The fight against stigma in sub-Saharan Africa can’t be won without access to correct medication and properly trained physicians and medical professionals, focusing on some important facts, namely:
• The belief in witchcraft is real
• Firmly establishing that dementia is not part of normal ageing but a terminal disease
• The very specific link between HIV-AIDS and
dementia in Africa
• Discussing the cause of the disease and the diagnosis in detail with patients and their carers is vital
• Explaining what the physician wants to achieve with the medication (e.g. suppression of the viral load, managing high blood pressure, high blood sugar etc.)
• Explaining and being transparent about possible side effects: establishing the benefit of the medication over the side effects or the danger of side effects and that these need to be reported and discussed immediately with the physician. Plus giving people clear examples of how side effects have been misunderstood as signs of witchcraft
In order to better support members, Alzheimer’s Dementia Namibia is in the process of employing a Registered Nurse with 11 years of experience in screening, awareness and education of people living with HIV-AIDS.
According to him, “Combination HIV medication can cause a lot of side effects, most of them are psychotic in nature and psychosis is seen as one of the key signs of being a witch. Identified side effects include hallucinations, violence, removal of clothes, talking to yourself, slurred speech, being withdrawn, drowsiness, irritability, constant headaches, loss of memory. This has misled a lot of health professionals because they did not, and still do not recognise these symptoms as side effects of the medication. We admit these people living with dementia and put them on anti-psychotic medication”.
This was brought to the attention of the Ministry of Health, and from 2019 new guidelines were implemented so that anyone developing psychosis, as a side effect of Efavirenz, is switched to another anti-retroviral drug.
This is now happening in Namibia and also in Zimbabwe.
The previous dosage of Efavirenz has now also been reviewed, reducing it from 600 to 400 milligrams.
Conclusion
The stigma and misunderstanding surrounding dementia in sub-Saharan Africa are a devastating reality for individuals living with the condition.
No nation can be free before everyone is free. People living with dementia are not free, not because of a disease such as Alzheimer’s or HIV-AIDS related dementia, but because of the stigma and discrimination against people living with dementia.
The challenges of stigma in sub-Saharan Africa regarding dementia diseases ask for a holistic approach of the origin, role and place in the belief of witchcraft, western medicine, the way western medicine is being practiced, the relationship between western and traditional medicine, judiciary (common law and the traditional
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law, and human rights balance with every country’s constitution.
References
1 Mkhonto, F. and Hanssen, I. 2017. ‘When people with dementia are perceived as witches. Consequences for patients and nurse education in South Africa’ Journal of Clinical Nursing 27(1-2) online:
https://onlinelibrary.wiley.com/doi/abs/10.1111/jocn.13909 Last accessed 19 August 2019.
2 Gershman, B. 2015. ‘Witchcraft Beliefs and the Erosion of Social Capital: Evidence from Sub-Saharan Africa and Beyond’ Journal of Development Economics 120 online: https://pdfs.semanticscholar.
org/6ef4/41f0162e5e2e60b899d580cc3822725918ac.pdf Last accessed 19 August 2019.
3 African Witchfinder. ©2016 Heehaw Ltd. online: http://www.
africanwitchfinder.com/ Last accessed 19 August 2019.
4 The Namibian. 2019. ‘Call to revise witchcraft suppression law’ online: https://www.namibian.com.na/185323/archive-read/Call-to-revise-witchcraft-suppression-law Last accessed 19 August 2019.
5 KLRC Blog. 2017. ‘Justification For Review Of Witchcraft Act, Cap 67’ Kenya Law Reform Commission (KLRC) online: http://www.klrc.
go.ke/index.php/klrc-blog/518-justification-for-review-of-witchcraft-act-cap-67 Last accessed 19 August 2019.
6 South African Law Reform Commission. 2011. ‘Thirty Eighth Annual Report 2010/2011’ online: http://www.justice.gov.za/salrc/anr/2010-2011-anr.pdf Last accessed 19 August 2019.
7 DoSomething.org. 2019. ‘11 facts about HIV in Africa’ online: https://
www.dosomething.org/us/facts/11-facts-about-hiv-africa Last accessed 19 August 2019.
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4.11 A carer’s perspective: My life with my father Joel Mbithuka Kasimu
Contributor: Elizabeth Mutunga, CEO & Founder Alzheimer’s & Dementia Organisation Kenya
My father’s name was Joel Mbithuka Kasimu. He was a senior police officer with the rank of Officer Commanding Station (OCS) and a very well-dressed individual who loved his family immensely. Although he was a busy man, he took time each evening to read to me and these story books helped develop my language and imagination.
Being the first born, in sharing these powerful stories, he made me believe I could be anything I wanted to be.
In 1984, when I was only 9 years old, my Dad went into a diabetic coma. It was frightening to see my hero unable to do much for himself. In 1985, he had to retire early due to medical reasons. This made him really sad, as he loved wearing his uniform and he also missed not being able to serve the community. In 1989, we lost a sister, and this added to my Dad’s sadness. The reason I am giving this background is to illustrate how far back the issues started. In 1992, my Dad moved the family from a four-bedroom house to a five roomed house. He then started selling the car in parts; the tyres separately from the rest of the vehicle. This was shocking to us. He then became violent which was totally out of character.
This created a rift in the family as he was always looking for an opportunity to fight with us. I soon had to go and look for work to provide for the family.
