Alma Ionescu details patterns of invisibility within the histories of psychiatry and mental health in Uganda
History has always been necessary to make sense of the present. This holds particularly true in relation to mental health, as stigma is often the accumulation and perpetuation of ideas, perceptions and attitudes that over time solidify into enduring understandings of what mental health is (Schomerus and Angermeyer, 2022; Earnshaw et al, 2022). Stigma can become cemented into structures of society that produce deeply embedded structural stigma (Hatzenbuehler, 2016). History allows us to make sense of these structures and patterns, and how they may have developed or endured over time. Diving deeper into the history of psychiatry in Uganda, one enduring pattern of its history – that of invisibility – can help to make sense of the mental health landscape today.
One might point out that psychiatry and mental health are not synonyms of each other and that psychiatry cannot even begin to encompass all the different aspects that we need to consider when we think about ‘mental health’. This is an important reality to be acknowledged in the context of Uganda, not only because of the colonial legacies of psychiatry, but also because psychiatry is not a dominant explanatory model through which mental health is viewed and understood (Abbo et al, 2019; Bwanika et al, 2022). As such, I do not conflate psychiatry with mental health. However, psychiatry – understood as an institution of power that extends beyond the four walls of a ward – is an important piece of the puzzle in that it is an ‘official’ language that governments and institutions use to frame mental health. In Uganda, the provision of ‘formal’ care (emphasis on formal) has almost exclusively been founded upon psychiatry (Molodynski et al, 2017, Kagaari, 2021). Consequently, its history matters because it has been inscribed into public discourse around mental health. In many ways, psychiatry thus shapes the parameters of discussion within the realms of public discourse and formal care settings.
When we as scholars think about mental health stigma, we often think about how it manifests itself in the existence of negative stereotypes – and the subsequent actions and reactions these engender. A common example is the falsely held idea that people with ill mental health are ‘violent’ – largely thanks to sensationalisation and mediatisation, which weaponize their existence (Large and Ryan, 2012). An aspect of stigma that is less often explored is that of rendering the existence of people as invisible. Unpacking stories and histories of invisibility is important because it allows to envision what it means do undo invisibility and the transformative power this can have.
In what follows, I will give a brief insight into the history of psychiatry in Uganda, focusing on emerging patterns of invisibility. I argue that the medical humanities provide the necessary tools to understand this history as it pertains to mental health change in Uganda today.
Distanced Provisions of Care
Psychiatric practice was for many decades a marginalised area of the colonial government. Psychiatry in many African countries did not constitute an arm of social control of colonial powers in the same way that mass confinement emerged in nineteenth century Europe (Vaughan, 1991; Akyeampong, 2015). The low standing of psychiatry in the hierarchy of medical disciplines, accompanied by a lack of resources and hesitance regarding diagnostic categories as they related to ‘the African’, meant that institutionalisation had little to offer as a setting of care (Vaughan, 1991, Pringle, 2019). As an institution, not dissimilar to other histories of psychiatry elsewhere in the world, it served a primary function of confinement of those deemed disturbing and allowed to keep patients away from the gaze of society. The resultant custodial nature created, and even encouraged, conditions that made patients invisible through means of segregation.
Psychiatry in Uganda was first introduced in 1921 by the colonial government. It was introduced some 30 years after the establishment of the British Protectorate in 1894, out of perceived necessity rather than interest. Up until then, mental health had received almost no attention, aside from occasional incarcerations of ‘lunatics’ being deemed aggressive and dangerous (Mahone, 2006). The conversion of Hoima Prison into a Lunatic Asylum marks the formal introduction of psychiatry (Pringle, 2019). The change in designation did not change much about the realities of that space – it very much retained its primary purpose of confinement, with little provisions for care.
The custodial nature endured over the years. It continued to develop and upkeep patterns of erasure, of rendering people invisible to the rest of society. The ‘removal’ from society was only the first step. The second step solidified distance by minimising meaningful interactions over time. Months and years could go by where patients were denied interactions with their families, in some cases, denying family members information about the death of their loved ones for years (Pringle, 2019).
Inside the asylum, distance was also part and parcel of service provision. Staff were instructed to keep their distance from patients, creating a disconnection in patient-carer relationships. There was no shame in hiding or concealing this truth. Charles Baty, the Superintendent at Mulago Mental Hospital in the 1940s, for example would instruct that while ‘some patients are unusually dirty, attendants should be unusually clean’ (as cited in Pringle, 2019, p46). The marking of a stark difference would also be used to frame psychiatry under the guise of altruism, as it supposedly represented ‘progress’ and ‘civilisation’. In this sense, psychiatry was promoted as doing good for society rather than for its patients. This discourse illuminates the extent to which the erasure of patients was normalised, as they would be treated as an afterthought.
Geographies that Erase
Following its geographical locations, psychiatry reveals a pattern of creating invisibility. The first ‘formal’ psychiatric hospital in Uganda was in Hoima, a city in the western part of the country. The prison turned ‘lunatic asylum’ was located conveniently far from the capital city of Kampala, at a comfortable distance that served to fulfil its role of creating invisibility. Over the years, however, the far-removed location started to become more of an inconvenience. High administrative costs and lack of personnel willing to relocate outside the city (and much less even work in psychiatry) made it harder to sustain the institutions.
The early 1920s coincided with a general shift to centralise the medical administration in Kampala. Decisions were made to shift the location of the psychiatric unit to Mulago Hospital, which is to date the biggest hospital in the country. Yet, the psychiatry unit was far removed from the main compound of the hospital and other units, an intentional design to limit disruption through physical distance and therefore reinforcing invisibility. In the following years, as the small unit at Mulago grew overcrowded, construction of a new psychiatric hospital began. The chosen location was Butabika, just outside the city of Kampala – once again, an intentional choice. Butabika remains active to this day and is the only tertiary facility in the country. All the locations that served as ‘the centres of psychiatry’ at one time or another are marked by a geographical distance – a distance close enough to not inconvenience administrators too much, but far enough to segregate and push to the margins.
Undoing Invisibility
In retelling a part of this history I do not mean to paint a single picture of psychiatry or ‘mental health’ in Uganda. The post-independence period (after 1962) saw a dynamic shift in mental health care provision that could have easily positioned Uganda as one of the leaders in mental health in the region at the time: from opening one of the first academic psychiatry departments at Makerere University to the creation of the National Alliance for Mental Health (NAMH) focused on mental health advocacy (Pringle, 2019). Today the landscape of mental health in Uganda is vibrant and burgeoning, with many actors and organisations dedicated to creating change and improving mental health outcomes.
A commonality that emerges across the work of mental health advocates, back then and today, is an effort at ‘undoing invisibility’. The popularity of peer support and ‘social contact’ events (Kitafuna, 2022), amongst many examples, speak to this. Understanding this points to the importance of medical humanities in mental health research in Uganda and beyond. More research needs to think about mental health change and fighting stigma in these terms. When we think about fighting stigma in traditional terms, we structure a response around how to undo negative (and wrongful) stereotypes through factual responses. However, thinking about mental health change in terms of undoing invisibility asks a whole different set of questions – it asks what it means to be seen and how people are made to feel seen.
About the Author
Alma Ionescu is PhD student in Global Health at University College London (UCL). Her work looks at mental health activism in Uganda to understand how grassroots actors envision and negotiate positive change around mental health.
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