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In April 1969, twenty-five psychiatrists from nine African countries, the UK and the USA met at Makerere University College in Kampala, Uganda, to discuss the organisation of mental health services in Africa. Among them were several ‘giants’ of African psychiatry, including Tolani Asuni, then of Aro Hospital, Nigeria, Taha A. Baasher, then of Khartoum North psychiatric outpatient clinic, Sudan, C. C. Adomakoh, of Accra Mental Hospital, Ghana, and Stephen B. Bosa, of Butabika Hospital, Uganda. Over three days, the participants considered the roles of psychiatrists in developing countries, the size and scope of psychiatric institutions, problems of stigma and outdated legislation, alternative forms of care, the use of auxiliary health workers and postgraduate training. They attended the opening of an exhibition of paintings of mental patients organised by the Uganda National Association for Mental Health (NAMH) and took advantage of the opportunity to socialise and exchange ideas—an opportunity that was highly welcome for those psychiatrists who worked single-handedly in their own countries.1

The discussions made it clear that there was no one vision for the future of mental health care in Africa. While some participants argued that existing mental hospitals, inherited from colonial rule, needed to form the basis of a ‘modern’ mental health care system on the grounds of economic and administrative efficiency, others were more cautious, highlighting cases of ‘social catastrophe’ or stigmatisation following admission. A few went so far as to demand the closure of mental hospitals altogether, stressing that hospitalisation was ‘anti-therapeutic’ and pointing to moves to close large psychiatric institutions in Europe and the USA. Discussions on alternative forms of care, meanwhile, highlighted a wide variety of experiments in progress, including music therapy, village settlements and rural psychiatric outpatient clinics, as well as mixed opinions on group therapy and the value of traditional healers.2 Even the role of the psychiatrist in a developing country was up for debate. In the dual contexts of decolonisation and nation building, the central question for participants was whether they should remain primarily in custodial and curative roles. Did they have a duty to contribute their expertise to issues of social planning and national development? On this question, one group maintained that psychiatrists needed to focus on the curative aspects of the profession, particularly as knowledge about the causes of mental illness and the significance of rapid social changes in developing countries was limited. The other group, by contrast, did not want to be limited to a single role. They saw their education, intelligence and expertise as raising a moral imperative to act. The psychiatrist, they stressed, ‘must be prepared to take on many mantles, and must be prepared to offer advice in those areas of social planning which were likely to influence the mental health and happiness of people’.3 These views, according to G. Allen German, Professor of Psychiatry at Makerere, reflected differences in human personality, the variety of which could be accommodated in mental health services in Europe and the USA: ‘In developing countries, however, where personnel are few, it may be that one man will have to adopt different roles, and this is one of the problems of working in a developing society which has to be accepted’.4

The meeting in Kampala was just one of several regional and international meetings on the practical problems of mental health care delivery in developing countries held between the late 1960s and the mid-1970s. They reflected the increasingly transnational character of psychiatry in the mid-twentieth century and belied any simplistic North–South or Western/non-Western transmission of knowledge or expertise. Psychiatrists gathered in Hong Kong in 1968, Chile in 1969, and Singapore and Cairo in 1970, with the participation of psychiatrists from developing countries made possible through the financial support of international organisations who were starting to look beyond Europe to problems of mental health worldwide.5 The Kampala meeting had been sponsored by the Commonwealth Foundation and the World Federation for Mental Health (WFMH), but they were not the only organisations involved. In 1970, an inter-regional seminar on the organisation of psychiatric services in the Soviet Union (USSR) was facilitated by the United Nations Development Programme (UNDP) and the World Health Organization (WHO), bringing together nineteen psychiatrists and public health officers from fourteen developing countries, including India, Mexico, Japan, Uganda and Tanzania. Over two weeks, the participants shared experiences from their own countries and studied how the USSR had established a network of psychiatric services in urban and rural areas, and their relationship with general health, social welfare and educational services.6 In January 1971, moreover, the Indian Psychiatric Association and the WFMH organised a workshop bringing together psychiatrists and clinical psychologists from across India to review the shortcomings of existing mental health services and draw up recommendations for future development. These recommendations included more investment in mental health training for general practitioners and auxiliary health workers, the revision of the 1912 Lunacy Act, the expansion of outpatient care centres and the appointment of a full-time advisor on mental health at the level of central government.7

Concern about the organisation of mental health services in developing countries was, in many ways, a logical extension of research conducted since the 1950s that was challenging many of the earlier held assumptions of psychiatrists under colonial rule. Work within both psychiatric epidemiology and transcultural psychiatry, a sub-discipline that was concerned with the presentation and management of mental illness across different cultures, was suggesting that mental disorders once regarded as comparatively rare in developing countries, such as depression, were in fact as common as elsewhere in the world. This research was also challenging fears that urbanisation and education would lead to increased rates of mental disorder, highlighting instead the ways in which such social changes might make communities less willing or able to care for the mentally ill, as well as the inadequacy of the mental health system bequeathed by the colonial powers.8 As a series of review articles on psychiatry in Africa, South America and South-East Asia commissioned by The British Journal of Psychiatry in 1972–1973 made clear, the expansion of mental health services in developing countries was a necessary part of social and economic development—pressure on existing services would only increase in the coming years.9

At a more fundamental level, however, concern about the organisation of mental health services reflected what might be termed as a ‘crisis of legitimacy’ among psychiatrists at the end of empire. Under colonial rule, psychiatry had in many territories been limited to a single mental hospital and a specialist European medical officer who may or may not have had training in psychiatric or psychological medicine. It was underfunded by colonial governments, of low status within the colonial medical hierarchy, and had little to offer its patients therapeutically. As many psychiatrists in developing countries were well aware, psychiatry still lingered on the edge of a much broader therapeutic landscape. While transcultural psychiatry, pursued by many newly trained indigenous-born psychiatrists, had from the 1950s offered renewed hope of a more culturally sensitive and patient-centred approach to psychiatry, there were few easy answers as to how psychiatrists might bridge what was a huge social and cultural gulf between psychiatry and its patients. During the period of decolonisation, then, psychiatrists in developing countries had to contend not only with an ongoing lack of resources and specialist personnel, but with their lack of social, cultural and professional legitimacy. Expressing his frustration at the problems facing psychiatry, particularly in Africa, Ayo Binitie, of the Nervous Diseases Clinic, Benin City, Nigeria, noted in 1974 that one of the most important difficulties facing mental health care planners was the ‘communication gap’—‘between the public and the psychiatrist, between the psychiatrist and the health administrator, and between psychiatrists and governments. In some countries there are no psychiatrists so that there is not even the beginning of dialogue’.10

It was against this backdrop of discussion and debate among psychiatrists that the WHO sought to provide strategic direction in the 1970s, notably through an inter-regional seminar on the organisation of mental health services in Addis Ababa, Ethiopia, in late 1973, and an Expert Committee on the Organisation of Mental Health Care Services in Developing Countries in Geneva in October 1974.11 While the papers presented at these meetings highlighted the wide variety of new approaches and methods being tried by psychiatrists in developing countries, the final Report of the Expert Committee, published in 1975, presented a coherent agenda for future mental health policy and research. Stressing that low levels of specialist personnel and funding required innovative approaches to mental health care in developing countries, the Report advocated that responsibility for mental health be shared between psychiatrists, general health workers and a range of community agencies. Psychiatrists would need to be trained in teaching and supervising, and then supported to implement new programmes, taking into account the needs and resources of their individual countries. This strategy of integrating mental health into primary (general) health care would go on to form the basis of WHO policy on mental health, itself in alignment with the focus on primary health care and development at the lowest possible cost that would soon be established at the Alma-Ata Conference in 1978.

