The French colonial expansion and the creation of the Colonial Health Service just before the dawn of the 20th Century are contemporaneous with S. Freud’s earliest works and the first faltering attempts of a psychiatry bent on using methods other than segregation and confinement. The complexity of these concepts explains their slow progress in the new overseas territories.

First of all, when dealing with little-known mental disorders, one notes the influence of tropical diseases. The psychiatric disorders observed in the European settlers also suggest the influence of climatic and living conditions.

The ties between culture and psychiatry in the native population are studied. They throw light on the "puzzling" behaviour of these people and lead colonial psychiatrists, following Aubin*, to consider as novel the clinical expression of psychiatric disorders in native populations.

For the inhabitants as a whole, the psychiatric assistance made available is that of the time, that is to say, confinement in asylums. In the second half of the 20th Century, ideas change as the influence of traditional culture on behaviour patterns is taken into account. Collomb*, in Dakar, is one of the founders of Ethnopsychiatry. With intelligence and modesty, he contacts African healers (medicine men) and develops a doctrine that he practises in his therapeutic methods and his conception of psychiatric assistance.

But all these countries, now independent, are in a process of rapid cultural mutation. The approach to African mental pathology is destined to go through further evolution.

EXPLANATION OF LATE BEGINNINGS AND DIFFICULTIES IN OVERSEAS PSYCHIATRY

Concerned first of all with deadly microbial diseases, the Colonial Health Service turns to psychiatric help only afterwards. Many causes are responsible for this delay :

– To begin with, the care demanded by the natives is less insistent in this domain than in other branches of medicine. Mental sickness has its place, its explanations and remedies in the mentality and culture of the existing societies.

– Next, offers of assistance by western psychiatrists lack enthusiasm because of their own uncertainty about the validity and, above all, the universality of their ideas and practices. So we must wait for the development of a psychiatry that takes into account cultural elements. This discipline is commonly known as Ethnopsychiatry. From 1904, Kraepelin in Singapore and in Java, Géza Roheim, at the request of S. Freud, in the South Pacific Islands (1913), confirm the "psychic unity" of the human race. But, by all evidence, what’s normal and what’s abnormal varies from population to population. That’s what A Béguin has said in our time: "We may be considered mad in a given society".

– Finally, linguistic differences are an obstacle when it comes to interrogations as meticulous as those needed for personality tests, psychoanalysis. Using an interpreter doesn’t assure success.

MENTAL DISORDERS CAUSED BY TROPICAL DISEASES

The first disease to be called into question is paludism (malaria), which is omnipresent overseas. In the course of the 19th Century, many authors designate it as a cause of "madness", mental alienation and psychic disorders. In 1902, Comméléran* devotes his thesis to the subject "Neurosis and Malaria" ("Névroses et paludisme"). Patients, fatigued by a painful sojourn and victims of frequent bouts of fever, go through periods of irritability followed by stages of apathy. The malarial origin, according to early authors, is evident because things come back to normal after treatment with quinine. Modern studies, while confirming the haematozoic impact of malaria on the brain, no longer imputes mental disorders to this disease.

The psychiatric school of the Pharo, while studying systematically the psychiatric influence of different tropical diseases, pays particular attention to chronic encephalitis resulting from trypanosomiasis. During the second stage of the disease, well-studied by Gallais*, psychic disorders are rarely absent. After a simple character modification to start with, a jovial subject becomes taciturn and apathetic or vice versa. In a few months, except during periods of abnormal sleepiness, there is mental deterioration. Absconding and criminal acts can follow and lead the patient into prison. It is not rare, in the course of systematic checks, to find, in living quarters for mentally disturbed people, one or two unrecognised cases of African trypanosomiasis… who can be cured with appropriate treatment, if the state of the illness is not too advanced.

PSYCHIATRIC DISORDERS IN EUROPEANS IN THE TROPICS

After a career in the colonies, Alexandre Le Dantec*, having become a Professor of Medicine in Bordeaux, remains convinced in 1927 of the reality of the "protracted action of heat on the nervous system". According to him, the sun "excites the mind". He relates the case of a colonial administrator who experienced insanity once in Saigon. Sent back to France, he recovers his health of mind. He leaves for Guyana… a new attack of madness… returns to France and is cured but declared "unfit for service in hot countries".

