Africa: Rethinking Mental Health in Africa

Kampala — As African countries strive to meet the UN Millennium Development Goals (MDGs) by 2015 and plot a new development agenda thereafter, health experts are gathering evidence across the continent to make a case for a greater focus on its millions of mentally ill.

Experts say investing in mental health treatment for African countries would bolster development across the continent, but national health priorities have been overtaken by the existing MDG structure, which has specific targets for diseases like malaria and HIV, placing them higher on countries' agendas than other health issues.

"Everyone is putting their money in HIV, reproductive health, malaria," says Sheila Ndyanabangi, director of mental health at Uganda's Ministry of Health. "They need also to remember these unfunded priorities like mental health are cross-cutting, and are also affecting the performance of those other programmes like HIV and the rest."

Global experts celebrated the passing of a World Health Assemblyaction plan on World Mental Health Day in May, calling it a landmark step in addressing a staggering global disparity: The World Health Organization (WHO) estimates 75-85 percent of people with severe mental disorders receive no treatment in low- and middle-income countries, compared to 35-50 percent in high-income countries.

The action plan outlines four broad targets, for member states to: update their policies and laws on mental health; integrate mental health care into community-based settings; integrate awareness and prevention of mental health disorders; and strengthen evidence-based research.

In order for the plan to be implemented, both governments and donors will need to increase their focus on mental health issues. As it stands, the US Agency for International Development (USAID), the world's biggest bilateral donor, will only support mental health if it is under another MDG health priority such as HIV/AIDS.

Meanwhile, mental health receives on average 1 percent of health budgets in sub-Saharan Africa despite the WHO estimate that it carries 13 percent of the global burden of disease.

"Mental health hasn't found its way into the core programmes [in developing countries], so the NGOs continue to rely on scraping together funds to be able to respond," Harry Minas, a psychiatrist on the WHO International Expert Panel on Mental Health and Substance Abuse and director of the expert coalition Movement for Global Mental Health, told IRIN.

"Unless we collectively do something much more effective about NCDs [non-communicable diseases], national economies are going to be bankrupted by the health budgets."

The post-MDG era

According to a May report from the UN Secretary-General's High-Level Panel of Eminent Persons on the Post-2015 Development Agenda, the MDGs have overseen the fastest reduction of poverty in human history.

Yet it also acknowledges that they have done little to reach the world's most vulnerable. The report says the MDGs were "silent on the devastating effects of conflict and violence on development" and focused too heavily on individual programmes instead of collaborating between sectors, resulting in a largely disjointed approach to health.

Experts say without a more holistic approach to global health in the new development era, the world's most vulnerable will only be trapped in that cycle.

"The MDGs were essentially a set of vertical programmes which were essentially in competition with each other for resources and for attention," said Minas. "We've gone beyond that, and now understand we're dealing with complex systems, where all of the important issues are very closely interrelated."

Poverty and mental illness

In Africa, where many countries are dealing with current or recent emergencies, WHO sees opportunities to build better mental health care.

"The surge of aid [that usually follows an emergency]combined with sudden, focused attention on the mental health of the population, creates unparalleled opportunities to transform mental health care for the long term," say the authors of the report Building Back Better: Sustainable Mental Health Care after Emergencies, released earlier this month.

In a study published in the Journal of Affective Disorders in July, researchers in northern Uganda - which, starting in the late 1980s suffered a two-decade long war between the government and the rebel Lords' Resistance Army - monitored the impact of group counselling on vulnerable groups such as victims of sexual and domestic violence, HIV-infected populations, and former abductees of the civil war.

It found that those groups who engaged in group counselling were able to return and function markedly faster than those who did not receive counselling, while reducing their risks of developing long-term psychiatric conditions.

"We need to be mentally healthy to get out of poverty," Ethel Mpungu, the study's lead researcher, told IRIN.

