PSYCHIATRY IN ETHIOPIA*

DAvmLIpPMAN, M.D. 1

Introduction Graham Greene has written that Africa is the only continent with the shape of the human heart (3). Using that image Ethiopia would lie in the region of the left auricle, near what is called the hom of Africa. It is the third most populous country in Africa, after Nigeria and Egypt, and has a population of about 27 million. In many ways it is distinctive within the spectrum of African history and culture, being unique: in its long history of Christianity, dating from the fourth century A.D.; in the fact that it never became a European colony, despite a brief Italian conquest; in that most of its people do not consider themselves to be negroes; and until recently in its uninterrupted history of imperial rule. The period during which I worked in Ethiopia began just after the former Emperor Haile Selassie had been deposed, and was characterized by the political instability of a new government attempting to establish itself in the presence of considerable domestic divisiveness. The political changes were not without effect on the psychiatric population, and one dramatic example of this occurred on the forensic service. Whereas during the previous year, defendants who denounced the Emperor were often referred for psychiatric opinion, later it was the Emperor's continued suppor*Manuscript received April 1976. 'Resident, Department of Psychiatry, University of Toronto, Toronto, Ontario. Can. Psychiatr. Assoc. J. Vol. 21 (1976)

ters who were likely to be sent by the courts. The Amanuel Hospital in Addis Ababa is one of two such institutions in the country. In terms of number of patients, it was the largest hospital in Ethiopia, with an average census of between 530 and 570 inpatients. Since the hospital had only 300 beds available, most patients had to double up or in some cases triple up. Of the six psychiatrists in Ethiopia, three worked in Amanuel Hospital (two Bulgarians and myself). In addition to inpatients, the physicians also saw about 50 outpatients daily who would line up for appointments beginning at 5 a.m. Due to the magnitude of the patient/physician ratio, pharmacological treatment constituted the mainstay of therapy, although ECT was also provided for both in and outpatients, together with brief psychotherapy with suitable patients if their English, French, or Italian was good enough to permit this. Ordinarily we worked with interpreters who were acquainted with one or more of the 27 Ethiopian languages and had received one year's training as medical auxiliary personnel. Outpatient Survey Two hundred and eighty-one outpatients were seen during the 51/2 day week studied and the following data were obtained and later analysed: age, sex, occupation, religion, place of residence, use of alcohol or

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chat (a local stimulant), previous psychiatric treatment, and diagnosis. Due to the limitation of time, assignment only to major diagnostic categories was possible. Some of the demographic data are necessarily incomplete since a few patients were genuinely unaware of their age, and others could not reliably report their place of origin. Moreover, .some of the patients were misinformed as to the type of problems handled by Amanuel Hospital; for example one with a middle ear infection consulted us because he had heard that we dealt with everything above the neck. Many of the patients had consulted native or priestly healers before coming to the hospital, and almost all the Christian patients had tried holy water as a potential remedy. Physical examination of the outpatients most interestingly revealed the variety of curative amulets the patients wore and the multiplicity of burns and scars induced in attempted treatment of malaria and other diseases.

Demographic Variables The mean age of the patients in the sample was 28.6 years. The range between 1 and 75 years, the youngest patient that week was an infant with seizures, and the oldest, a man with arteriosclerotic organic brain syndrome. Interestingly, men outnumbered women as outpatients, almost exactly 2:1, with women comprising 33 percent and men 67 percent of the sample. Only 35 percent of the patients lived in Addis Ababa itself; another 30 percent lived in the capital province of Shoa, one of 14 provinces in the country, but this left more than a third who must have spent one full day, and in some cases several days, in the journey to the hospital. Although no non-Ethiopian patients happened to be included in this sample, some from the neighbouring countries of Somalia and Yemen did consult the hospital as it was the nearest psychiatric facility. The most common occupation of the 281 outpatients was listed as "student" which designated anyone studying at any level in the educational system. Ethiopians often begin their schooling at a rather late age, and it was not uncommon to observe men