Those who are predisposed or fragile are likely to develop emotional disturbances, especially if they are bachelors and relegated to isolated posts where the very high temperatures induce nights of insomnia. These emotional states, however disturbing, are compatible with professional activity… while waiting for a desired transfer or the end of the period of duty.

In Sudan there rages the most typical form of this disease and the most widespread : "Soudanite". But in Southern Algeria "Biskrite" is also observed (in Biskra), etc...

– Everything is calm in the centre where two or three Europeans live without any distraction. Then, one day, without warning, an argument breaks out with unusual violence. The most trifling detail increases hatred and can provoke a duel. "Man is transformed into a tiger", says Le Dantec*.

– In contrast to this phenomenon, "tropical neurasthenia" can be observed in other people. Having no desire to walk or to work, lying back in a deckchair, a man loses his appetite but also sleep. Every effort, physical or intellectual, becomes impossible. In despair, he fights against suicidal ideas. Then the hot season comes to an end, the trade winds blow again or the period of duty ends and everything returns to normal.

Meanwhile, some regrettable habits may have been acquired. Colonial alcoholism is not a legend. And this sort of dependence cannot be got rid of on returning to France !

In fact, from 1930 onwards, these emotional disturbances become exceptional when living conditions improve.

THE "PUZZLING" BEHAVIOUR OF NATIVE POPULATIONS - ETHNIC DISORDERS

Doctors as well as explorers have been struck by certain stereotyped behaviour patterns observed in the indigenous populations which are "abnormal", at least in their view. This "insanity of savages" is now called "ethnic disorders" or "mental illnesses characteristic of a culture". These disorders are specific to each society. P.Giudicelli* characterizes them as "homage rendered by Madness to Culture".

In Madagascar, collective fits of insanity called "Ménabé" and "Velonandrano", which Le Dantec* relates to hysteria, are observed. Groups of fifty or a hundred persons indulge in extremely frenzied and incoherent dance rituals. The contagion may spread to the whole village. "The wizards combat Ménabé with the beating of drums and all sorts of jugglery". The individuals subject to these paroxysms inspire dread; nobody dares to stop them or "prevent the propagation of the evil".

Under "ethnic disorders" we can also include the Madagascan "Tromba" and the banal "Fiu" of the Tahitians. These queer phenomena, however picturesque they happen to be, are difficult to fit into the present western psychiatric nomenclature.

PSYCHIATRIC DISORDERS IN NATIVE POPULATIONS

In order to identify a mental disorder and to measure its divergence from a hypothetical state of normality, the project of defining "indigenous mentality" is launched. France entrusts the pursuit of this study to two eminent colonial surgeons who are, moreover, anthropologists, Huardes* and Pales*.

– In Indochina, the study of ethnic groups is actively led by the anthropological school of Hanoi, directed by P. Huard*. Meanwhile, Dorolle* devotes many works to mental deficiency and Annamese mentality. Segalen does the same in China.

To solve the enigma that every mental patient represents, Aubin* is the first Frenchman to conceptualize the importance of culture in psychiatry. His colonial career takes him to India and Africa. His masterpiece, "L’homme et la magie" ("Man and Magic"), published in 1952, is a classic of French ethnopsychiatry. Under his direction, the Pharo school of psychiatry is initiated, which brings up to date the nomenclature of indigenous mental illnesses. This is an immense undertaking of which we can but mention a few examples :

– Schizophrenia, a disease typical in western psychiatry, is found overseas only in extreme forms whereas fits of delirium said to be polymorphous, brief and reversible, are very frequent in black people.

– Acute mania, with its spectacular agitation and noisy vociferations, has been the first, indeed the only psychiatric ailment that alienates a patient, that is, separates him from his family and his village and forces him to seek admittance to a hospital run by "Whites".

– Collective crises, rituals of possession similar to voodoo trances, remain enigmatic : their pathological nature (hysteria for westerners) has not been demonstrated. They correspond to what the group to which these people belong consider as normal or even beneficial.

– The same goes for delinquency: it is not to be found in tribal environments and if, in Madagascar, the Bara tribe steals cattle, they are merely following a rite of initiation.

THE ORGANIZATION OF PSYCHIATRIC ASSISTANCE IN THE FRENCH EMPIRE

Very early on, the French authorities are concerned about psychiatric assistance.

