Over a century ago, in 1910, British colonial authorities in Kenya redesigned a then-smallpox isolation center into what became the Nairobi Lunatic Asylum, a dire institution in which African patients-95 percent of the asylum's population-were kept in the worst conditions and European patients in the best. Until independence in 1963, only Europeans worked there as psychiatrists, senior doctors, and nurses.
Much has changed in the 60 years since Kenya became independent, including at the asylum, which later changed its name to Mathari National Teaching and Referral Hospital, and today offers specialized inpatient and outpatient mental health services. Kenyans now increasingly see mental health as an element of wider health, and people who experience mental distress as a part of the community.
The legal landscape has also improved, with Kenya adopting a new constitution with a progressive bill of rights in 2010 and ratifying the UN Convention on the Rights of Persons with Disabilities (CRPD) in 2008, which redefines mental health conditions through the social model lens as a disability.
But stigma and discrimination remain, and ridicule and isolation, rather than dignity and inclusion, continue to be the experience of many people with mental health conditions in Kenya today.
Oppression, Stigmatization
Under colonial rule, mental health laws were used politically to suppress rebellion and detain individuals or groups whom the colonial establishment viewed as a threat to its control. Such was the fate of Elijah Masinde, founder of the spiritual Dini Ya Msambwa sect and an anti-colonial activist, whom authorities declared ''insane'' and detained in Mathari Hospital for two years, from 1945 to 1947.
In 1963, the English Mental Health Act of 1959 governed Kenyan health care and the Mental Health Department was under the control of the inspector of prisons-a structure that some commentators have cited as contributing to the stigma and criminalization affecting people with mental health conditions.
In 1989, Kenyan authorities replaced the English Mental Health Act with the Mental Health Act, and later the Mental Health (Amendment) Act of 2022, which today governs Kenya's mental health system.
Oppress People
Historically, though, the law has been used to oppress people with mental health conditions. Earlier mental health laws (including criminal justice laws with provisions on mental health) viewed people with mental health conditions as ''objects'' of care rather than as rights holders. They faced an increased risk of arrest and detention for petty offences due to biases in law enforcement practices. In one example, an exploratory study found, behavior such as removing one's clothes in public-often due to tactile sensitivity-might have been seen as indecent exposure, subject to a jail term.
The Mental Health (Amendment) Act of 2022 introduced for the first time the words ''human rights'' in the law governing access to mental health care. Rights recognized in this law include the right to fully participate in community affairs and to seek medical, social, and legal services. Yet, it still has echoes of the English Mental Health Act; for example, it permits involuntary treatment. Evidence does not support the conclusion that involuntary outpatient treatment is more effective than intensive voluntary outpatient treatment and, indeed, shows that involuntary, coercive treatment is harmful.
A Stigma that Never Ends
We authors not only share a name; we also share experience of Kenya's mental health system; one as a user of mental health services and one as a family member of a person with a mental health condition. In our personal and professional lives, we have worked with others who have themselves experienced mental health conditions to bring concerns about the mental health system to the public's and government's attention.
Over the years, Kenya has developed numerous policies and action plans on mental health. Some of these include the Kenya Mental Health Policy (2015-2030); Kenya Mental Health Action Plan (2021-2025); Kenya Health Policy (2015-2030); and Kenya National Patients' Rights Charter 2013. Other related documents include the Kenya Mental Health Investment Case 2021 and the Suicide Prevention Strategy (2021-2026).
Stigma against people with mental health conditions is a universal phenomenon. But a country's culture influences its impact, including in Kenya. Despite all the policies and plans, discrimination against people with mental health conditions is systemic and deeply entrenched, including in language used in relation to mental health. The Penal Code uses ''imbeciles'' and ''idiots'' when referring to people with mental health conditions. The Constitution uses ''unsound mind,'' and the Evidence Act uses ''lunatic.'' And, when patients ''escaped'' from Mathari Hospital in 2013 and in 2016, social media had a field day mocking people with mental health conditions.
Despite using human rights terminology, the Mental Health (Amendment) Act of 2022 fails to adequately protect those rights. In addition to involuntary treatment, the Act allows coercion in other forms including restraints and seclusion, which does not align with frameworks that respect and protect the rights of people with mental health conditions.