This book locates Uganda and Uganda’s psychiatrists within this reimagining of psychiatry and mental health care at the end of empire. I examine the challenges facing a new generation of psychiatrists as they took over responsibility for psychiatry, and explore the ways psychiatric practices were oriented towards and responded to shifting political and economic contingencies, periods of instability and tension, and a broader context of transnational and international exchange. I argue that the distinctiveness of psychiatry in the early postcolonial era is that of a culture of experimentation and creativity, something that was, fundamentally, a response to a new contextually sensitive politics. In Uganda, while the institutions of psychiatry remained largely unchanged during the decades of decolonisation, psychiatrists aimed to refigure the relationship between psychiatry and the mentally ill in light of the needs and priorities of development and nation building, as well as an awareness of the professional, economic and cultural constraints on psychiatric practice. Their activities represented an attempt to extend the reach of psychiatry in novel ways at a time when colonial institutions needed to demonstrate their relevance, and when globally, the authority of psychiatry was increasingly coming under attack, not least through deinstitutionalisation. Yet while the approaches trialled in Uganda contributed to the development of international policy on the organisation of mental health services in developing countries, there remained a large gap between intentions and practices within Uganda. Psychiatric practices were contested and negotiated, and the power of psychiatry limited, not least by patients themselves. Through an in-depth historical study of Uganda, I contend that the reorientation of psychiatry during the decades of decolonisation was no straightforward process. Nor was it one that was entirely successful.

Psychiatry and Decolonisation in Africa

The period of decolonisation saw the human sciences being mobilised for empire on an unprecedented scale. The establishment of the Colonial Social Science Research Council (CSSRC) in 1944, following the 1940 Colonial Welfare and Development Act, channelled the first significant amounts of funding for the social sciences into Africa. This included the establishment of the East African Institute for Social Research (EAISR) at Makerere in 1948, under the guidance of Audrey Richards, and which was host to research on patterns of social change, the effects of urbanisation, attitudes to Europeans, ‘traditional’ law, land tenure systems and acculturation (or culture contact).12 Psychological concepts and expertise were also at the heart of psychological warfare, or the battle for ‘Hearts and Minds’, in counter-insurgency operations in Malaya, Cyprus, Kenya, Algeria and Southern Rhodesia.13 Psychiatrist and philosopher Frantz Fanon spoke of the effects of physical and psychological violence on suspected nationalist sympathisers in Algeria’s ‘brainwashing centers’, while psychiatrist J. C. Carothers was commissioned by the Kenya Government to study the causes and nature of the Mau Mau rebellion (1952–1960).14 Carothers framed Mau Mau as a pathology stemming from the inability of Africans to cope with ‘the transition between the old ways and the new’.15 While he noted the importance of economic and historical grievances, ‘both real and imagined’, Mau Mau was the inevitable result of ‘an anxious conflictual situation in people who, from contact with the alien culture, had lost the supportive and constraining influences of their own culture, yet had not lost their “magic” modes of thinking’.16 Mau Mau oaths, existing ‘in all the depravity that is imaginable’, therefore had a profound psychological effect on initiates, and required all the tactics of the government’s ‘Screening Teams’ to break their hold.17

The application of psychological and psychiatric knowledge to the problems of empire was not new. Since the early twentieth century, ethnopsychiatry, a field of study concerned with the psychology and behaviour of non-Western peoples, had developed a powerful language through which to understand the native psyche and to usefully articulate the problems facing colonial administrators.18 While ethnopsychiatry had its intellectual roots in the comparative psychiatry of Emil Kraepelin and the writings on primitive mentalities by Sigmund Freud, it largely comprised a loose group of individuals with varying levels of medical training, including the esteemed psychiatrist Antoine Porot, as well as Wulf Sachs, J. B. F. Laubscher, Carothers, and the teacher and self-taught psychoanalyst J. F. Ritchie.19 Between the 1920s and the 1950s, when ethnopsychiatry in colonial Africa was at its height, much of their writing revolved around the problems of acculturation, or culture contact, a facet which bound the field to anthropology, and presupposed that psychiatric knowledge could be applied to political issues. Within the ‘East African School of Psychiatry and Psychology’, as it became known, H. L. Gordon, Visiting Physician to Mathari Mental Hospital, Kenya, 1930–1937, stressed how his experience at Mathari had shown him that mental illness in Africans was primarily organic in origin, and that the peculiarities of African psychopathology could be explained by fundamental differences between Africans and Europeans in brain size and growth. Carothers, who followed Gordon at Mathari, emphasised the importance of cultural, as opposed to biological difference (though he by no means saw these as discrete categories). He argued that a number of mental disorders frequently seen in Europe, such as depression and the neuroses, were completely absent in East Africa.20 More overt forms of ‘mental derangement’, by contrast, were increasingly common, as ‘detribalisation’—something that encompassed such diverse aspects as ‘Christianization, secular education, working relationships with non-African employers, relationships with Government officials and with shop-keepers (the latter mostly Indian), life in townships, and the introduction of syphilis and alcoholic spirits and other drugs’—took hold.21 The failure of African cultures to incorporate the traits of individual control, abstract thought and personal responsibility, it was theorised, meant that ‘westernisation’ and ‘detribalisation’ were particularly dangerous for Africans and required the immediate extension of ‘social protection and control’.22

Acknowledging the ways in which anthropologists, psychologists and psychiatrists informed colonial policies, or provided theories that were attractive to colonial officials and settlers, is not to state that the human sciences were unproblematic tools of empire.23 Many of these ‘experts’ negotiated multiple and often ambiguous roles within colonial structures and institutions, and their professional and intellectual ambitions frequently bore little resemblance to their daily practice. This was particularly the case within psychiatry, where theories about acculturation and detribalisation were rarely reflected in diagnostic categories or treatment regimes. Ethnopsychiatric theories tended to focus on the collective, rather than the individual; they were warnings that African societies were, as a whole, becoming psychologically unstable. It is noteworthy that only a small number of those under the grip of Mau Mau’s collective ‘madness’, for example, were regarded as clinically insane. While individuals who challenged colonial rule could face charges of mental illness, particularly if they exhibited violent behaviour, in most cases, psychiatry was simply not an effective tool of social or political control. Firstly, the processes of confinement were laborious, involving examination by two registered medical practitioners who had to agree on a diagnosis, which then had to be accepted by a magistrate. Secondly, suggestions of mental illness conflicted with desires to see ‘troublemakers’ prosecuted under law and set as an example to others.24

