The brain drain of medical professionals from African countries to rich countries in Europe, North America, and the Middle East has been particularly pronounced since the 1980s. As Bibilola Oladeji and Oye Gureje have noted, as of 2011, there were more than 17,000 African physicians practicing in the US alone, over two-thirds of whom had been trained in African medical schools. Of this group, two-thirds were trained either in Nigeria or South Africa, the two countries with the most extensive medical training systems on the continent. Psychiatrists have also made up a significant piece of the larger medical migration, drawn by higher salaries, better facilities, opportunities for professional development, and prospects for long-term stability to seek jobs outside of the continent.

The brain drain has become a commonplace terminology to describe the emigration of highly skilled labor from developing countries to highly industrialized states in the post-colonial world. The concept has been particularly valuable for understanding persistent underdevelopment in sub-Saharan African countries as related not so much to deficiencies in African expertise as its redirection primarily for the benefit of wealthy countries. Similar to the “brawn drain” of the Atlantic slave trade or the natural resource depletion that characterized European colonialism in much of the continent, brain drain has had long-lasting impacts on African countries’ internal development and position in the global economy.

The impact of the brain drain on mental health care in Africa can be seen through the example of Nigeria, one of the few sub-Saharan African countries with university hospitals providing accredited medical training in psychiatry. Nigeria’s first trained psychiatrist of indigenous background was Thomas Adeoye Lambo, who studied at Birmingham and the Maudsley Hospital in the UK before returning to Nigeria to practice at the newly founded Aro Mental Hospital in 1954. Lambo and his acolyte, Tolani Asuni, developed much of the infrastructure of Nigerian psychiatry in the 1960s and 1970s, and several Nigerian universities began producing psychiatrists by the 1980s. The purpose of developing such programs was to produce a qualified mental health workforce for the country. Students from other countries in West Africa also trained in psychiatry at Nigerian institutions. Nigeria’s mental health care workforce grew slowly but surely from only three psychiatrists in 1955, to 25 by 1975, and 100 by 2001. But the brain drain has had a major impact on Nigerian psychiatry. Today, there are roughly 250 psychiatrists in Nigeria to serve a population of approximately 190 million. At the same time, a study from 2010 found that there were 384 Nigerian psychiatrists practicing in the US, UK, Australia, and New Zealand, a number 50% higher than the estimated total practicing in Nigeria.

The effects of this psychiatric brain drain have been significant. Beyond the worsening of the psychiatrist-to-population ratio, this phenomenon has the potential of severely weakening ongoing reproduction of this limited resource as more freshly qualified psychiatrists and senior residents are being enticed/encouraged to relocate on the guise of training opportunities abroad, from which they never return. In addition to psychiatrists, mental health nurses are also leaving the continent in droves, with packages designed to make emigration easy and more likely to be permanent. The rate of migration far outstrips the rate of production, leaving a huge deficit in human resources, one of the major pillars of a health system, according to the World Health Organization.

Several reasons have been proffered for the exodus of medical doctors from Africa to the economically developed world. Oberoi and Lin classified these reasons into endogenous and exogenous factors. Endogenous factors include poor working conditions, poor remuneration, and lack of job satisfaction and job security with little or no opportunities for career development. Exogenous factors include social pressures from relatives, preponderances of civil unrest, and armed conflicts with attendant high levels of insecurity. Ironically, the factors that push mental health care workers to relocate abroad are the same ones that likely contribute to rates of psychological distress in their communities of origin that, in turn, require more and better mental health care.

Since the late 2000s, the “global mental health” movement has sought to ameliorate this “treatment gap” in mental health services in developing countries, including Nigeria and others in sub-Saharan Africa. In most cases, reducing the treatment gap relies heavily on training lower-qualified workers to perform the duties of highly-skilled practitioners, a set of practices known as “task shifting.” Task shifting in international public health has existed for a long time, and has been employed extensively in the field of HIV/AIDS diagnosis and treatment in many environments. But it’s use in psychiatric care is somewhat more controversial. Most notably, global mental health has been critiqued as potentially socially and culturally insensitive, importing knowledge and practices from western industrialized countries that might not adequately reflect local cultural beliefs or social determinants of health, while simultaneously marginalizing indigenous health systems.