The link between mental illness and persisting poverty is being made the world over. According to a 2011 World Economic Forum report, NCDs will cost the global economy more than US$30 trillion by 2030, with mental health conditions alone costing an additional $16 trillion over the same time span.

"It really is around issues of development and economics - those things can no longer be ignored," says Minas. "They are now so clear that ministries of health all around the place are starting to think about how they are going to develop their mental health programmes."

Putting mental health on the agenda

As mental health legislation is hard to come by in most African countries, Uganda is ahead of most on the continent with its comprehensive National Policy on Mental, Neurological and Substance Use Services, drafted in 2010.

The bill would update its colonial era Mental Treatment Act, which has not been revised since 1964, and bring the country in line with international standards, but is still waiting to be reviewed by cabinet and be voted into law.

Uganda is also part of a consortium of research institutions and health ministries (alongside Ethiopia, India, Nepal and South Africa) leading the developing world on mental health care.

PRIME - the programme for improving mental health care - was formed in 2011 to support the scale-up of mental health services in developing countries, and is currently running a series of pilot projects to measure their impact on primary healthcare systems in low-income settings.

Research shows that low- and middle-income countries can successfully provide mental health services at a lower cost through, among other strategies, easing detection and diagnosis procedures, the use of non-specialist health workers and the integration of mental healthcare into primary healthcare systems.

Although a number of projects have shown success in working with existing government structures to ultimately integrate mental health into primary health care, the scaling up of such initiatives is being hindered by a lack of investment, as the funding of African health systems is still largely seen through donor priorities, which have been focused elsewhere.

"Billions of philanthropic dollars are being spent on things like HIV/AIDS or water or malaria," said Liz Alderman, co-founder of the Peter C. Alderman Foundation (PCAF), which works with survivors of terrorism and mass violence. "But if people don't care whether they live or die, they're not going to be able to take advantage of these things that are offered."

Somalia: 'Biggest Guns' to Control Somalia's South

Mogadishu — Somali clan leaders say that an Aug. 27 agreement between the government and only a few leaders from the country's three southern Jubba regions, which aims to resolve the ongoing dispute over who controls the area, creates more problems than it solves.

"The agreement, in essence, gives in to the original demands of one clan, the Ras Kamboni militia, for the domination over other communities just because they have the bigger guns. And that is unfortunate," Mohamed Hassan, a clan elder in the southern port city of Kismayo, told IPS.

Since the 2012 ouster of the Islamist militant group, Al-Shabaab, from much of this Horn of Africa nation's southern territories, the Somali government and the local militia group Ras Kamboni have been at loggerheads over control of the area.

On May 15, Ras Kamboni selected Ahmed Mohamed Islam, better known as Sheikh Madobe, leader of the group and as president of a self-declared regional autonomous state, which they named Jubbland. Kismayo was declared the state's capital city. The Somali government, however, refused to recognise the state, which comprises the three southern regions Gedo, Lower Jubba and Middle Jubba.

In June, fighting broke out between the Ras Kamboni militias and local clans after they rejected Madobe's authority. The World Health Organisation said that more than 70 people were killed and hundreds more injured as a result.

But Hassan said that the Jubba agreement, which was signed in the Ethiopian capital, Addis Ababa, did not address the core issue of the conflict and could lead to a more "uncertain future" for the people in the three provinces.

"With the exception of changing the name of the self-proclaimed state from Jubbaland to the Interim Jubba Administration, such an arrangement will further ignite communal conflict," he said.

The deal establishes a two-year interim administration that will be run by leaders from the three southern states. It outlines managing the region's federal institutions and infrastructure, including the airport and seaport - two of the main revenue generators for Gedo, Lower Jubba and Middle Jubba regions.

The agreement also envisages the integration of the local militias into the Somalian National Army and calls for reconciliation and confidence building between communities in the regions.

But Hassan cautioned against the agreement institutionalising a "one-clan hegemony" in Somalia's most-diverse regions.

