Rights of Persons with Disabilities, which sets out that the state needs to ensure that an independent monitoring body inspects all facilities and services designed for people with disabilities.

The Lunacy Act of 1958 regulates detention and involuntary treatment. This colonial relic allows for a doctor and a magistrate to detain “lunatics” a definition which include “idiots” and people of “unsound mind”. You can read more about this charming piece of legislation here.

Global biomedical approach

During the workshop it became clear that there is little interaction between the psychiatric and the traditional healing sectors. The closest to dialogue seems to be that psychiatrists admitting patients to hospital patients whose hands and feet were tied up by family members or by traditional healers.

The World Health Organization has observed but seemingly done little to encourage inter-sectoral dialogue. The 2006 WHO report cited above describes itself as an “assessment of the mental health system in Nigeria”, yet in its 36-page report it mentions traditional healers only once, observing that there are “no formal avenues for interaction” between primary healthcare staff and traditional/spiritual healers. This usefully confirms what I found out easily on a three-day trip. Excluding traditional healing from the report’s scope seems remarkable given that a reported 70% of mental ‘healthcare’ is delivered by the traditional healing sector (according to a 2004 paper published in the British Journal of Psychiatry).

True, nine out of ten Nigerians lack access to medication and talking therapies. The treatment gap is clearly made out. But given the scarcity of trained personnel and the prevailing satanic belief system (itself verging on the diagnosably delusional), a western-style medication-based approach seems inadequate to ensure the range of human rights to which people are entitled, and the culture in which rights-respecting mental health services can be imagined.


Responsibility to protect

A disability activist at the roundtable gave an example of a traditional healer who burned a child’s legs and then cut them off, in order to cure some ailment. The activist described traditional healers posing “a great danger to society”. Another participant suggested that the reason these abuses occur was that the traditional practices are “based on ignorance.”

The Nigerian government has a duty under binding international law to protect people within its jurisdiction from torture, inhuman or degrading treatment or punishment. (For the nerds, these obligations are set out in articles 1 and 16 of the UN Convention against Torture, and articles 15, 16, and 17 of the UN Convention on the Rights of Persons with Disabilities). The duty to respect this right means that state officials such as government-paid psychiatrists do not carry out such ill-treatment. The state’s duty to protect means that the state must ensure that private individuals like traditional healers or a religious pastors do not inflict ill-treatment. The Nigerian government is failing both to respect and to protect.

A human rights approach

That the Nigerian government is complicit in wide-spread abuse and violence against its population by failing to take any effective action to prevent and remedy these acts is a charge which government lawyers would find difficult to defend. The government must eradicate abuses and also ensure people have access to a range of community-based supports (again for the nerds, this is set out in Article 19 of the CRPD, and MDAC has done a lot of work on this issue).

This will not happen overnight, nor will it happen without investment from within and outside the country. A range of interventions are required. These include capacity-building of the country’s nascent disability rights movement and active involvement of them in policy development. Actions should include engagement with the judiciary through training and bringing test cases before them. Some serious law reform needs to take place and the National Human Rights Commission seems well-placed to play a leadership role, garnering support from the grassroots, ensuring the inclusion of all stakeholders (including, crucially, tribal chiefs, religious leaders and traditional healers), and getting top-down support from the various governmental departments.

A human rights approach needs to be embedded in a country currently dominated by demonic misbeliefs and lunatic laws.