What an examination of psychiatry at the end of empire forces us to confront is that colonial psychiatry, more generally, was not a unified force. Colonial governments and military leaders may have been enthralled by the possibilities offered by psychological knowledge, but the methodologies, aims and assumptions of researchers varied considerably. Even as Carothers’ WHO-sponsored monograph, The African Mind in Health and Disease, hit the shelves in 1952, the racial and cultural determinism it espoused was already under dispute. Criticisms came from a range of disciplines. It involved Americans, Europeans and a new generation of indigenous-born and Western-trained psychiatrists.25 Nigerian psychiatrist Thomas Adeoye Lambo described the work of a number of ethnopsychiatrists, including Carothers, as being: ‘At their worst…glorified pseudo scientific novels or anecdotes with a subtle racial bias; at their best…abridged encyclopedias of misleading information and ingenious systems of working hypotheses, useful for the guidance of research, but containing so many obvious gaps and inconsistencies, giving rise to so many unanswerable questions, that they can no longer be seriously presented as valid observations of scientific merit’.26 G. I. Tewfik, moreover, Specialist Alienist at Mulago Mental Hospital, Uganda, likened such psychiatric literature to racial prejudice towards Jews in Europe, stressing that ‘Criticisms of one race by another have been shown to be nearly always fallacious. Man is a very poor judge of his fellows’.27

In the context of decolonisation, research that questioned the assumptions of ethnopsychiatry about racial and cultural difference—whether implicitly or explicitly—represented a strand of a broader project in which psychiatrists were making professional and political claims to equality. As Matthew Heaton has convincingly argued, Nigerian psychiatrists were acutely aware of the political significance of their research, contributing to the deracialisation of psychiatric theories not just in Africa, but globally, through participation in major international collaborative research projects and conferences.28 Lambo’s central role in the Cornell-Aro Mental Health Research Project, for example, not only led to a methodology for effective cross-cultural comparison of major psychiatric disorders (in this case between the Yoruba and Canadian communities), but also helped to undermine assumptions about the relationship between race, culture and mental illness.29 Similar claims can be made for psychiatrists elsewhere in Africa, including Uganda, where psychiatrists were also involved in developing new methodologies, including clinical interviews, field surveys, hospital and government records, and psychological questionnaires. In doing so, psychiatrists in Africa actively shaped the nascent fields of transcultural psychiatry and psychiatric epidemiology, and embarked on a process of decolonising some of the more insidious aspects of colonial psychiatry. Yet psychiatric theories represented only one legacy of colonial rule. The decolonisation of psychiatry needed to include psychiatric practices and a reconfiguration of the dynamics of power, too. Here, change was much more uneven.

While histories of colonial psychiatry have provided us with a picture of psychiatric practices and discourses that are remarkably consistent across geographical contexts, there is no one history of psychiatry and decolonisation.30 ‘Africanisation’, a political process consisting of policies aimed at increasing the number of Africans in the colonial administration through training and promotion, was patchy at best within psychiatry. By the late 1960s, Uganda, Nigeria and Senegal represented the few countries in Africa (excluding South Africa) with formal programmes for the training of psychiatrists and psychiatric nurses, and consequently could boast of considerably more African psychiatrists within psychiatric institutions. Psychiatrists in newly independent countries also often had very different ideas about how psychiatry might best be developed. In a statement on Senegal, but which could apply to Africa more generally, Alice Bullard has noted that with independence, ‘Colonial psychiatry transformed into a diverse range of practices, ranging from collaborations with traditional healing to biomedical, pharmaceutical-based psychiatry’.31 Such innovations included the introduction of the accompagnant at the Fann Psychiatric Clinic, Dakar, in 1972, comprising a family member or close friend who stayed with a patient during their hospitalisation, and which claimed ‘its genesis in “traditional” African ways of life’.32 In Nigeria, moreover, Heaton has shown that the political context of decolonisation allowed psychiatrists not only to argue for the deracialisation of psychiatric theories, but also to experiment with community-based psychiatry and collaborations with traditional healers. The most famous of these new schemes was Lambo’s Aro Village project, founded in 1954, and consisting of a day hospital attached to four villages. Patients, who were accompanied by at least one relative, were boarded out in the villages where, in addition to the physical therapies received at the hospital, they could be employed on nearby farms and participate in daily village life.33 Such experiments were exceptional, however; they were often expensive and made many psychiatrists—expatriate and African alike—uneasy about the implications for the status of psychiatry as a ‘modern’ science.34 Most newly independent governments, moreover, were scarcely more interested in investing in or experimenting with mental health care than their predecessors. This was most visible in the institutions themselves, as Richard Keller has commented for the Maghreb, where well into the postcolonial era they ‘represented the only real resource for managing mental illness’.35

Shifting historiographical periodisation away from the artificial divide of colonial/postcolonial to decolonisation, which for a history of psychiatry should span the first moves towards Africanisation following the Second World War, to the political crises of many African states during the 1970s and 1980s, allows for deep analysis of continuities and divergences in psychiatric practices, not only in relation to colonial rule, but also between countries in Africa. As I show in this book, the capacity of psychiatrists to reform psychiatric practices, to contribute to international debates and to provide care for patients was tied to the changing social, political and economic contexts in which they worked. Some of the continuities, such as the ongoing concentration of resources and personnel in a single mental hospital, need to be seen as necessities, as psychiatrists struggled to convince newly independent governments to commit the vast sums required to reorganise mental health services. Many of the divergences, meanwhile, can be usefully framed as responses and contributions to the evolving needs and priorities of development, nation building, modernisation and manpower, as well as the ability to access funding and to travel. Yet all, ultimately, need to be linked to shifting periods of political stability, upheaval and crisis, which challenged the ability of psychiatry to successfully decolonise.

Psychiatry as a Transnational and Global Phenomenon

Since the mid-twentieth century, psychiatry has constituted an increasingly transnational and global body of knowledge and practices, which no history of psychiatry and decolonisation can ignore. This transnationalism was not in itself new to psychiatry. The development of psychiatry in colonial settings, as historians of psychiatry and empire have demonstrated, was not simply the result of a uni-directional flow of ideas from the metropole, but involved psychiatrists, particularly in South Asia, engaging in discussions about concepts and approaches both within and beyond empire.36 In Europe and the USA during the 1920s, moreover, the rise of international health organisations and a broader spirit of collaboration saw discussion of mental health move beyond predominantly national confines to address comparative approaches to institutional care, law, social welfare and training.37 The International Committee on Mental Hygiene (ICMH) was founded in 1919 to advocate for mental hospital reform and to encourage mental health in ‘normal’ populations, with numerous national branches. The ICMH’s 1930 International Congress, held in Washington DC, brought together over 3000 participants from twenty-two countries, predominantly European in origin, but including the USSR, India, Japan, Siam, Venezuela and the Union of South Africa.38 It was not until after the Second World War, however, that patterns of transnational communication and exchange changed significantly in a process that was inextricably linked with a project of modernity and what Marijke Gijswijt-Hofstra and Harry Oosterhuis have called ‘a more general process of psychologisation - a change of mentality combining growing individualisation, internationalisation, and self-guidance, related to changing social manners and relationships’.39 It is from the mid-twentieth century that ideas and practices within psychiatry started to be increasingly similar in different geographical and cultural contexts. This move towards universalism was cemented by the development of universal diagnostic criteria, as exemplified in the WHO’s International Classification of Diseases 9 (ICD-9) in 1975, as well as the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders III (DSM-III) in 1980, yet is one that has belied a single explanation. Historiographically, it has been tied to the rise and power of international health organisations, the pursuit of progress and modernity within psychiatry, and the need of psychiatry to reform and unify in the face of various crises since the 1950s.40 This book adds an additional perspective—that of shared challenges facing psychiatrists in developing countries, which stimulated debate on new ways to organise mental health services, and which directly fed into the development of WHO policy.