"We all know these regions are not inhabited by one clan, but are the most diverse regions in Somalia. Giving priority to one clan over others is calling for a continuation of the conflict, so I call on the Somali government and the international community to annul the so-called agreement and organise a real reconciliation for all clans here," Hassan told IPS.

"We are for peace and brotherhood between the peoples here, not legitimising clanism. We will not accept anything less than justice, equality and respect for all."

Yusuf Omar, a political scientist and independent analyst from Kismayo, told IPS that most of the local clans had not been represented in the talks that culminated in the signing of the Aug. 27 agreement.

"The conflict is not between the Somali government on the one hand and one clan in the Jubba regions on the other. The conflict is between local communities over the future of the provinces, and most were not represented at the talks," he said.

While clan leaders say that the deal does not change anything on the ground, both the Somali government and leaders of Ras Kamboni insist that the agreement guarantees the new interim administration will be "an all-inclusive and representative body of all clans and constituencies."

But the Mogadishu-based independent Somali think tank, the Heritage Institute for Policy Studies (HIPS), said the agreement was deliberately "crafted in worryingly vague terms."

"In the absence of reliable population data and a recent census, the accurate distribution of seats [among the] clans is not possible. Representation lies at the heart of Somalia's political conflict. Use of this language threatens to incite further conflict," HIPS said in a reporttitled the "Jubba Agreement: Imperfect Progress", which was released after the signing of the deal.

Kulmiye Yusuf, a local academic from Kismayo, agreed that the ambiguity of the terms of the agreement could lead to problems during its implementation phase. However, he believes that the deal marks a new start in the relations between the government and Madobe, the leader of the Ras Kamboni militia and the self-declared president of Jubbaland.

"I do agree with the assessment of the institute [HIPS] that what has been achieved so far is an imperfect progress. But what is needed is to view this as a good start and that genuine reconciliation between the local communities can now be initiated," Yusuf told IPS.

Nigeria: Boko Haram Being Progressively Weakened - Jonathan

President Goodluck Jonathan has said that with the security measures put in place by his administration, the Boko Haram sect is being progressively weakened.

Speaking at the Presidential Villa in Abuja yesterday while receiving the outgoing representative of the delegation of the European Union to Nigeria and ECOWAS, Mr. David Mac Rae, Jonathan said his administration would remain proactive in combating terrorism.

According to the president, although measures taken by his administration have significantly reduced the occurrence of terrorist attacks in the country, the government will continue doing everything possible to further enhance security in all parts of the country.

"As a government, we are doing everything possible to improve our country on all fronts. We are consistently adapting our security architecture to deal with terrorism which has become a challenge to the whole world. Boko Haram is being progressively weakened but we are not resting on our oars. We will continue to do everything possible to achieve greater security for all who reside within our borders," the president said.

Jonathan, who maintained that many positive things were happening in the country, added that his administration would continue to do its best to correct negative perceptions about the nation, such as the notion of widespread insecurity and corruption.

He welcomed the declaration by the outgoing ambassador that he had recently travelled to the Niger Delta and some northern states and found people there going about their normal lives and businesses without fear.

Egypt Arrests Muslim Brotherhood Leader Beltagi

Cairo — Egyptian police captured Mohamed el-Beltagy, a senior Muslim Brotherhood official, on Thursday, Former labour minister Khaled al-Azhari was also held.

Beltagy, a former member of parliament and head of the Brotherhood's Freedom and Justice Party, was arrested in Giza governorate, just outside of the Egyptian capital, state television reported on Thursday.

Beltagi had urged Egyptians to join rallies against the military on Friday, in a recorded statement aired by the Qatari-owned Al Jazeera television news network this week.

Egyptian Police threatened to use live rounds at planned anti-government rallies, pressing ahead with a campaign that has thrown Egypt's oldest Islamist organisation into disarray.

Uganda Struggles to Come to Terms With Its Disappeared

Lamwo — When Uganda resident Rose Lamwaka had two sons abducted by the rebel Lord's Resistance Army (LRA) 10 years ago she felt she had lost all hope. "I was feeling a lot of pain, I was feeling like committing suicide," says the 51-year-old widow with seven grandchildren.