Task shifting has also been proposed as a strategy for alleviating the effects of the brain drain on the health care sector. In a review of policies to address brain drain in sub-Saharan African countries, Edward Zimbudzi has identified some areas of possible intervention. These include ethical recruitment, brain drain tax or compensation for source countries, increasing investment in training more professionals, improving remuneration of health workers and working conditions in general, importing more staff, ensuring political stability, and encouraging remittances. However, the review concluded “that there is considerable consensus on task shifting as the most appropriate and sustainable policy option for reducing the impact of health professional brain drain from Africa.” While some studies have concluded that task shifting has effectively filled the treatment gap, others have indicated that it is by no means a comparable substitute for professional mental health care due to lack of proper supervision and training of lower level workers, among other factors.

But we would like to offer a different critique of the task-shifting discourse: it’s tendency to normalize the brain drain of health care professionals. Global mental health has always emphasized practicality over ideology: anything that can be done to fill the “treatment gap” is presumably better than not doing it. The origins of the medical brain drain are not really global mental health’s concern, but its consequences are a large part of the foundation of the movement’s argument for “scaling up” the health care workforce to address the “treatment gap,” which is effectively the primary justification for the movement’s existence. However, in making the case for immediate action, the discourse on task-shifting in global mental health replicates the long history of ignoring the long-term exploitation of African resources in order to focus on short-term, externally funded, non-state interventions to provide what Africa supposedly “lacks.”

Promoting task shifting to lower cadre health care workers as the best way to scale up mental health services in low- and middle-income countries indirectly suggests that these countries cannot hope for better, even as billions of dollars are lost by African countries from investment in training highly qualified health workers who go on to treat patients in wealthy countries. Meanwhile wealthy countries acquiesce to helping train up less-qualified caregivers to fill the “treatment gap” created in part by this brain drain. It also implies that African countries can get by on less than wealthy countries. Indeed, severe mental illness continues to be neglected under the “task shifting” model that does little to increase specialist capacity to handle such cases. While this rather popular principle in global mental health appears practical, it inadvertently panders to the notion that some lives are more important than others, and calls to question the relative value placed on the health and lives of citizens of the developing countries of Africa compared to the developed world. It reinforces and normalizes global inequalities.

Mitigating the psychiatric brain drain must ultimately be about much more than filling “treatment gaps.” It must also be about addressing the geopolitical and macroeconomic conditions that have produced the gap in the first place. Developing equitable and sustainable mental health services for all Africans is a political, economic, moral, and ethical issue of contemporary urgency and historical significance.

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This post is from a partnership between Africa Is a Country and The Elephant. We will be publishing a series of posts from their site once a week.

Kenya’s mixed election history

Sometimes it is said, with some validity, that the only peaceful, non-violent, free, fair, credible, verifiable, and acceptable elections took place during the “sunset” years of British colonialism in Kenya (1957-1963).

During these six years we elected our African representatives to the now multi-racial Legislative Council (LEGCO). It is during this period that decolonization talks took place in Kenya and later at Lancaster House, London.

In 1961 Jomo Kenyatta was released from his detention at Maralal in the Samburu County. He soon joined his fellow Africans in the LEGCO, participated in the independence talks at Lancaster, London, as the leader of Kenya African National Union (KANU).

His party KANU won the 1963 Elections, forming the internal self- government (Madaraka) from 01 June 1963. He became our first Prime minister on 12 December 1963 and the first President of our  Republic on 12 December 1964.

Although it was widely accepted that the colonial government and the British settlers would have loved a government of Kenya African Democratic Union (KADU) and the liberal British settlers, KANU was the more popular party.

Rigging an election against KANU was out of the question. Gone were the days the colonial government would select their colonial chiefs from the outcomes of rigged queue voting (if for some reason they thought this voting was necessary).

The post-colonial times are peppered with stories of the rigging of elections, particularly during the few years the Kenya People’s Union (KPU) existed before it was banned and its leaders detained in 1969.

The by-election in Kandara (1966) in which independence hero Bildad Kaggia ran on a KPU ticket was rigged by making sure that ballot boxes were thrown out into coffee farms as government land rovers ferried cast votes to the district headquarters for the Loyal and law-abiding peasants in Kandara who showed up with the ballot boxes they found in their coffee farms were routinely arrested and detained!

Later in local government elections that took place, all the KPU candidates were disqualified because it was said they were unable to fill their nomination forms correctly! What saved the country from widespread violence was the strength of the provincial administration and the machinery of violence that the KANU government was able to mobilize.

The chilling call “Fanyeni fujo muone/Cause trouble at your own risk was often repeated, driving the point home that Jomo Kenyatta’s KANU would not be defied. That is not to say there was no resistance against the subversion of the right to vote.

When Kenya became a de facto one-party state in 1969, the KANU party and its government used many tricks to disqualify its members from running for elections. Members were either expelled from the party under dubious party disciplinary proceedings, or simply denied nominations to run for elections.