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and women in their early 20's still completing primary grades. While students made up 26 percent of the sample, housewives constituted 16 percent, farmers another 10 percent, and 15 percent were unemployed. The remaining 33 percent were distributed among priests, unskilled labourers, clerical and professional workers and merchants and craftsmen. Although no accurate census figures exist, this sample is, if anything, representative of a somewhat higher social status than that of the Ethiopian population as a whole, in which the rate of illiteracy has been estimated to be as great as 90 percent. The distribution of religion in Ethiopia is. reported to be about one-third Christian, one-third Moslem and one-third native religions (10), with the Falasha Jews, a very small minority, comprising between 15 and 40 thousand persons. Christian patients represented by far the majority of the outpatient sample, constituting 81 percent, the remainder being entirely made up of Moslems. Although there is some geographical overlap in religious distribution within the country, this Christian predominance is not unexpected in the light of the major concentrations of Moslems to the North and East of Addis Ababa and the almost exclusive representation of the pagan Ethiopians to the Southwest. The outpatient survey also included the use by the patients of alcohol and chat, an evergreen shrub found in eastern Africa and Arabia containing the central nervous stimulant cathine (d-nor-isoephedrine). While 15 percent of the sample admitted to alcohol use, 20 percent were or had been chat-eaters. Whereas neither alcohol nor chat use was significantly correlated with any diagnostic category, a highly significant association was found between Moslem religion and chat usage, which again was geographically J readily understandable. The diagnostic frequencies of the sample summarized in Table I indicate that 195 patients (60 percent) were considered to have a psychiatric disorder, 74 (26 percent) had neurological difficulties and 12 (4 percent) fell into the medical diagnostic group.

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TABLE I

DIAGNOSIS

Neurosis Schizophrenia Epilepsy Schizophreniform Psychosis Personality Disorders Organic Brain Syndromes Affective Disorders Mental Retardation Bell's Palsy Other Neurological Disorders Medical Diseases

NUMBER

PERCENTAGE

3 3 17 12

37% 21% 19% 5% 2% 2% 1% 1% 1% 6% 4%

281

99%

104 58 53 IS

6 6 4

Relative frequency of diagnosis in representative outpatient sample N =281.

Epidemiological Correlations Although neither age, sex, religion, occupation, or chat or alcohol usage was significantly associated with a greater probability of presenting with neurological, psychiatric or medical problems, there were some variations in the commoner psychiatric diagnoses. Men made up a larger than expected proportion of the schizophrenic group, 81 percent, and almost half the women in the sample, 48 percent, were diagnosed in the neurotic category. In the jobless occupational category, schizophrenia was more common and neurosis less common than in any of the other occupational groups; and schizophrenia was least common among the clerical, professional and craftsman groups. The further a patient had travelled to the hospital, the more likely he was to have a psychiatric rather than a medical or neurological difficulty. Whereas for Addis Ababa, the figures for the patients were 63 percent psychiatric patients, 31 percent neurological patients and 6 percent medical; the percentages for the province of Harrar, about 300 miles away, were 94 percent psychiatric problems, 6 percent neurological and no medical problems. The preponderance of men in the sample

is in contrast to many epidemiological surveys finding psychiatric disorders more prevalent among women but it is similar to a six-month survey of all new admissions in 1976 to a psychiatric hospital in Togo, West Africa, where the M/P ratio was about 3: I (77 percent males, D. Lippman, unpublished data). Several possible hypotheses might contribute to an explanation of this finding. As mentioned above, almost onefifth of the patient sample was epileptic, and a large New York study by Lennox found some greater prevalence of epilepsy in males as compared to females over the age of 10 (8, p. 756). In the Ethiopian sample the percentage of epileptic males was 66 percent-a figure essentially the same as that for the sample as a whole. More generally, however, prevailing across many of the diagnostic categories, the greater potential destructiveness of the psychotic male patient, and the greater interference that a psychiatric illness posed in his more specialized work, might lead to more males being brought to psychiatric attention. In the polygamous or extended family situations that prevail in Ethiopia, a disruption in the social functioning of a female relative might more easily be taken care of within the extended family network.

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hysterical disorders, the occurrence of special transitory schizophreniform psychoses, and the rarity of depression. While evidence of all three trends was observed, only the rarity of depression will be discussed here. In 1909 Kraepelin noted that melancholia and mania were rarely observed in Java (6). Carrothers has reported that both psychiatrists and natives perceive depression to be very uncommon in Kenya (2). Several possible explanations could be advanced. Perhaps the rarity of depression reflected social attitudes rather than actual incidence, since depression was often not considered to be a condition requiring medical diagnosis and treatment in the Ethiopian culture. Because the average life expectancy in Ethiopia is low (38.5 compared to 72 in Canada), depressive disorders which would ordinarily occur in the older age group may thus fail to appear. The average age of the few patients with primary affective disorders in this sample, however, was 19.6 years, a figure considerably lower than that of the sample as a whole, which was 28.6 years. Perhaps the similarity of some depressive symptoms to the apathy and lassitude of the common nutritional deficiencies and parasitic infestations, makes the condition appear less remarkable (5). It is possible that the ceremonies of mourning in Ethiopia, involving extensive ritualized wailing and other expressions of grief, may act cathartically to prevent the development of some depressions. Probably many depressions are treated by native healers and thus never become part of the psychiatric statistics, and almost certainly some of the secondary responses to depression are reduced in Ethiopia (9). The suicide rate in Ethiopia is not known with precision, but in 15 years of the hospital's records only two suicides have been recorded. The suicide rate of Africa as a whole has been estimated as I per 100,000 (1), which is less than one-tenth as high as in Canada. While the age differences of the Infrequency of Depression two populations undoubtedly contributes to Three trends have often been observed in the low African rate, in Ethiopia two the epidemiology of psychiatric disorders in additional factors may be relevant. First, third world countries: the frequency of several studies have tended to suggest an

