The Culture of Mental Illness and Psychiatric Practice in Africa, a collection of essays by a diverse group of scholars in history, ethnography, epidemiology, and psychiatric research, addresses a much neglected field of study and does so in a broad and interdisciplinary fashion. Growing out of a working group at Harvard, “Health, Healing and Ritual Practice,” the volume considers the historical antecedents of contemporary practice, the current state of mental health care, and implications for policy and development initiatives.

The predominant themes, which are inevitable in any survey of psychiatry in Africa in the twenty-first century, are those of lack and inadequacy—of human resources, of financial support, of training, of medications, and of research. In October 2015 the New York Times published two photo essays about mental illness in West Africa, showing psychotic patients in shackles and describing in detail the lack of services and of understanding of psychiatric illness. The photographs were thought to be so potentially disturbing to readers, even those accustomed to the usual NYT fare graphically showing poverty and destitution, that they published an accompanying “Q&A” article, explaining the group editorial process that was used to decide “which images were most powerful without violating ethical standards.” It has been reported that only 50 percent of African countries have a mental health policy and 70 percent spend less than 1 percent of their small health budgets on mental health. The frequently cited World Health Organization’s statistics on prevalence of psychiatric disorders in low-income countries, the overwhelming social cost of unipolar depression, bipolar disorder, and schizophrenia as measured in DALYs (disability-adjusted life years), and the suffering, morbidity, and mortality associated with psychiatric illness are staggering.

Several of the authors in this volume address these familiar themes of scarcity of resources and discuss the reality of these hardships in specific contexts that highlight the lack of comprehensive services and both human and material resources, but also point to directions in policy and service provision that could lead to improved outcomes. Ama de-Graft Aikens, for instance, describes the mutually reinforcing processes of mental illness and destitution in urban Ghana and points to ways in which intervention could have a significant impact on this cycle. A surprising and important contribution to the literature of scarcity by Giuseppe Raviola documents the impact on caregiver mental health of the HIV/AIDS epidemic in sub-Saharan Africa, when already scarce resources became even scarcer and the fundamental intellectual and moral bedrock of medical practice—using knowledge of physiology to ameliorate and to cure—was no longer operative as this seemingly incurable illness ravaged the population. And while the prevention and treatment of HIV have become a more sophisticated and satisfying part of the practice of medicine over the last decades, the Ebola and Zika epidemics have revisited this dilemma in even starker terms.

Yet under the recurrent and expectable drumbeats of lack and want, there are other motifs that recur in a number of the chapters that tell a somewhat different and perhaps more muddled, if less desultory, story. In the 1970s the World Health Organization conducted a large study of schizophrenia in ten countries, including Nigeria, in which the researchers replicated earlier contested findings that long-term outcome was better for patients with chronic and severe mental illness in low-income countries than in the developed world. What is it in the nature of family and community life in these countries that may provide some kind of support for individuals afflicted with illnesses which we know to be genetic and biochemical in origin but for whom the progress and outcome of the disease is so profoundly influenced by cultural and social factors? Several papers in this volume document initiatives within the African context that do not simply attempt to replicate contemporary state-of-the art Western therapeutics in systems beset with lack of resources.

René Collignon, in a fascinating history of the Neuro-Psychiatric Clinic of Fann in Dakar, traces its origins in 1956, just before the independence of Senegal. The founders of the hospital studied the Senegalese theories of etiology and nosology of psychiatric illness and developed treatment models based on understandings of causation and cure shared among patients, families, and treaters. Collignon describes the “fertility of this confrontation between clinic and cultural signposts” and the case studies that came out of this work that illustrate the “attention focused on the modalities of expression used by patients to speak of their experience” (167). Henri Collomb, the founder of the hospital, undertook efforts toward establishing therapeutic communities, called “psychiatric villages,” with collaboration between traditional healers and medical doctors, and there was some attempt at replication and expansion of these innovative and humane efforts in other regions of Senegal and farther afield in Francophone West Africa.

Elialilia Okello and Seggane Musisi contribute an important chapter on the role of traditional healers in mental health care in Africa. They point out that 80 percent of Africans use traditional healers, that psychotherapy by healers has always been an “essential and dynamic basis of African medicine” (251), and that “traditional healers outnumber Western doctors by at least a hundred to one in most African countries” (253). They make a powerful argument for integration of traditional and Western health care systems and propose four different potential models for accomplishing an effective and seamless collaborative system of care that would be effective in the treatment of a range of psychiatric illnesses.

As a psychiatrist who has come to the practice of global mental health work late in my career and found the work to be profoundly challenging to the models of treatment in which I have abided for more than three decades, this book was very useful in raising all the questions that should trouble those of us who do this work. I found myself at the end with no more answers but with still more troubling questions, which is, perhaps, as it should be.