In cases where elections took place and so-called KANU “dissidents” were elected, a Judiciary, enslaved by KANU party and its government was able to nullify such victories. Others who were found guilty of election offences were barred from running for office for five years.

It was in 1988 when KANU dropped all pretense of holding free, fair, and credible elections. The Mlolongo/Queue Voting (where candidates would be elected based on the length of the queues of supporters lining up for them) took place and rigging took place in broad daylight.

In Othaya Constituency where former President Kibaki was a candidate, KANU party and its government tried to rig him out of his victory displayed by a long queue, far longer than his opponent’s.

It was during this election that Kibaki famously told the Presiding Officer that he could not rig that election because “it takes intelligence to rig elections.” Clearly, if the Presiding Officer had tried to declare Kibaki’s opponent the victor he may not have left Othaya alive!

The post second liberation elections of 1992 and 1997 elections were won by KANU because of the violence in the Rift Valley, a divided opposition, a subdued Electoral Commission of Kenya and its twin institution, the Judiciary.

Although in 1997 the KANU party and government allowed for opposition representation in the Electoral Commission, the changes didn’t curb electoral fraud.

The 2002 Presidential election was won by NARC (National Rainbow Coalition) because the barons (mabaroni/mababe vita) of the five communities that control over 70% of the vote (Kalenjin, Kikuyu, Luhya, Kamba, and Luo) voted for President Kibaki. It is safe to assume both Kibaki and Uhuru being Kikuyus shared the Kikuyu vote.

The violence that took place after the 2007 Presidential election is well documented. The loss of property and lives are well documented. The raping of women is well documented. One only needs to read both the Kriegler and Waki Commission Reports for the details.

This time round the Judiciary was rejected as a possible institution to hear the Presidential election petition by the losing political party. Again the Electoral Commission of Kenya was rightly accused of not conducting free, fair, peaceful, and credible elections.

It is clear to me that the 2013 Presidential elections did not result in violence because Raila Odinga stated that he accepted the decision of the Supreme Court although he did not agree with it.

In 2017 the Supreme Court nullified the Presidential election. The subsequent presidential election was boycotted by NASA Coalition and the resultant presidential petition filed by citizens was dismissed by the Supreme court.

The Supreme Court had shown that it could rule against either of the political factions, Jubilee and NASA. The “we shall revisit” warning by Jubilee to the Judiciary is still being felt.

It is possible that the two Supreme Court decisions birthed the dictatorship of the government and opposition (the Handshake and its child named BBI) and the continued political instability in the country.

Potential Electoral War in 2022

The potential for conflict, strife, instability, and violence in 2022 cannot be ruled out. The dynasty/hustler narrative is fraught with danger. Demystified it simply means that a possible war between haves and have-nots that the intra-elite conflict instigates.

The author of the hustler narrative, Deputy President Ruto identifies four dynastic families (Kenyatta, Odinga, Mudavadi, and Moi) as the cause of all societal problems in Kenya. He refuses to acknowledge he is the political orphan of the Moi dynasty.

He refutes the scientific wisdom of the OXFAM report that states that 8,300 billionaires and multimillionaires own assets equals to what the rest of the population of 48 million own.

Now that is the comprador bourgeoisie that can be characterized as the dynasty/monarchy. And without a doubt, the Deputy President along with other black, white, and brown dynasties are part of that class.

He is not calling for a class war between Kenya’s working people and the middle classes against the comprador bourgeoisie, the dynasties/monarchs/walalahai/Mabwenyenye who are multi-racial and multi-ethnic and who rule this country with their foreign masters.

The Deputy President is not calling for that class war, but a war against competing dynasties who are grouped in BBI, NASA, and the One Kenya Alliance.

He is inviting Kenyan youth to join in that war with a promise of a budget of 30 billion Kenya shillings to set them up in the so-called wheelbarrow economics!

If we go back to 2008 and ask ourselves who sowed the seeds for the post-election violence (PEV) we know it was the ethnic barons representing their cartels and the comprador class in their struggles to capture political power.

Unable to reach a consensus on how to protect their collective interests they used their evil genius in the politics of division to declare war on the people of Kenya. We still face this danger, more so because no alternative political leadership exists to warn Kenyans of the dangers they face if they are duped to participate in this intra-elite war. Already, we can clearly hear the war drums being beaten.

What the Kenyan youth must do

The 2019 national census told us that 75% of our over 48 million population comprises youth aged under 35. It is the youth who have borne the brunt of the denial of their material interests: education, water, land, national resources, housing, work, sanitation, health, food, and security. Without these public goods available to the youth we cannot talk of their human dignity.