Previous Hospital Contact More than half the patients (52 percent) in the sample had had previous outpatient visits at Amanuel Hospital. Eleven percent had previously been hospitalized, and 68 percent of this group were schizophrenic. None of the neurotic patients had ever been hospitalized and none of the patients with primary affective disorders had previous psychiatric contact. As might be expected, the largest group of patients with prior outpatient visits were epileptic, 72 percent of whom had been seen previously. Epilepsy is estimated to have a prevalence of 365/100,000 in the United States (8). While no comparable figures exist for Ethiopia, that it constituted almost 19 percent of the outpatient population during the week studied seemed typical of the usual pattern. The fact that deaths from both epileptic status and burns received by having fits near the house fire were well known, and that prophylactic medical treatment was demonstrably effective, certainly contributed to the large size of the clinic epileptic population, but one could not avoid the impression that the incidence of this disorder is high in Ethiopia. Bell's Palsy was also seen very frequently, and no week would pass without seeing at least two or three new cases. All inpatients received a routine VDRL determination. This was positive in over a third of the cases, and although yaws may have contributed some false positive results, neurosyphilitic syndromes were never seen. Penicillin treatment was of course given in the hospital, but presumably a long interval often existed between the onset of infection and the institution of treatment. Perhaps the absence of neurosyphilis could be explained by the probable occurrence in the Ethiopian patients of several febrile illnesses including malaria, which, prior to penicillin, were deliberately induced in the fever treatment of syphilis of WagnerJauregg (II).

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inverse relationship between the suicide rate To eat alone or eat on the street is regarded and homicide rate in at least some cultures as almost a sacrilege, and the custom of (4), and whereas suicide is rare in Ethiopia;' gursha, or putting a handful of food into the homicide is a distressingly common occur- mouth of another, is a very widely practised rence. Many Ethiopian men possess rifles gesture of affection. Prohibitions concernand almost all carry a large wooden stick, ing eating are also widespread and frequent. called a dulla, for protection. Second, in Whereas feasting accompanies all public Ethiopia social isolation is very rare indeed occasions, such as christenings, engageeven in a big city 'such as Addis Ababa, and ments and annual holidays, fast days are if in fact few Ethiopians ever spend any long anything more frequent. The moderately periods of time alone. Almost every patient religious family observes a partial fast each coming to the hospital was accompanied by Wednesday and Friday of every week, and a number of friends and relatives, and the the pious man fasts between 180 and 250 various communities seemed always to be days a year. aware of and feel responsible for their The traditional Ethiopian greeting is a members. ritual involving ceremonial kissing and Kiev (5) has cited the psychoanalytic bowing from 8 to 10 times to each other. hypothesis of depression, involving am- Aggressive oral activities, however, also bivalence toward a loved object and the play an important role in social interaction. turning in of aggression following the loss For example, it is the victor's prerogative, of the loved object, as a possible explana- after the annual Christmas team competition of the rarity of depression in some less tion, to insult the losers with complete developed countries. In Africa, where impunity. The art of composing a clever numerous surrogate parents are present, ties insult is much valued, and the typical to individual parents, he states, become less Ethiopian farmer spends much of his spare intense and less ambivalent. Abraham and time in lengthy litigation concerning minute later Rado pointed to the importance of an or obscure land rights. The content of the oral predisposition to depression, and the dispute often appears much less important rarity of depression in Ethiopia may be than the opportunity it provides to produce related to some of the very conspicuous oral clever and insulting arguments and crosstrends present in the upbringing of children examinations. and carried over into adult society. The first With such overt patterns of oral gratificaritual act performed after the birth of an tion, oral prohibition and oral aggressiveEthiopian infant is the placing of some ness, it is not surprising that manifest oral butter in his mouth, in the belief that this content was very frequently found in a will keep his voice from becoming harsh. study of the dreams of Ethiopians. Whereas The infant is breast-fed usually until the age manifest orality was considered to be of three, suckled whenever he wishes and present in 22 percent of a sample of the rarely separated from his mother during day dreams of young male Americans, and the or night. Until he is weaned the Ethiopian figure was 38 percent in a sample of child is fondled and indulged by parents and non-Moslem Nigerians, the percentage for a other relatives, always eating first. Thumb sample of Ethiopians was 64 percent (7). It sucking is readily accepted and the child is possible that this overt, unrepressed often sucks the parents' thumb as a pacifier. expression of oral drives with the If an Ethiopian child is adopted, this background of an early oral period with ceremony is formalized by having the child very few frustrations, may also contribute suck the honey-dipped finger of his foster to the scarcity of clinical depression obparent (7). served in the Ethiopian hospital population. Eating continues to occupy a central role Summary in the adult life of the Ethiopian. Mealtimes have a deeply serious tone, and the food is Ethiopia, the third most populous country chewed aloud so that all present can hear. in Africa, having about 27 million people,