Last week, Lamwaka joined hundreds from the northern district of Lamwo to remember their abducted children, still missing from the decades-long civil war between the LRA and the government. More than 200 family members with relatives still unaccounted for read the names of their lost ones in a ceremony of prayer and song.

Northern Uganda was the epicentre of a legacy of violence, and the International Committee of the Red Cross (ICRC) says the number of people abducted since the war started in the late 1980s ranges between 52,000 and 75,000. Though Uganda has been free from LRA attacks since 2006, and a number of former child soldiers have returned, the ICRC estimates thousands remain missing from the north as a result of the conflict.

"Because there is no official figure of those missing, we had to extrapolate on what we found here," said Camilla Matteucci, ICRC protection coordinator. "And our projection is that at least 10,000 people are still missing in northern Uganda."

Left behind

The commemoration in Uganda not only acknowledged those still missing but also marked the end of a four-month community counselling pilot programme for more than 200 affected family members of the abducted in Lamwo District. As that project initially targeted only one sub-county, it used those affected families as a baseline to extrapolate the total number that have gone missing across the northern region.

According to Beatrice Ocaya, the local women's councillor in Lamwo, the ceremony was an important step in recognizing the ongoing support needed by families torn apart by the LRA conflict.

"There is no longer war, but some parents are ever crying," she said.

ICRC says relatives left behind have been silently suffering with ambiguous loss, and the isolation that breeds has far-reaching social and economic impacts on populations still recovering from conflict.

Congo-Kinshasa: DRC Accuses Rebel M23 of Shelling Rwanda

The Democratic Republic of Congo's government has denied that its armed forces, known as F.A.R.D.C, have been launching cross-border attacks into Rwanda.

Rwanda said Thursday that more than 30 bombs and rockets have been fired across the border in the last week by the DRC military.

But DRC Information Minister Lambert Mende told VOA it is the M23 rebels who have been shelling Rwandan territory in an attempt to draw Rwanda into the conflict in eastern Congo in support of the M23.

"I can say that at this moment since the fighting began not even a single the FARDC fire at Rwanda. We know that there are shellings from the Congo territory that are exploding in the Rwandan territory.

"But we know that this shelling is the fact of M23 rebels who are trying to bring Rwanda in the conflict officially because we know Rwanda is helping them, but it is not doing so openly," he said.

In a statement Thursday, Rwanda's Deputy Ambassador to the United Nations, Olivier Nduhungierehe accused Congo of trying to draw Rwanda into the conflict between the DRC army and M23 rebels in the city of Goma, which sits on the Congolese-Rwandan border.

Nduhungierehe said the Congolese army crossed a red line by shelling Rwanda territory and that Rwanda reserves the right to defend itself.

"The persisting shelling on Rwandan territory is unacceptable as it would be to any sovereign nation. We have the capacity to determine who fired at us and will not hesitate to defend our territory," Nduhungierehe said.

Mende said the DRC army, already occupied with fighting the M23, has no reason to attack Rwanda.

"If they are saying it may be that they are in complicity with the M23 to implicate themselves in the conflict for reasons, I don't know, economic. All what we want is that our neighbor be far away from this conflict because we have lost a lot of people due to their implication in the conflict in Congo," Mende said.

Mende accused M23 rebels of initiating the latest fighting prompting the Congolese army to retaliate.

"It is M23 who attack the positions of F.A.R.D.C. and the F.A.R.D.C. had to absolutely defend itself. F.A.R.D.C. retaliated and pushed them away and then they started shelling on Goma, shelling from Kibati and we have some shelling from Rwanda. That is why MONUSCO came in to repulse the M23 so that the civilian population in Goma is protected because it is the mandate of MONUSCO to protect civilian population," Mende said.