Two international health organisations occupied central positions within the increasingly transnational and international field of psychiatry and mental health: the WHO and the WFMH. The WHO was established in 1948 as a specialised agency of the United Nations (UN) and whose mission, according to Javed Siddiqi, was infused with notions of spillover theory, in which international cooperation in public health might ‘spillover’ into the political arena by promoting peace and security around the world.41 The creation of the WHO’s Mental Health Unit shortly after the founding of the WHO reflected this broader aim, coinciding with optimism within policy circles about the ability of psychiatric and psychological expertise to assist in post-war reconstruction and rehabilitation efforts.42 Notions of a broader purpose were also present in the aims of the WFMH, founded in 1948 under the leadership of John Rawlings Rees, a British military psychiatrist, with the assistance of George Brock Chisholm, a Canadian psychiatrist and first Director-General of the WHO. In its founding document, ‘Mental Health and World Citizenship’, the WFMH declared that ‘the ultimate goal of mental health is to help [people] live with their fellows in one world’.43 It understood ‘world citizenship’ as a form of ‘common humanity’ in which individual and cultural differences needed to be respected. Both the WFMH and the WHO foregrounded the importance of mental health in broader public health efforts, taking as their goal the need to understand the psychosocial as well as biological causes of mental disorder, a field of study that would become known as ‘social psychiatry’.44

The WHO and the WFMH spurred an international mental health field by facilitating the formation of a series of loose networks of psychiatrists and related professionals who exchanged research and practical experiences via international meetings and conferences. The WHO’s Expert Committee on Mental Health met on a yearly basis to discuss such themes as the training of psychiatrists, psychosomatic disorders and the role of general practitioners in mental health care, as well as to suggest recommendations for member states.45 Psychiatrists from around the world were also in attendance at the International Congresses of the WFMH and the World Congresses of the World Psychiatric Association (WPA), founded in 1961, and which included a Transcultural Psychiatry Section. Yet manpower, along with political and economic dynamics within newly formed nation states, often restricted the ability of psychiatrists from developing countries to take part in the internationalism that increasingly characterised psychiatry during the decades of decolonisation. For those in developing countries, participation in international mental health more commonly took the form of what Sunil Amrith has called the ‘administrative pilgrimages’ or ‘journeys by a coterie of experts’ that saw regional and inter-country exchanges.46 The WHO and the WFMH were important actors here, not only as a source of financial support, but because they were free from political links with former colonial powers, making their input politically acceptable.47 Yet, as Nitsan Chorev has made clear, the WHO, far from being a neutral actor, was itself an agent of international health, with officials at the WHO Secretariat, Geneva, actively seeking to shape policy.48 Nor was internationalism free from regional interests or international politics. Political and economic connections between Kenya, Tanganyika and Uganda, forged under British colonial rule and cemented with the East African Community in 1967, were reflected in ongoing close links between psychiatrists in East Africa. Former British and French colonies also found that language difficulties restricted interactions within networks of psychiatry, despite the Association of Psychiatrists in Africa, founded in 1969, making a concerted effort to involve both English- and French-speaking nations. Psychiatrists also deliberately avoided holding meetings in apartheid South Africa, and were to be found travelling to non-aligned India and the USSR, but not to countries geopolitically situated in the US sphere of influence, such as South America.

The power of international health organisations in the latter half of the twentieth century has been their ability to structure and mobilise knowledge: to classify and organise information, to fix meanings by establishing parameters of action and to diffuse universal norms and standards.49 Within the WHO, the first Chief of the Mental Health Unit, Ronald Hargreaves, envisaged large-scale cross-cultural research projects, with the ultimate aim of understanding the global landscape of mental disorders.50 Hargreaves and his successors pursued this through the development of rigorous methodology for large epidemiological surveys, drawing on research already being undertaken by psychiatrists in Scandinavia as well as other European and American contexts. The result was the launch of the WHO’s International Pilot Study of Schizophrenia in 1966, which tested the cultural applicability of translated versions of a diagnostic tool for schizophrenia, the Present State Examination, across nine research centres in different countries.51 The study, which published its first results in 1973, concluded that while symptoms, or the ‘cultural colouring’ of schizophrenia, might vary in different cultural settings, it was possible to develop criteria for its diagnosis cross-culturally.52 Such findings were central to the development of a universal diagnostic system for psychiatric illnesses, as established in ICD-9. This trend towards universalism within the WHO was not limited to diagnostic categories, however. From the 1970s, the WHO also sought to develop a methodology for collecting information on and assessing the effectiveness of mental health services around the world. Following the 1974 Expert Committee on the Organisation of Mental Health Services in Developing Countries, the Collaborative Study on Strategies for Extending Mental Health Care aimed to assess different techniques for community-based mental health care, with the aim of both refining its own guidelines on the organisation of mental health care and providing evidence through which they could convince member states to integrate mental health into national health care plans.53 Such attempts at collecting standardised data were largely unsuccessful, however. Instead, the WHO continued to base policy on the collective knowledge and shared experiences of psychiatrists engaged in the reorganisation of mental health care in their own countries. This approach confirms for Africa, and indeed developing countries more generally, what Steve Sturdy, Richard Freeman and Jennifer Smith-Merry have shown for Europe—that the role of the WHO in setting policy on mental health services has been one of creating opportunities for the emergence of an ‘epistemic community’, in which ‘context-sensitive knowledge’ rather than ‘standardised forms of data’ has been key.54

Participation in the epistemic communities making up the field of international mental health has represented a key expression of modernity, not least for the psychiatrists who have been able to make claims to international, if not global citizenship. The pursuit of progress and modernity has pervaded psychiatry throughout the twentieth century, in developing countries as much as in Europe and the USA.55 And it has taken multiple forms—it has involved psychiatrists keeping up to date with research published in international journals, the deliberate use of English as a dominant language of communication, the formation of new research collaborations and the adoption of the latest treatments and technologies—forms that have not been without their own politics.56 In developing countries, the pursuit of modernity among psychiatrists was inextricably linked to the politics of decolonisation and development. In Nigeria, as Matthew Heaton has made clear, many psychiatrists were closely engaged in a project of modernity, yet they ‘did not simply buy into the idea that Western ideas could be universally applied to bring about the development of the emerging Third World’. Instead, they sought to adapt and rework psychiatric ideas and practices so they could be regarded as both universal and culturally specific.57 In Argentina, moreover, according to Andrew Lakoff, psychiatrists felt an intense pressure to pursue a global professional identity, yet found themselves fiercely opposed to the biological model of mental illness espoused by the DSM, itself in conflict with their own psychoanalytic model and ‘unresolved project of social modernity’.58 The pursuit of ‘modernity’ was certainly not synonymous with ‘westernisation’. Nor did it mean that psychiatric theories and practices were adopted without contestation or adaptation. Rather, it provoked tensions between ‘modernity’ and ‘westernisation’ that psychiatrists in developing countries struggled to resolve.

