Madmen and Englishmen

Mad people are everywhere in Malawi. They’re generally pretty easy to spot. They usually have excessively ripped brown clothing, if wearing anything at all, and have longer, unruly hair or dreads and facial hair. They’re also usually smack in the middle of the road, totally unaware of the traffic, people or any other hazards around them.

Now, this is not to say there are proportionately more mad people here in Malawi than, say, in the UK. But they are a lot more visible here and that is a reflection on how society supports and manages those who are mad, or deranged, or with psychiatric illnesses or whatever is the current terminology. And a bit of time here, or in Tanzania or plenty of other places prompts a well-needed shake up of our own ingrained assumptions and fears concerning those who we marginalize in society.

Most people will be familiar with the system of community care that is the backbone of social support in many African societies. “Care in the Community” is not something that needs reinvented here because, it is a concept that never went away.

There is a cultural element to this of ‘the extended family’, kinship, blood and belonging, increasingly irrelevant in places like the UK. There is also a pragmatic element in that there is a low level of welfare provision in many of these countries and a need to look after your own (and of course what goes around comes around – your own form of health insurance is helping others). Whatever the root of the differences is, however, it means that those who we marginalize from society in the UK are, for us visitors, strangely visible at the centre of everyday life in Malawi. There is one national institution for those found to be clinically insane, mainly reserved for those of greatest risk to themselves, but outside of that there are no local support networks for people with psychiatric illnesses in Malawi.

Yet, considering the number of such people you see every day the difficulties you encounter are virtually nil. One lady latched on to me for a while and followed me around town. She even followed me into the District Commissioner’s office on the one occasion I was honoured enough for him to give me an audience, to everyone’s confusion but no one’s real inconvenience. I later learnt of her plot to take me to Mozambique, but it was easily foiled when I drove off in my car without her.

There was one recent occasion that really summed up the contrast in my culture and attitudes as compared with those of my Malawian colleagues. Recently at the National Day of Education celebration in the local sports ground one such madman had attached himself to me for the day, following me around and trying to communicate with me. I had been, on reflection, a little rude on my part in minimalising any discussion to avoid encouraging him. At one point a colleague on the main stage spotted me in the crowd and sent someone to get me on stage to the top table. I was a little embarrassed given that I had no formal role in the day but eventually obliged.

Within 10 minutes or so my friend the madman had darted up onto the stage and sat at my feet. I panicked and automatically looked around for support and assistance, presuming he would be removed quite quickly. I remember feeling slight relief when my colleague reached out towards the man. Instead, however, of moving the poor man or shooing him away, he offered him a bottle of coke and some snacks. The man was happy enough, uttered something in way of thanks and eventually moved off the stage of his own accord. I felt very very sheepish indeed but, luckily, I don’t think anyone had known what I was feeling privately and escaped with my pride in tact.

When discussing the differences between Malawian and British attitudes recently with a Malawian friend I remarked on this in particular. Now whilst I am not up to speed by any stretch with developments in psychiatry I do know that you don’t often see people with severe learning disabilities or psychiatric illnesses roaming the street in the UK. And more often than not people with mental disabilities are mainly categorised by and intervened upon based on what threat or burden they cause to the outside world, rather than their existence as people themselves.

“But they have rights!” my friend says. “They have rights to be free and walk around and make choices”. And he wasn’t talking about life long choices about where to be, but the practical freedom to choose every day where they will go and what they will do, no matter how strange these choices may seem to an observer.

That seems pretty simple, but quite a poignant statement from my friend behind the bar.

I listened to a Radio 4 documentary just this week that was comparing psychiatric treatment in an institution in Berkshire as compared to a witchdoctor somewhere in Western Nigeria. The presenter concluded that despite access to some medications and techniques not available in Nigeria the hospital in the UK was forced to overmedicate and constantly restrain its inmates, due to lack of available skilled staff that could avail more progressive solutions to complex conditions. Both countries claimed to have more humane responses to supporting people with these conditions but with different justifications, which resonates with the situation in Malawi. One lacks what might be deemed to be the sophisticated, humane psychiatry techniques but has a supportive and humane environment with which to enact it. The UK might be described as entirely the inverse situation. Yet there doesn’t seem to be much point in being at the forefront of humane and progressive psychiatry if you don’t have a humane and understanding community to support these people or any budget with which to enact them. If forced to choose one environment or the other I’d say most would rather be wandering around town in Mulanje than be lying overmedicated in a bed in Berkshire.