I never knew that our entire healthcare infrastructure was in such a bad state. Those were the sentiments expressed by Nigeria’s Chairman of the Presidential Task Force on COVID-19, Boss Mustapha, as he updated leadership of the National Assembly on the fight against the pandemic. This virus provides an opportunity to examine our national health system in dire need of reforms and funding; the Chairman pointed out to the lawmakers.
Conspicuously absent from recommendations for legislative reform was a key issue highlighted by COVID-19: mental health. Government-mandated social distancing and the implementation of other public health guidelines have led to emotional anguish and psychological challenges amidst restrictions on public life, economic hardship, and illness. Rather than mental health being at the periphery, a robust national response to this novel virus mandates the issue takes front and center stage.
A lack of research on Nigeria’s mental health demographics has contributed to it being a low priority among policymakers and inadequately funded. The largest nationally representative study on general mental health in the country was published by the World Health Organization (WHO) in 2004 — over 15 years ago! The research found that one in eight Nigerians would develop a mental health condition during their lifetime and that fewer than 10% have access to the care they need. Recent investigations are even more sober. According to the 2018 Nigeria National Depression report, produced by Joy, Inc., in partnership with NOI Polls, a leading polling organization in West Africa, and research partners at Yale, one in three Nigerians are experiencing depressive symptoms. In a country that surpasses 200 million, it means over 60 million Nigerians are at risk of depression. As isolation intertwines with mortality and hunger, these individuals could be pushed over the edge.
The country does not have nearly enough resources to tend to this impending crisis. Infrastructure is deficient with only eight federal neuropsychiatric hospitals in Nigeria, and three operating at the state level. Mental health workers have complained that these facilities are too few, face strained budgets, poor work conditions, staffing issues, and residents experience abuse. At the community level, mental health care is limited, which falls short of the global standard set out by the United Nations Convention on the Rights of Persons with Disabilities. Human capacity is also a challenge. The Association of Psychiatrists in Nigeria has only 250 psychiatrists registered to it when millions potentially face mental health challenges. Nigeria’s poor mental health infrastructure is currently governed by a framework that has roots that date back to 1916. Starting as an ordinance in the British colonial era, the statute became codified as a law called the Lunacy Act of 1958. To put the law in perspective, it was adopted two years before Nigeria’s independence. In 2003, the Nigerian Mental Health Act was proposed to replace the Lunacy Act. It failed to pass and was eventually withdrawn from the Senate in April 2009. It was reintroduced in 2013, but also did not make it through the legislative process.
Recently, there has also been movement on mental health legislation. In November 2019, the Senate passed a mental health bill for second reading. Progress continued in February this year, when the upper chamber held a public hearing on the proposed law. If the history of failed efforts is to be our guide, however, there is little reason to think there will be passage of the legislation.
Though the proposed mental health bill may seem like progress, it still fails to adequately address key issues of quality care, comprehensive community response, funding, and respecting the human rights of those with psychological conditions in Nigeria. As policymakers are planning a comprehensive approach to this virus, mental health and its governing architecture must be part of the package.
Those debating macroeconomic interventions from stimulus funds to conditional cash transfers should take heed as well. As we deliberate the best way to reignite growth, understanding the profound link between mental health and economic development is crucial. A 2016 WHO led study quantified the impact, estimating that for every $1 put into scaled up treatment for common mental health conditions, there is a return of $4 in improved health and work productivity. Demonstrating how promoting mental health serves as a fiscal enabler.
Narrow understandings of epidemiological responses also lead to public health blind spots. For instance, the most notable exchange of the Presidential Task Force on COVID-19’s discussion with the National Assembly concerned hazard pay to frontline health workers. Reducing the issue of support to simply cash.
Medical workers need more than finances. Their mental health is at risk as they endure long hours, bear extreme isolation, cope with dwindling medical supplies, and are in constant proximity to death. Research published by the Journal of the American Medical Association highlights the psychological fallout. The study examined the mental health outcomes of 1,257 health care workers attending to COVID-19 patients in 34 hospitals in China. Many experienced symptoms of depression (50%), anxiety (45%), insomnia (34%), and psychological distress (71.5%). Nurses and women were the hardest hit, reporting especially severe symptoms — modeling other polls which show COVID-19 has had a negative impact on women and mothers at higher levels — demonstrating that suffering has been disproportionate along gender lines. Additionally, Frontline workers in Wuhan, the epicenter of the outbreak, exhibited a greater psychological burden than Chinese health care workers father away. Meaning our most critical lines of defense, those health officials engaged day-to-day against the virus, are the most psychologically at risk. This could result in more mistakes on the job and burnout, leading to worse outcomes for patients.
A comprehensive public health response to COVID-19 should include mental health preparedness. The United Nations recently sounded the alarm to the international community to do more to protect those with increased mental vulnerabilities during this period. Policymakers in Nigeria need to continuously elevate mental health as a vital part of the national discussion. The first place they could start is by prioritizing passage of mental health legislation that is more human rights centered and updating the national mental health policy. Nigeria needs a new regulatory framework that eschews colonial origins and supports those with mental health conditions during this pandemic.
By Chime Asonye and Hauwa Ojeifo