It is no coincidence that the trend towards universalism within psychiatry globally occurred at a time when psychiatry faced a series of challenges to its own authority over mental illness. In Europe and the USA, psychiatry’s hegemony over mental illness was increasingly challenged from the 1950s by deinstitutionalisation, attempts to extend patients’ legal rights, the expansion of new counselling and psychotherapy services, and the intellectual critiques of the antipsychiatry movement.59 In the USA, the crisis facing psychiatry created the conditions in which psychiatry moved from an environmental and behavioural model of mental illness to that of the biological, symptom-based classificatory scheme represented by DSM-III. This ‘revolution’ in psychiatry, according to Rick Mayes and Allan V. Horwitz, was couched in the language of ‘objectivity, truth, and reason’.60 It allowed psychiatrists to measure mental illness in a ‘scientific’ manner, helping to ‘silence the critics of the previous system, who claimed that mental illnesses could not be defined in any objective way’, and thus provided legitimacy to a profession under attack.61 There was no comparable antipsychiatry movement in developing countries. Yet, as I argue in this book, psychiatrists in Uganda, and indeed more generally in Africa, were acutely aware of their lack of social, cultural and professional legitimacy. While most were only one of a handful of psychiatric professionals working within their own countries, these shared challenges proved a unifying force. They not only spurred experimentation in local settings, but stimulated debate on mental health services at transnational and international levels. Running through these discussions were questions about the role psychiatrists in developing countries should have, not only in relation to their patients, but to other health workers, legal professionals, and community agencies. In Uganda, as I show in this book, efforts to mobilise other professionals in support of psychiatry constituted an attempt to extend the reach of psychiatry at a time when psychiatry was facing increasing constraints on its power. While attempts to refigure the place of psychiatry within other institutions and services were not entirely successful within Uganda, the experiences of psychiatrists nevertheless proved influential in wider discussions on mental health services in developing countries, representing one of the first attempts to articulate mental health in primary care.

Recognising psychiatry as a transnational and global phenomenon is to acknowledge that late colonial and postcolonial histories of psychiatry cannot be told as isolated national stories, and certainly not through the lens of colony (or former colony) and metropole. Yet we must be careful not to erase or overlook the social, cultural and professional contexts in which psychiatrists worked. Indeed, these have been central not only in shaping the priorities and aims of psychiatrists, but in determining the ability to travel and participate in debates. As the Uganda case makes clear, despite a period of intense activity in the late 1960s and early 1970s, in the longer term, psychiatrists in Africa faced barriers to participation that resulted in disproportionately few contributions to research and policy both within their own countries and at transnational and international levels. These imbalances of power were reinforced in many contexts in the 1980s and 1990s by structural adjustment policies, which undermined national health care systems, civil wars and internal conflict, and the emergence of an international humanitarian aid industry that increasingly turned its attention to the mental health and psychological consequences of war and violence. Humanitarian psychiatry, and new techniques of psychological counselling that developed alongside it, not only universalised a particular type of suffering body, but privileged westernised notions of distress and trauma.62 Since the 1990s, moreover, the global mental health movement, which aims ‘to improve services for people living with mental health problems and psychosocial disabilities worldwide, especially in low- and middle-income countries where effective services are often scarce’, has become a dominant force in the global psychiatric landscape. It has been challenged as ‘colonial medicine come full circle, a modern-day version of Kipling’s ‘White Man’s Burden’, full of good intentions, but also a form of anthropologically uninformed cultural imperialism’.63 What this book aims to do is to provide a historical investigation into the conditions in which these developments have been deemed possible, even necessary.

Psychiatry in Uganda

Uganda may at first seem an unusual choice for a history of psychiatry and decolonisation. Next to Kenya, home to the infamous East African School of Psychiatry and Psychology, there was little to distinguish psychiatry in Uganda under colonial rule. Like most other countries in Africa, Uganda had for most of the colonial period only one mental hospital: Hoima, Mulago and then Butabika. Reflecting the low priority accorded to psychiatry, provision for the mentally ill also came long after the formal establishment of Uganda as a British Protectorate in 1894. Hoima Prison, in western Uganda, was officially designated as a Lunatic Asylum only in 1921, with minimal attempt made to offer patients anything more than custodial care. This was followed in 1935 by a new, purpose-built mental hospital on a site near Mulago Hospital, Kampala, in central Uganda, which promised to treat mental illness by psychiatric means for the first time. By the late 1940s, overcrowding had reached such an extent that plans were made to build a new mental hospital at Butabika, seven miles outside of Kampala. The first patients were transferred to Butabika Hospital in 1955, and in 1964, Mulago Mental Hospital was closed for good. It was only at Independence in 1962 that the first attempts were made at outpatient and non-custodial care: first through a mental health clinic at Mulago Hospital and then in 1964 through the designation of ‘Ward 16’ for the treatment of a small selection of mental patients.64 In the organisation and day-to-day running of these mental hospitals, there was also little that made Uganda unique. The general underdevelopment and neglect, poor sanitary conditions, overcrowding, the importation of psychiatric practices from Europe (including the English nineteenth-century ‘moral management’ regime), the copying of lunacy legislation from other colonies, and the reproduction of colonial hierarchies of race, gender and class in the organisation and management of inmates are all common themes in the history of psychiatry and empire. So too is the fragile hold of psychiatry by the end of colonial rule, with psychiatry remaining, perhaps more than any other medical discipline introduced under colonialism, on the periphery of a much broader therapeutic landscape.