Stigma has resulted in the-ill treatment of people with mental health conditions over the years, including chaining. As recently as February 2020, Human Rights Watch researchers interviewed Paul, a man with a mental health condition chained in the Holy Ghost Coptic Church in Kenya. He told them he had been chained for five years:
The chain is so heavy. It doesn't feel right; it makes me sad. I stay in a small room with seven men. I'm not allowed to wear clothes, only underwear. I have to go to the toilet in a bucket. I eat porridge in the morning and if I'm lucky, I find bread at night, but not every night.... It's not how a human being is supposed to be. A human being should be free.
Disability Laws and Glimpses of Hope
Kenya is party to the international Convention on the Rights of Persons with Disabilities (CRPD), which recognizes those with mental health conditions as people with disabilities and protects their rights. The bill of rights under the Kenyan Constitution and the Persons with Disabilities Act also support the freedom of people with mental health conditions to live with dignity in the community.
Mental Health
A promising development on mental health over the years has also been the increase in self-advocacy by people who have experienced mental health conditions. In line with the mantra of the disability movement-that there can be nothing about us without us-people who have had experiences of mental distress or engaged with the mental health systems have coalesced into groups that have been at the forefront in advocating for their rights.
In addition, interest in mental health in Kenya has grown steadily. Many reports have been published in recent years detailing the problems people with mental health conditions experience in Kenya while seeking solutions to existing challenges.
The Kenya National Commission on Human Rights (KNCHR), which has the legal mandate to monitor the protection of the human rights of people with disabilities, has published numerous reports on the subject. In 2011, KNCHR published a report titled ''Silenced Minds'' that exposed the systemic neglect of the mental health system in Kenya. This was after CNN aired a documentary that showed the inhumane condition faced by patients, including a deceased patient lying in an isolation cell in a male ward with another patient seen lying next to him.
In 2017, the Auditor General published a performance audit report on mental health services in Kenya that also highlighted gaps in their provision. Some of the gaps include that the Ministry of Health has not effectively delivered on its mandate of providing health policy and standards management and that Mathari Hospital and county governments lack sufficient resources to deliver services efficiently. The audit report also stated that awareness campaigns to enlighten the public on mental health conditions are lacking and people with mental health conditions are stigmatized and their actions criminalized.
In his official Madaraka Day (Independence Day) speech on June 1, 2019, then-President Uhuru Kenyatta called for an appropriate policy response to facilitate mental well-being, resulting in the formation of a task force to address mental health issues in Kenya in December 2019. It published its report in 2020, calling for the government to declare ''mental illness a national public health emergency of epidemic proportions'' and laying out concrete recommendations for change. These include establishing community-based services with focus on primary mental health care and anti-stigma and mental health promotion campaigns.
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Global initiatives have also been introduced to bring change to mental healthcare systems. They include the World Health Organization's QualityRights Toolkit, which seeks to transform health systems and services toward a person-centered and human rights-based approach, in line with the UN disability treaty. It has accelerated the impetus for improvements in this field.
The Next 60 Years
Kenya has systems and structures in place to improve quality and human rights standards in mental health systems, save for the problems with some of the laws outlined above. There is an urgent need to increase investment in community mental health services, and to focus on social determinants of mental health, including safe and inclusive communities, systems to deal with injustice, access to income, and violence-free societies.
There are many organizations led by people with lived experience of mental health conditions that continue to advocate and raise awareness on the rights of persons with mental health conditions, with the majority undertaking activities that support access to justice and litigation; health services and inclusive education for persons experiencing mental distress. These, among others, are the rights-based programmes that seek to promote, protect, and enhance the rights of people with mental health conditions. These need to be scaled up to reach a wider population. It is also worth investing in good practice alternatives in mental health.
Most important, people who have themselves experienced mental distress should be at the forefront of creating a society in which the mental health system respects, protects, and fulfills everyone's human rights. Normalized human rights violations, including shackling, need to end.
Some 113 years after the Nairobi Lunatic Asylum was created, we hope the next century brings better tidings for mental health in Kenya.