It wasn’t until 2007 that I heard the word dementia. I was shocked when we were informed that there was no cure. This was almost 15 years after fighting with Dad and not understanding what the issue was. A lot of people in Africa in the 1990’s believed that dementia was a disease of the West and thus Africans could not get it. My father came from a community where people believed if there were issues happening to you and they could not be explained it was because you had been bewitched; you must have done something bad to the gods and thus you were being punished. As he was elderly, others believed it was a normal part of ageing.
Due to the stigma of the disease, a lot of people would not visit our homestead for fear of the same disease affecting them.
This prompted me to look for a support group to plug into so I could understand more about the condition - but there was none. This pushed me to start a group, which ran till 2009, when my Dad rested. The journey with dementia was gruesome and I did not want anything to do with it anymore and so packed away that part of life and moved on.
In 2013, I received five phone calls from different individuals who had been referred to me, or who had read my story, as I used writing as a way of dealing with the pain I went through with my Dad’s illness. I was initially quite angry when I received all these calls as I had made a pact with God and myself that I would never
do anything or come close to this condition again. The people calling were so persistent that I decided to have one meeting where we could decide way forward. We never turned back since then and the support group still runs today. We have invited experts to come to speak to caregivers during the monthly meetings and educate them on the condition. This has changed their perceptions on dementia.
As caregivers one of the things we have worked on is creating awareness about dementia. We have used both print and digital media and awareness in the church to combat stigma and the misbeliefs surrounding the condition. Initially, when we started creating awareness, we would have to make many calls for even one radio or television station to interview us but now it is them calling us, and that is a great shift.
Referrals from neurologists have also helped Alzheimer’s and Dementia Organisation Kenya (ADOK) in that we are now able to support more people. Involvement by the Ministry of Health in all their Technical Working Groups has helped in pushing forward the agenda of ensuring that we are moving towards having a national dementia plan in Kenya and policies to cater for people living with dementia and their carers.
There are a lot of studies now being carried out in Kenya as there is very little data on dementia and even the Government needs to recognise it is a huge burden to the carers; financially, emotionally and spiritually. Kenya is also part of STRiDE (Strengthening responses to dementia in developing countries) and this has been beneficial as we have more interactions with the Ministry of Health and so, for anything on dementia, ADOK is the go-to organisation. In 2017 Kenya also held our first conference in partnership with ADI and this was an eye opener to how big the problem of stigma really is. I remember most people were shocked to know that there was an Alzheimer’s association in Kenya.
The issue of stigma is still rife especially in some areas in Kenya, but this is changing as more people are calling ADOK to ask where to start. If they have seen a doctor, then they are directed to attend our support group. By meeting other people going through the same thing, it helps with acceptance. People are then more confident to speak out and this reduces self-stigma. Self-stigma is the greatest hinderance to dealing with dementia and once this is dealt with, it will have a ripple effect on the issue of stigma in general.
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4.12 Fighting stigma in the Middle East. Who speaks on behalf of people with Alzheimer’s and dementia?
Contributor: Princess Nouf bint Muhammad, acting CEO of the King Khalid Foundation
My first encounter with Alzheimer’s, that then curious disease with a strange sounding name, came many years ago when most of what we knew of such mental health issues was “senile dementia”, which seemed inevitable, yet you prayed and hoped your elderly relatives, and eventually yourself, would escape its ravages.
What was it, what did it mean, how did it differ from other forms of dementia; all questions still unknown to many of us at the time; talked about quietly, and only between family members. Visits were limited to a smaller and smaller number of people, not as result of the anxiety it might cause, but to preserve the dignity of the person living with dementia. Sons and daughters wanted to protect their loved one as they lost their ability to communicate, to judge situations, and conduct themselves in the manner that suited their age and social standing, as family patriarch or matriarch.
As family awareness of the disease increases, and we know more about how it starts, how it affects the mind, and that it could start much earlier on in life, the stigma is reducing. Understanding the different stages, and that it is a medical condition and not a natural progression of old age, has helped family members cope better, and has reduced the embarrassment that they felt for themselves, as well as their diagnosed family member.
Unfortunately, that is only one source of stigma reduced and others remain.
Stigma associated with diseases and mental disorders manifest through a series of interconnected factors such as the spread of misinformation, lack of awareness, and prejudice that leads to discrimination. The fear of tackling cultural taboos and the systemic lag in public provision of education, health and social services are among the culprits as well. As I have been privileged with chairing the board of the Saudi ADHD (Attention Deficit Hyperactivity Disorder) Society (Ishraq), I have also seen the dangerous side effects of stigma, against what are considered mental health disorders. Many of the families were often resistant to accepting diagnosis and seeking assistance out of fear of the stigma they and their children might face. I believe this also happens to people living with Alzheimer’s disease and other dementias, their carers and families. Moreover, unfortunately, limiting their options to seek care and support, accept diagnosis, and take advantage of the coping mechanisms that can be available to them.
Arab societies assign larger roles to extended families and greater social connections. We consider values of respect and dignity for the elderly as a duty and source of pride. This leads some families to avoid reaching out to healthcare professionals, carers or professional social services to help relieve the burden of their ill loved ones or the responsibilities associated with taking care of them. Families are intimidated by the stigma of care
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homes, which might be perceived as abandonment.
Another disincentive to families seeking care is the damaged reputation of public social care institutions for the elderly and the perceived poor quality of the services they provide. Due to those factors, the stereotype about older age and dementia pushed people living with it to stay in the shadows. For that, the role of raising awareness of the disease and advocating for the rights of people living with it and their families serves as important solutions to those problems.