Psychiatry in colonial Uganda was neglected and underdeveloped as a field. Nevertheless, during the years of decolonisation, psychiatrists and other medical practitioners saw themselves as uniquely placed to address questions about the future of psychiatry in Africa. This stemmed not from an existing tradition of psychiatric research and practice, but from the commitment to training and research at Makerere Medical School, first opened at Mulago Hospital in 1923.65 When the school was opened, there was only one other medical school for Africans on the continent (in Dakar, Senegal), and the training of Africans in medicine quickly became one of the defining features of Uganda’s Colonial Medical Service. While European medical officers did not always regard their African colleagues as equals, they nevertheless believed that their training programmes set Uganda apart as more liberal than other colonies, and in particular from Kenya.66 During the 1940s and 1950s, when medical practitioners from across Eastern and Southern Africa raised concerns about the ability of Europeans to understand their African patients, it was Makerere that responded. By the late 1960s, Uganda was one of the few countries in Africa that could train psychiatrists and psychiatric nurses in country, foregoing the need to send them overseas. Following the opening of a Department of Psychiatry in 1966, moreover, a new group of Ugandan and expatriate psychiatrists established Africa’s first mental health association, the NAMH, introduced programmes for training and delegating responsibility to a range of health care workers, and developed psychiatric training and research to a point where it could no longer be ignored by health and legal professionals. Uganda gained a reputation both within Africa and the WHO as a place of innovation and reform. ‘Mental health services in Uganda’, as the WHO African Mental Health Action Group acknowledged in 1987, were ‘once the best in the region’.67

The drive to reorganise mental health services stemmed from the challenges facing psychiatrists, particularly in reaching their patients. This theme of distance between psychiatry and those it seeks to help runs through the book. The idea that Africans had natural cultural insight into mental illness, which could be harnessed for clinical practice and research, fed into the first calls for the training of Ugandans in psychiatry. Initial optimism had faded by the 1960s, however, as it became clear that people were scarcely more likely to turn to psychiatry when facing mental illness. The newly independent Uganda Government, moreover, proved little more interested in listening to the ideas of Ugandan psychiatrists than had their colonial predecessors. Following the opening of the Department of Psychiatry, the need to extend the reach of psychiatry both within and beyond the walls of the mental hospital became central to justifying new experiments and training programmes. In the contexts of development and nation building, these efforts to reform mental health services were framed as the ‘psychiatry of poverty’, in which the limited ability of governments to invest in psychiatric services and manpower not only distinguished psychiatry in Africa from that in Western contexts but required new ways of thinking about the use of non-specialists in mental health care. Uganda was not unique in facing these challenges—discussions about how best to organise mental health care, and the implications this might have for psychiatrists, would dominate the agendas of regional and international conferences over the next decade. This collective experience would play a key role in bringing psychiatrists together on a regional basis, as well as coming to shape the direction of international mental health policy. Notably, the experiences of psychiatrists in experimenting with mental health care within their own countries, particularly through training and delegation, would provide the basis for the WHO’s policy on mental health in primary care. Yet the innovations in psychiatry during the late 1960s and early 1970s had minimal impact on the reach of psychiatry in Uganda. The power of psychiatry was repeatedly challenged, not only through the practical difficulties of effecting change with few resources and personnel, but by patients, who continued to assert their agency as they navigated psychiatric services in which they were given no official say. Yet the limits on psychiatry were most prominently brought to the fore in the 1970s and 1980s, when Uganda faced political and economic insecurity, firstly under the rule of Idi Amin, who took power following a coup in January 1971, and then in the violence of the successive regimes that followed.68 Psychiatry was not only brought to the brink of collapse, but it was not regarded as an appropriate agent to deal with distress associated with conflict or violence. Since the 1980s, the limited role of psychiatry has only been exacerbated by the influx of humanitarian and non-governmental organisations concerned with trauma and Post-Traumatic Stress Disorder, and the ongoing marginalisation of the mentally ill within health and social welfare systems. Psychiatry might have ‘Africanised’, but it has by no means decolonised.

Notes

  1. 1.

    Mental Health Services in the Developing World: Reports on Workshops on Mental Health, Edinburgh (1968) and Kampala (1969), Commonwealth Foundation Occasional Paper IV (Hove, 1969); World Health Organization Archives (WHOA) NIE-HMD-002 Jkt 1 (Medical School, University of Ibadan); A. Boroffka, ‘The Delivery of Mental Health Care’, n.d.

  2. 2.

    Mental Health Services in the Developing World, pp. 38–41.

  3. 3.

    Ibid., p. 33.

  4. 4.

    Ibid.

  5. 5.

    G. M. Carstairs, ‘Psychiatric Problems of Developing Countries’, The British Journal of Psychiatry 123(574) (1973), pp. 271–277; Organizacion Panamericana de la Salud, Grupo de Trabajo Sobre La Administración de Servicios Psiquiátricos y de Salud Mental, Vina Del Mar, Chile, 14–19 de Abril de 1969 (Washington, DC, 1970).

  6. 6.

    The Work of WHO 1970: Annual Report of the Director-General to the World Health Assembly and to the United Nations (Geneva, 1971), pp. 81, 269.

  7. 7.

    World Health Organization Library (WHOL) SEA/Ment./19 Annex 7, ‘Recommendations of the International Workshop on Priorities in Mental Health Care (held in Madurai, from 21 to 22 January 1971, under the auspices of the World Federation for Mental Health)’, n.d.

  8. 8.

    The history and implications of this research are addressed in Chapters 5 and 6 of this book, as well as: J. Bains, ‘Race, Culture and Psychiatry: A History of Transcultural Psychiatry’, History of Psychiatry 16 (2005), pp. 139–154; M. M. Heaton, Black Skin, White Coats: Nigerian Psychiatrists, Decolonization, and the Globalization of Psychiatry (Ohio, 2013).

  9. 9.

    J. S. Neki, ‘Psychiatry in South-East Asia’, The British Journal of Psychiatry 123(574) (1973), pp. 257–269; C. A. Leon, ‘Psychiatry in Latin America’, The British Journal of Psychiatry 121(561) (1972), pp. 121–136; and G. A. German, ‘Aspects of Clinical Psychiatry in Sub-Saharan Africa’, The British Journal of Psychiatry 121(564) (1972), pp. 461–479.

  10. 10.

    World Health Organization Library (WHOL) OMH/EC/74.7, A. Binitie, ‘Mental Health Services in Developing Countries with Special Reference to Africa’, Paper Presented to the Expert Committee on Organization of Mental Health Services in Developing Countries, Geneva, 22–28 October 1974, p. 3.

  11. 11.

    T. A. Baasher et al., eds., ‘Mental Health Services in Developing Countries’, Papers Presented at a WHO Seminar on the Organization of Mental Health Services, Addis Ababa, 27 November to 4 December 1973 (Geneva, 1975); World Health Organization, Organization of Mental Health Services in Developing Countries, Sixteenth Report of the WHO Expert Committee on Mental Health (Geneva, 1975).

  12. 12.

    D. Mills, ‘British Anthropology at the End of Empire: The Rise and Fall of the Colonial Social Science Research Council, 1944–1962’, Revue d’Histoire des Sciences Humaines 6(1) (2002), pp. 161–188.

  13. 13.

    E. Lindstrum, Ruling Minds: Psychology in the British Empire (Cambridge, MA, 2016), Ch. 5.

  14. 14.

    F. Fanon, The Wretched of the Earth, trans. R. Philcox (New York, 1963), pp. 213–216.

  15. 15.

    J. C. Carothers, The Psychology of Mau Mau (Nairobi, 1955).

  16. 16.

    Ibid., p. 15.

  17. 17.

    Ibid., pp. 15–16.

  18. 18.

    S. Mahone, ‘East African Psychiatry and the Practical Problems of Empire’, in S. Mahone and M. Vaughan, eds., Psychiatry and Empire (Basingstoke, 2007); J. McCulloch, Colonial Psychiatry and ‘The African Mind’ (Cambridge, 1995).