Of course, the youth are not homogenous, but the majority are not the offspring of the 8,300 billionaires and millionaires. We are talking here about the daughters and sons of working-class and middle-class Kenyans. It is this youth that the elite have been able to divide on the bases of ethnicity, religion, region, race, generation, gender, clan, class (where the elites have successfully convinced these youth that their problems are caused by their parents who in reality subsidize the failings of the government and the ruling elite), and sports.

It is also this youth, particularly those who come from the working classes that are used as cannon fodder for the intra-elite battles through bloody handouts that do not result in any of their material interests being realized.

It is on the basis of the history that I lay out here, and the potential for war in 2022 that I call upon Kenya’s youth to do the following:

• Demand that IEBC immediately complies with the Constitutional decree to register every youth who is over 18 to vote in 2022 election;
• Support the parties that the youth are forming on the basis of their interests and ensure they come into power;
• Refuse to vote for the baronial elite parties that have shown in the last 58 years they cannot give the youth of the working classes human dignity;
• Absolutely refuse to be divided along the bases I have stated and stay focused on their material interests, particularly the right to work which is the basis of their humanity dignity;
• Refuse to be recruited in ethnic and other criminal militias to be deployed to kill fellow youths in the country;
• Solidly support the implementation of the Constitution and join movements that call for Linda/Tekeleza Katiba/Protect and implement the 2010 Constitution;
• Vote out the elite and their factions of Kieleweke, Tinga Tinga, Tanga  Tanga, One Kenya Alliance, Wipa Wipa, Fodi, Fodi, all Dynasties including those calling themselves Hustlers;
• Demystify and expose the cruelty and inhumanity of laughing at the working people, the real hustlers, by endangering their lives in a war among the elite;
• Promote peace among fellow Kenyans and save the Motherland from warmongers and ethnic barons who are the causes of war amongst Kenya;
• Join in struggles can seek alternative political narratives to those of theft, corruption, banditry economy, leadership by agents of foreign interests, politics of division, politics of foreign and national exploitation (Wavuna Jasho ya Wavuja Jasho), politics of incurring national debts against our collective national interests;
• Understand clearly how elections are rigged today; through the capture of institutions implicated (IEBC, the Armed Forces, the Treasury, cartels, the Judiciary among others), use of Public Relations agencies, and Artificial intelligence (for example algorithms) that we are now familiar with;
• Ensure that you focus on the MCA seats so that challenges can come from the grassroots; and
• Defend the Motherland and its people.

A time for transformation

If we go back to the elections of 1963 and 2002 it is clear that there are elections that cannot be rigged. In both elections the voice of the majority was clear. That voice could not be reversed. It could not be revoked.

The powers that be, the colonial government and the Moi-KANU dictatorship respectively knew what would be the consequences of rigging those elections.

The voice of the majority in 2022 must be the voice of the Kenyan youth. Giving this country a political chance to implement different economic, social, cultural, spiritual, and cultural narratives that subvert the status quo is the result of our poverty.

It is true that our elections are about money, big money. What Kenyans should remember is that the first people’s representatives in the 1950s were financially supported by the people themselves.

There is absolutely no reason why this cannot happen again and our people see the need to invest in alternative politics that will be anchored on their collective humanity.

My dear Kenyan youth, all I can think of under these suggestions I have made to you is a clarion call to action, to transformation, to fundamental change in this country, to the protection of the Motherland by all means necessary, including death! I believe this is the reality that has to be said.

We must think of freedom and emancipation from forces that enslave and divide us. We can start this patriotic dialogue by putting in place a political leadership that cares about your humanity, a leadership that you participate in directly and not as proxies.

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This article was first published by Africa Uncensored, an independent media house set up by Kenya’s finest investigative journalists.

Vladimir Putin has placed a high premium on rebuilding Russia’s stature as a global power, and these efforts extend to Africa. He first visited the continent in 2006, promising $1bn in investments and making a clear declaration of Russian interest.

If you google “Russia-Africa relations”, some of the first results include news articles about Russia and its “return” to the African continent. What does Russia want from Africa, many ask, and what’s behind Moscow’s recent push into the continent?

You may also see mention of the 2019 Russia-Africa Summit, the first of its kind, held in Sochi and attended by 43 African heads of state. Several memoranda of understanding were signed at the summit, including between the Russian government and the African Union.

