The issues created by Africas large number of languages affect almost every aspect of African life.

Professor John Mugane addresses these complexities in relation to madness in his article, The Role of Language in the Manifestation, Diagnosis, and Treatment of Madness. Mugane explains that language plays a large role in how madness presents itself in patients and in how doctors are able to diagnose this madness. Thus, if a doctor or healer is not familiar with the culture and language of a patient, the patient may be improperly diagnosed or may not be able to be easily treated. Building upon Muganes arguments, we can see that to ameliorate the current situation, Africa could consider various policies, such as incentivizing physicians in Africa to become psychiatrists, encouraging more Africans to trust psychiatrists to heal their problems, and improving the linguistic diversity in psychiatric clinics and practices. In The Role of Language, Mugane discusses several different ways in which language relates to madness. He begins by discussing a number of different diseases that manifest as problems with speech (3, 12). In order to diagnose these impairments in sentence construction or word choice, Mugane says that doctors need to understand the structure of the patients language in cultural context (3). Indeed, he explains that doctors must often translate between their own language and the language of the patient, sometimes with more than one translator (4). Mugane next uses data from the World Health Organization to describe Africas lack of formal psychiatrists. On average there is only one psychiatrist per million people in Africa, meaning that much of mental care is left to next of kin and traditional healers for most of sub-Saharan Africa (6). Mugane also discusses how language reveals cultural attitudes towards madness both in names for madness (7-9) and in religious and traditional beliefs about madness (10-11). He concludes the paper by explaining the importance of language in psychiatry. Indeed, he states The way people describe madness, the symbols they use, their beliefs and rituals they perform are all mediated by the spoken word (14). When a doctor is speaking with a patient through a translator, he must be careful to phrase questions in such a way that their meaning is maintained through translation (15). If the patient does not properly understand the psychiatrists questions, the psychiatrist might not get the information necessary for diagnosis or the patient might even be offended based on his own societal norms. One way to combat such lack of understanding would be to create sets of questions, or instruments, that are deemed to be equivalent in several criteria when translated between languages

(16). However, in Muganes mind, most language problems would be best solved by the psychiatrist learning the language of his patients (17). Based on Muganes analysis, the first problem that needs to be addressed in Africa is the dearth of psychiatrists. There are two ways to confront this issue. The first is to incentivize more people to become psychiatrists. Governments could institute national training programs, perhaps as outshoots of existing medical programs, that focus specifically on psychiatry. Additionally, a national government could institute a set of fellowships for medical students who choose to specialize in psychiatry, giving them an economic incentive. Another way to ensure that these students stay in Africa upon completing psychiatric training would be to subsidize the cost of running their practice. The other issue that must be addressed is that of encouraging Africans to go to psychiatrists for help. As Mugane points out, many sub-Saharan Africans believe madness to be caused by gods witchcraft, curses (5) and so on. These beliefs lead them to seek treatment from traditional healers only, or sometimes from both healers and psychiatrists (13). While greater availability of psychiatrists would alleviate some of this problem, governments must also sponsor national education campaigns. These campaigns could describe the benefits of seeing a trained psychiatrist and explain that some mental illness can only be treated through medicines that regulate biochemistry. The second major problem with the current psychiatric system in Africa is the language barrier between doctors and patients. As Mugane describes in detail, shared language and culture are essential to diagnosing mental illness. As with Freuds talking cure, the treatment of many psychiatric problems can only come about through extensive discussion with the patient and his family about the patients life and thought processes. Mugane believes that Bilingualism/biculturalism is essential in providing quality care for patients and their families (17). However, in countries that have more than just two or three major languages and cultures, it is nearly impossible for an individual doctor to be well versed in all. Therefore, we can suggest another possible solution for private psychiatric practices. Namely, alongside one or two main doctors, the practice would also employ medical residents and nurse practitioners (NPs). To provide full coverage, each practice could be purposefully staffed with residents and NPs who come from a variety of cultural and linguistic backgrounds. A new patient would be assigned to a resident or NP from a similar culture and the assigned helper would conduct an initial interview and report results to

the primary physician. Ultimately, the main psychiatrist would work in conjunction with the residents and NPs to help each patient. Having translators who also understand the psychiatric goals of the doctor will greatly eliminate many of the translational problems currently faced by psychiatrists. Indeed, the residents and NPs will be able to phrase and tailor questions to best fit the linguistic background of the patient. Thus with the extra help of qualified individuals, psychiatrists would be able to better serve the need of all members of a country, regardless of language or culture. A final problem we must avoid is assuming that a psychiatrist in the Western sense is ideal for every case of madness in Africa. In fact, as Mugane points out, ideas of what madness is vary according to culture and religious beliefs (6). For example, in Tanzania, a certain form of madness occurs when the spirit of a dead relative enters a mourner (9). In uniquely African cases such as this, traditional healers would be far more appropriate. Furthermore, often a traditional healer is preferable to a psychiatrist simply because the healer most likely lives in the same community as the patient and understands the patients history and circumstances much more than would a psychiatrist whom the patient has never met. However, in cases such as depression and schizophrenia which have fairly well developed pharmaceutical treatments, a psychiatrist is almost certainly preferable. Thus, the question of psychiatrist versus traditional healer must be considered on a case-by-case basis. We have seen that the interplay of madness and language in Africa is multifaceted and often problematic. I have proposed many solutions that could perhaps alleviate some of the issues addressed by Mugane. However, it would most likely be impossible to enact more than a few of these policies, as the budget of many Africans countries is already limited. While psychiatrists are not needed in every case of madness, having more psychiatrists is indisputably a necessity. Therefore, anything that a country could do to increase the number of psychiatrists and to break down the linguistic and cultural barriers to treatment would be of great benefit to the mental health of its people.