  19. 19.

    W. G. Jilek, ‘Emil Kraepelin and Comparative Sociocultural Psychiatry’, European Archives of Psychiatry and Clinical Neuroscience 245(4–5) (1995), pp. 231–238; J. McCulloch, Black Peril, White Virtue: Sexual Crime in Southern Rhodesia, 1902–1935 (Bloomington, IN, 2000); and H. Pols, ‘Psychological Knowledge in a Colonial Context: Theories on the Nature of the “Native Mind” in the Former Dutch East Indies’, History of Psychology 10(2) (2007), pp. 111–131.

  20. 20.

    On the East African School, see especially: G. C. Beuschel, ‘Shutting Africans Away: Lunacy, Race and Social Order in Colonial Kenya, 1910–1963’ (Unpublished PhD thesis, University of London, 2001); S. Mahone, ‘The Psychology of the Tropics: Conceptions of Tropical Danger and Lunacy in British East Africa’ (Unpublished DPhil thesis, University of Oxford, 2004); and McCulloch, Colonial Psychiatry.

  21. 21.

    J. C. Carothers, ‘A Study of Mental Derangement in Africans, and an Attempt to Explain Its Peculiarities, More Especially in Relation to the African Attitude to Life’, East African Medical Journal 25(5) (1948), pp. 153–154.

  22. 22.

    J. C. Carothers, ‘A Study of Mental Derangement in Africans, and an Attempt to Explain Its Peculiarities, More Especially in Relation to the African Attitude to Life’, East African Medical Journal 25(5) (1948), pp. 217–218; M. Vaughan, Curing Their Ills: Colonial Power and African Illness (Cambridge, 1991), Ch. 5.

  23. 23.

    This point is also made by Lindstrum in Ruling Minds.

  24. 24.

    S. Mahone, ‘The Psychology of Rebellion: Colonial Medical Responses to Dissent in British East Africa’, Journal of African History 47(2) (2006), pp. 241–258.

  25. 25.

    WHOA M4/445/13. See, for example, M. J. Herskovits, ‘The African Mind in Health and Disease: A Study in Ethnopsychiatry by J. C. Carothers’, Man 54 (1954), p. 30.

  26. 26.

    T. A. Lambo, ‘The Role of Cultural Factors in Paranoid Psychosis Among the Yoruba Tribe’, The British Journal of Psychiatry 101(423) (1955), p. 241.

  27. 27.

    G. I. Tewfik, ‘Mulago Hospital Clinical Staff Meeting April 26, 1958: The African Mind Fact or Myth?’ East African Medical Journal 35(8) (1958), p. 512.

  28. 28.

    Heaton, Black Skin, White Coats.

  29. 29.

    Ibid., Ch. 2.

  30. 30.

    The now substantial body of literature on colonial psychiatry includes: W. Ernst, Mad Tales from the Raj: Colonial Psychiatry in South Asia, 1800–58 (London, 2010); L. Jackson, Surfacing Up: Psychiatry and Social Order in Colonial Zimbabwe, 1908–1968 (Ithaca and London, 2005); R. C. Keller, Colonial Madness: Psychiatry in French North Africa (Chicago, 2007); J. Mills, Madness, Cannabis and Colonialism: The ‘Native Only’ Lunatic Asylums of British India, 1857 to 1900 (Basingstoke, 2000); J. Parle, States of Mind: Searching for Mental Health in Natal and Zululand, 1868–1918 (Scottsville, 2007); J. Sadowsky, Imperial Bedlam: Institutions of Madness in Colonial Southwest Nigeria (Berkeley and Los Angeles, 1999); M. Vaughan, ‘Idioms of Madness: Zomba Lunatic Asylum, Nyasaland, in the Colonial Period’, Journal of Southern African Studies 9(2) (1983), pp. 218–238; and S. Mahone and M. Vaughan, eds., Psychiatry and Empire (Basingstoke, 2007).

  31. 31.

    A. Bullard, ‘Imperial Networks and Postcolonial Independence: The Transition from Colonial to Transcultural Psychiatry’, in S. Mahone and M. Vaughan, eds., Psychiatry and Empire (Basingstoke, 2007), p. 197.

  32. 32.

    K. Kilroy-Marac, ‘Of Shifting Economies and Making Ends Meet: The Changing Role of the Accompagnant at the Fann Psychiatric Clinic in Dakar, Senegal’, Culture, Medicine and Psychiatry 38(3) (2014), pp. 427–447.

  33. 33.

    Heaton, Black Skin, White Coats, Chs. 2, 5.

  34. 34.

    Heaton has also made this point for Nigeria.

  35. 35.

    Keller, Colonial Madness, p. 196.

  36. 36.

    W. Ernst, Colonialism and Transnational Psychiatry: The Development of an Indian Mental Hospital in British India, c. 1925–1940 (London, 2013); W. Ernst and T. Mueller, eds., Transnational Psychiatries: Social and Cultural Histories of Psychiatry in Comparative Perspective c. 1800–2000 (Newcastle, 2010); and S. Kapila, ‘The “Godless” Freud and His Indian Friends: An Indian Agenda for Psychoanalysis’, in Mahone and Vaughan, eds., Psychiatry and Empire.

  37. 37.

    P. Weindling, ed., International Health Organisations and Movements, 1918–1939 (Cambridge, 1995).

  38. 38.

    M. Thomson, ‘Mental Hygiene as an International Movement’, in Weindling, ed., International Health Organisations and Movements, 1918–1939.

  39. 39.

    J. C. Burnham, ‘Transnational History of Medicine After 1950: Framing and Interrogation from Psychiatric Journals’, Medical History 55(1) (2011), pp. 3–26; M. Gijswijt-Hofstra and H. Oosterhuis, ‘Introduction: Comparing National Cultures of Psychiatry’, in M. Gijswijt-Hofstra et al., eds., Psychiatric Cultures Compared: Psychiatry and Mental Health Care in the Twentieth Century: Comparisons and Approaches (Amsterdam, 2005), p. 15.

  40. 40.

    M. Gijswijt-Hofstra et al., eds., Psychiatric Cultures Compared: Psychiatry and Mental Health Care in the Twentieth Century: Comparisons and Approaches (Amsterdam, 2005); Heaton, Black Skin, White Coats; N. Henckes, ‘Narratives of Change and Reform Processes: Global and Local Transactions in French Psychiatric Hospital Reform After the Second World War’, Social Science & Medicine 68(3) (2009), pp. 511–518; A. Lakoff, Pharmaceutical Reason: Knowledge and Value in Global Psychiatry (Cambridge, 2006); and R. Mayes and A. V. Horwitz, ‘DSM-III and the Revolution in the Classification of Mental Illness’, Journal of the History of the Behavioral Sciences 41(3) (2005), pp. 249–267.

  41. 41.

    J. Siddiqi, World Health and World Politics: The World Health Organization and the UN System (London, 1995).

  42. 42.