“We are not going to participate in a new ‘repartition’ of the continent’s wealth; rather, we are ready to engage in competition for cooperation with Africa. We have a lot to offer our African friends,” President Vladimir Putin said at the summit. This too sparked debate about Russia’s growing influence on the continent.

Did Russia ever really leave Africa? That depends on who you ask.

In March 2021, building on previous work, the SA Institute of International Affairs (SAIIA) launched a two-year research programme seeking to understand Russia’s strategic engagement and policy impact in Africa. A series of online scoping workshops showed there are vast and varying opinions on the topic.

Sanctions Trigger Renewed Engagement

It’s well known that the Soviet Union provided support to a number of African countries during their anti-colonial struggles. Most scholars agree that in the early 1990s, at the height of the USSR’s transition to a multi- (or one-) party system, and preoccupied with domestic challenges, Russia’s presence in Africa reached an all-time low.

In 1991, the then president, Boris Yeltsin, announced that Russia’s foreign aid policy would come to an end. By 1992, nine embassies and four consular offices were closed, while many cultural centres disappeared.

Since then, Putin has placed a high premium on rebuilding Russia’s stature as a global power, and these efforts extend to Africa too. He first visited the continent in 2006, promising $1-billion in investments and making a clear declaration of Russian interest. By the following year, Russia had written off approximately $20-billion of debt incurred by African countries during the Cold War.

But some argue that it wasn’t until 2013 that material engagements emerged. Putin again visited South Africa, often seen as the gateway to Africa, for a Brazil, Russia, India, China, South Africa (BRICS) summit. Russia signed a Comprehensive Strategic Partnership with South Africa, with provision for cooperation in the political, economic, and defence spheres.

Diplomatic links between Russia and Africa have also increased, with several heads of state visiting Moscow since 2015. Through the UN, Russia has actively participated in aid programmes, providing food and medical assistance to African countries in need. It has also courted African votes on the UN Security Council and UN General Assembly. It’s widely speculated that renewed engagement is linked to economic sanctions placed on Russia in 2014 by the West, due to the Ukraine conflict and the “annexation” of Crimea. Here, two distinct interests stand out.

Military and Natural Resource Interests

Russia is a major supplier of arms to Africa. According to the Stockholm International Peace Research Institute, Africa accounted for 18% of all Russian arms exports between 2016 and 2020, with Algeria being the largest recipient. Defence relationships between Russia and Africa are also growing.

Since 2014, Rosoboronexport – a Russian state-owned agency that exports military products and services – has signed bilateral agreements with multiple African countries, including Angola, Equatorial Guinea, Mali, Nigeria, and Sudan. Apart from military equipment, the agreements contain provisions for countering terrorism and the joint training of troops.

Russia also has clear economic motives when it comes to natural resources. Although it boasts some of its own mineral wealth, Russia’s natural resources are difficult to extract, making it easier to import them instead. Notable developments are taking place in Zimbabwe (platinum group metals), Angola (diamonds), and Namibia (uranium).

Several Russian state-owned energy companies such as Gazprom, Rustec and Rosatom are also active in Africa, with key investments in the oil, gas and nuclear sectors in Algeria, Egypt, Uganda and Angola. It’s worth noting that state-led investments are often linked to military or diplomatic initiatives. For example, while an agreement is in place to construct two nuclear power plants in Nigeria, Russia has at the same time committed to countering terrorism there.

Incremental Growth

Events since 2014 have led to concerns from other countries about the return of the “bear” (in a 2018 speech, the then US national security adviser, John Bolton, singled out the expansionist efforts of Russia and its “influence across Africa”).

And while much attention is paid to Russian movements on the continent, it’s difficult to compare Russian engagement with Africa’s traditional partners like the US, UK and France, or with emerging powers like China, whose involvement dwarfs that of Russia. Interest from Turkey, Israel, the United Arab Emirates and others also means African countries can now pick and choose who they would like to partner with. These decisions are informed by a complex web of priorities.

Conversely, while Putin has named Africa a foreign policy priority, it is not number one on the list. “In terms of overall economic ties, Russia still does much more trade with Europe and Asia than with Africa,” Alexandra Arkhangelskaya, researcher at the Russian Academy of Sciences’ Institute for African Studies, told SAIIA. This was due to its geographic location, she said.

Plans for the 2022 Russia-Africa summit are well under way, again causing a stir around growing Russian presence on the continent. Rumored to be taking place in either Cairo, Dakar or Addis Ababa, the summit will bring together hundreds of representatives from business and government.

Is this part of Russia’s new Africa strategy or a continuation of its prior involvement? Either way, we should expect incremental growth in levels of engagement.

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This article was initially published in the Daily Maverick.