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has a mental health system involving two psychiatric hospitals and six psychiatrists. The author worked as a psychiatrist for six months in the Addis Ababa psychiatric hospital and obtained statistics relating to the patients consulting the outpatient department. Age, sex, occupation, religion, place of origin, alcohol and chat (a local stimulant) usage, diagnosis and previous treatment data were recorded for all the 281 patients evaluated during one 51/2 day week. These data are described and analysed, and examples and comments are given additionally on the frequency of some neurological syndromes and the rarity of depression. This latter finding is then discussed in the light of several of the conspicuous oral trends in the upbringing of children and also in the adult life of Ethiopian society. References 1. Benedict, P., Jacks, I.: Mental illness in primitive societies, Psychiatry, 17: 377389,1954. 2. Carrothers, r.c. The African Mind in Health and Disease, a Study in Ethnopsychiatry, Geneva WHO Monograph series, 1953. 3. Greene, G.: Journey Without Maps, London, William Heinemann, Ltd., 1950. 4. Kendell, R.E.: Relationship between aggression and depression, Arch. Gen. Psychiatry 22: 308-317, 1970. 5. Kiev, Ari: Transcultural Psychiatry, New York, The Free Press, 1972. 6. Kraepe1in, Emil: Psychiatrie, I, 8th Ed., Leipzig, Barth, 1909. 7. Levine, D.: Wax and Gold, Chicago, The University of Chicago Press, 1965. 8. Merritt, H.H.: A Textbook of Neurology, Philadelphia, Lea and Febiger, 1970. 9. Murphy, H.B.M., Wittkower, E.D., Chance, N.A.: Crosscultura1 inquiry into the symptomatology of depression; A pre-

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liminary report, Int. J. Psychiatry, 3: 6-21, 1967. 10. Ullendorf, E.: The Ethiopians, London, Oxford University Press, 1973. 11. Wagner-Jauregg, J.: Uber die Einwirkung der Malaria auf die Progressive Paralyse, Psychiatr Neurol Wochenschr. 20: 132, 1918-19.

Resume

L'Ethiopie, le troisieme pays le plus peuple en Afrique, dont la population atteint vingt-sept millions d' habitants, posede un systeme psychiatrique qui n' offre a cette population que deux hopitaux psychiatriques et six psychiatres. J' ai travaille comme psychiatre pendant six mois a Addis Ababa dans un hopital psychiatrique. J' ai pu consulter les statistiques des patients qui se presentaient au departement de psychiatrie pour y recevoir les soins offerts aux patients externes. L'age, le sexe, l' occupation, la religion, le lieu d'origine, le degre d'alcoolisme et Ie "chat" sorte de stimulant tres en usage dans ce pays; les diagnostiques, les informations sur les traitements deja donnes etaient enregistres pour chacun des deuxcent-quatre-vingt-un patients que l'on avait evalue dans la semaine de cinq jours et demi. Ces renseignements sont decrits et analyses, on donne en plus quelques exemples et commentaires sur la frequence de syndromes neurologique et la rarete de depression chez ce peuple. On y discute les dernieres decouvertes a la lumiere de certaines tendances de I'oralite dans I'education des enfants, mais egalement dans la vie des adultes dans cette societe d'Ethiopie.

Psychiatry in Ethiopia.

PSYCHIATRY IN ETHIOPIA* DAvmLIpPMAN, M.D. 1 Introduction Graham Greene has written that Africa is the only continent with the shape of the human hea...
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