    On the early work of the WHO’s Mental Health Unit, see World Health Organization, WHO and Mental Health 1949–1961 (Geneva, 1962).

  43. 43.

    As cited in E. B. Brody, ‘The World Federation for Mental Health: Its Origins and Contemporary Relevance to WHO and WPA Policies’, World Psychiatry 3(1) (2004), pp. 54–55.

  44. 44.

    H. Y.-J. Wu, ‘World Citizenship and the Emergence of the Social Psychiatry Project of the World Health Organization, 1948–c. 1965’, History of Psychiatry 26(2) (2015), pp. 166–181.

  45. 45.

    See, for example, World Health Organization, Psychosomatic Disorders: Thirteenth Report of the Expert Committee on Mental Health (Geneva, 1964); World Health Organization, The Role of Public Health Officers and General Practitioners in Mental Health Care: Eleventh Report of the Expert Committee on Mental Health (Geneva, 1962); and World Health Organization, Training of Psychiatrists: Twelfth Report of the Expert Committee on Mental Health (Geneva, 1963).

  46. 46.

    S. S. Amrith, Decolonizing International Health: India and Southeast Asia, 1930–65 (Basingstoke, 2006), p. 14.

  47. 47.

    J. Pearson-Patel, ‘French Colonialism and the Battle Against the WHO Regional Office for Africa’, Hygiea Internationalis 13(1) (2016), pp. 65–80.

  48. 48.

    N. Chorev, The World Health Organization Between North and South (Ithaca, 2012).

  49. 49.

    M. N. Barnett and M. Finnemore, ‘The Politics, Power, and Pathologies of International Organizations’, International Organization 53(4) (1999), pp. 710–715.

  50. 50.

    H. Y.-J. Wu, ‘From Racialization to World Citizenship: The Transnationality of Taiwan and the Early Psychiatric Epidemiological Studies of the World Health Organization’, East Asian Science, Technology and Society 10(2) (2016), pp. 183–205; Wu, ‘World Citizenship’.

  51. 51.

    J. L. Cox, ‘Aspects of Transcultural Psychiatry’, The British Journal of Psychiatry 130(3) (1977), p. 218.

  52. 52.

    World Health Organization, Report of the International Pilot Study of Schizophrenia (Geneva, 1973).

  53. 53.

    World Health Organization, Mental Health Care in Developing Countries: A Critical Appraisal of Research Findings: Report of a WHO Study Group (Geneva, 1984); N. Sartorius and T. W. Harding, ‘The WHO Collaborative Study on Strategies for Extending Mental Health Care, I: The Genesis of the Study’, American Journal of Psychiatry 140 (1984), pp. 1470–1473.

  54. 54.

    S. Sturdy, R. Freeman, and J. Smith-Merry, ‘Making Knowledge for International Policy: WHO Europe and Mental Health Policy, 1970–2008’, Social History of Medicine 26(3) (2013), pp. 532–554.

  55. 55.

    See, for example, the chapters in: Gijswijt-Hofstra et al., eds., Psychiatric Cultures Compared.

  56. 56.

    Burnham, ‘Transnational History of Medicine After 1950’.

  57. 57.

    Heaton, Black Skin, White Coats, p. 5.

  58. 58.

    Lakoff, Pharmaceutical Reason, p. 44.

  59. 59.

    G. N. Grob, ‘The Attack of Psychiatric Legitimacy in the 1960s: Rhetoric and Reality’, Journal of the History of the Behavioral Sciences 47(4) (2011), pp. 398–416; D. V. Kritsotaki, V. Long, and M. Smith eds., Deinstitutionalisation and After: Post-War Psychiatry in the Western World (Basingstoke, 2016).

  60. 60.

    Mayes and Horwitz, ‘DSM-III and the Revolution’, p. 250.

  61. 61.

    Mayes and Horwitz, ‘DSM-III and the Revolution’, p. 251.

  62. 62.

    D. Fassin and R. Rechtman, The Empire of Trauma: An Inquiry into the Condition of Victimhood (Princeton, 2009); B. Taithe, ‘The Cradle of the New Humanitarian System? International Work and European Volunteers at the Cambodian Border Camps, 1979–1993’, Contemporary European History 25(2) (2016), pp. 335–358; and M. Vaughan, ‘Changing the Subject? Psychological Counseling in Eastern Africa’, Public Culture 28(3) (2016), pp. 499–517.

  63. 63.

    R. Whitley, ‘Global Mental Health: Concepts, Conflicts and Controversies’, Epidemiology and Psychiatric Sciences 24(4) (2015), p. 289. See also: S. Cooper, ‘Global Mental Health and Its Critics: Moving Beyond the Impasse’, Critical Public Health 26(4) (2016), pp. 355–358; G. Miller, ‘Is the Agenda for Global Mental Health a Form of Cultural Imperialism?’, Medical Humanities (Published online 13 March 2014), pp. 1–4; C. Mills and S. Fernando, ‘Globalising Mental Health or Pathologising the Global South? Mapping the Ethics, Theory and Practice of Global Mental Health’, Disability and the Global South 1(2) (2014), pp. 188–202; V. Patel and M. Prince, ‘Global Mental Health: A New Global Health Field Comes of Age’, JAMA 303(19) (2010), pp. 1976–1977; and D. Summerfield, ‘Afterword: Against “Global Mental Health”’, Transcultural Psychiatry 49(3–4) (2012), pp. 519–530.

  64. 64.

    Mahone, ‘The Psychology of Rebellion’; J. F. Wood, ‘A Half Century of Growth in Ugandan Psychiatry’, Uganda Atlas of Disease Distribution (Kampala, 1968).

  65. 65.

    The school was referred to as Mulago Medical School from 1927 and Makerere Medical School from 1939.

  66. 66.

    On medical education, see C. Campbell, Race and Empire: Eugenics in Colonial Kenya (Manchester, 2007); W. D. Foster, ‘Makerere Medical School: 50th Anniversary’, British Medical Journal, 3(5932) (1974), p. 675; J. Iliffe, East African Doctors: A History of the Modern Profession (Kampala, 2002); M. Lyons, ‘The Power to Heal: African Medical Auxiliaries in Colonial Belgian Congo and Uganda’, in D. Engels and S. Marks, eds., Contesting Colonial Hegemony: State and Society in Africa and India (London, 1994); A. M. Odonga, The First Fifty Years of Makerere Medical School and the Foundation of Scientific Medical Education in East Africa (Kampala, 1989); and C. Sicherman, Becoming an African University: Makerere, 1922–2000 (Trenton, 2005), Ch. 8.

  67. 67.

    WHOL MNH/POL/87.3, African Mental Health Action Group, Tenth Meeting, Geneva, 8 May 1987, p. 8.

  68. 68.

    On Uganda’s social and political history since 1962, see especially: S. R. Karugire, A Political History of Uganda (Kampala, 2010); A. B. K. Kasozi, The Social Origins of Violence in Uganda, 1964–1985 (Montreal, 1994); P. Mutibwa, The Buganda Factor in Uganda Politics (Kampala, 2008); and R. Reid, A History of Modern Uganda (Cambridge, 2017).