South Sudan: Immense Humanitarian Needs in Jonglei

Pibor — Tens of thousands of people, many of them displaced, remain in need of humanitarian assistance in South Sudan's Jonglei State following clashes there in July.*

Some 74,000 residents of the state's Pibor County - around half of its entire population - have been registered to receive aid, notably food.

In all, some 42,000 have received food rations in different parts of the county, half of them in Pibor town. There have been no distributions in that town since a series of incidents precipitated a review of operations on 18 August, by which time the World Food Programme (WFP) had, according to spokeswoman Challis McDonough, helped the majority of those in need who had managed to reach the town.

On 29 August, WFP started distributing 15-day rations of sorghum, vegetable oil, pulses and salt to some of the 23,000 people from 20 villages that have been registered in the town of Gumuruk.

"In all we hope to reach 60,000 people, the vast majority women and children in Pibor County, many of whom will need help for the rest of the year because they missed the planting season," said McDonough.

"This is one of the most challenging environments in terms of security and logistics - there is a dire lack of usable roads at this time of year which means many places can only be reached by helicopter, which have a limited capacity and require security arrangements on the ground to ensure safe distribution," she said.

"People are suffering," said Moses Ajak, a representative in the commissioner's office.

Outside his window people who had been hiding in the bush for weeks and then walked for days - some up to a week - to register for the food packages are waiting in the yard, many without protection from the heavy rain.

"During the night we host as many as we can in the commissioner's office. Others are forced to sleep outside," Moses Ajak said.

Over 100,000 displaced

More than 100,000 people are still displaced or in other ways affected by the violence that broke out in July between the Lou Nuer and Murle communities, and following clashes between the government and a rebel group led by David Yau Yau.

Many of them are out of reach of humanitarian support. In Pibor town, some people who had already left their villages to come here to look for food were either left in town among the soldiers or returned home empty-handed.

"I came to Pibor when I heard they were handing out food," said Thalano Kolen who walked from the village of Lilot with her six remaining children. The other two, a boy and a small girl, were killed when groups of what Thalano believes was Lou Nuer youth attacked the village.

"We have been living in the bush without food or shelter for weeks. I gave the children some wild fruits but when they got diarrhoea I decided to come here. I do not feel safe staying in town with the soldiers but I cannot walk back to the village without food," Thalano said.

Many of the displaced are women and children. The men are hiding in the bush, afraid to come into town because of the military presence, the women explained.

Others, like Thalano Kolen's husband, were killed in the fighting.

They are left to fend for themselves in a region that remains cut off due to insecurity and heavy rains.

The rainy season, which turns roads, villages, market areas and cattle camps into mud, restricts the movement and reach of aid agencies. Only 10 percent of Jonglei is accessible by road during the rains.

Limited air assets and lack of useable airstrips make it difficult to reach the neediest, especially with heavy foodstuffs.

"People need plastic sheeting to build their 'tukuls' [huts]. They also need medical treatment, but most of all they need food," said James Nyikcho, who works with a local NGO in Pibor town.

In Pibor town local authorities and aid workers stressed the need for aid to resume.

"When two women were killed by SPLA [Sudanese People's Liberation Army] soldiers and one woman was raped coming to town, all NGOs left. I heard they might return at the beginning of September but no one knows for sure," said Moses Ajak at the commissioner's office.

Hopes for peace

In late July, Archbishop Daniel Deng Bul, who chairs the recently established National Reconciliation Commission, called for the full implementation of a peace agreement signed in May 2012 by the paramount chiefs of all six communities in Jonglei State.

In a statement, Deng said this agreement had set a "peace from the roots" process in motion but that this was subsequently derailed by Yau Yau, whose "rebellion against the central government is not part of the same dynamic as the conflict between communities" but has nonetheless drawn these communities back into conflict and rearmament.

"We believe that the 2012 Jonglei peace agreement is still a viable option," said the archbishop, who went on to urge Yau Yau to accept an amnesty offered by President Salva Kiir.