The first two asylums are established in 1832 in Saint Claude in Guadeloupe, then in 1872 in Saint Paul in the Reunion Island. In Martinique, the asylum founded at the end of the nineteenth century is destroyed in 1902 by the eruption of the Pelée Mountain. In Madagascar, the Hospital of Fenoariva is built in 1902, then that of Itasy.

In 1912, at the Congress of Specialists in Mental Illness, the organisation for psychiatric assistance in overseas territories becomes the object of some wished-for changes, notably :

– the training of colonial psychiatrists, both military and civilian,
– the construction of premises and establishments that constitute a network of psychiatric assistance,
– the complete stoppage of the transport of mentally ill people to French asylums.

The First World War interrupts these efforts. Later on, although not uniformly, the first achievements continue to develop.

In the 1930s, the disposition of training centres in the empire is as follows :

– In Indochina, three psychiatric hospitals : Cochin-China (700 patients), Tonkin and Cambodia.
– In Madagascar, the asylum of Anjanamasina, built in 1913, not far from Antananarivo (Antananarivo).
– In French West Africa (AOF), no psychiatric hospital but annexes in hospitals - One in Saint Louis, two in Dakar including the ambulance of Cap Manuel, dependant on the Principal Hospital.
– French Equatorial Africa (AEF) has no specialized training facilities. Some cases of sleeping sickness are treated in hypnosis centres for mental disorders.
– In the remote islands, one finds the asylums already mentioned - those of Guadeloupe and Reunion Island. In New Caledonia, the remnant of a prison administration office shelters 16 patients.

In 1938, the Congress of Specialists in Mental Illness is held in Algiers. The spokesman is Aubin*. He defines the new basis of indigenous psychiatric assistance (API). He speaks of mental hygiene and prophylaxis and proposes two grades : that of the colony and that of the federation. For French West Africa, a great psychiatric hospital in Thiès, Senegal, is envisaged. It will never see the light of day... As after the congress in Tunis, a worldwide armed conflict annihilates these projects.

COLLOMB AND THE FANN SCHOOL

In 1958 Collomb* (1913-1979) arrives in Dakar as the first incumbent to occupy the newly constituted chair of neuropsychiatry at the faculty of medicine. His colonial career has already given him a knowledge of Somalia, Ethiopia and Indochina. He has just vacated the corresponding chair in the Pharo.

He serves in the new Fann Hospital. He soon gathers round himself a host of ever-changing collaborators from different horizons: psychiatrists, but also psychologists, sociologists, ethnologists, both European and African. Among the latter, there are doctors and nurses trained in the west, but also healers, from the humblest to the most reputed. He says he has learned much from them simply by being with them often "without asking direct questions in the manner of interrogators".

Collomb is also keen on meeting healers and patients in their own environment. He himself goes willingly towards them - using modern means of transport ! Flying his own plane, he goes to and fro across the sky in West Africa. The "flying psychiatrist", this white man coming down from the sky and going up again ! What an impressive symbol in the eyes of the black village healer (medicine man) for whom he has made the journey !

In university circles, he founds journals, learned societies, academic cycles of specialisation. The fame of the Fann School of Psychiatry spreads beyond Black Africa and France. In 1978, leaving his post to one of his African students, Collomb returns to France and is given an appointment at the Faculty of Medicine in Nice. He dies the following year.

THE DOCTRINE

From the time of his masterful lectures at the Pharo in 1955, Collomb makes it clear that his field of studies is essentially Black Africa "for reasons of experience and documentation".

To the Black African, the Western idea of the complete man seems insufficient. To the dualism of body-soul and psycho-somatic, the African substitutes the quadruple complex "theo-socio-psycho-somatic", according to the terms used by the Benin ethnosociologist, Father Daï. African cultures which influence the healer take into consideration, moreover, the soul and religion as well as membership of the group.

First of all, religion impregnates everything. "The African is always religious" says the learned Malian Amadou Hampaté Ba. He must therefore live in peace with superior beings - on the one hand God and/or animistic divinities; on the other hand, spirits, invisible creatures, what the Ouolofs of Senegal call the "rab".

Next, the traditional individual cannot be studied and does not even conceive himself except in relation to his group (family, tribe, clan, ethnic group …). "In Africa, there are only groups" says Collomb. The group surrounds and protects everyone but expects conformity of thought and behaviour. "The I of the African is a collective I" says the aphorism. The individual who forgets that becomes vulnerable.

As Aubin* emphasises, contrary to the what is called scientific thinking, "there is, for ’magic thinking’, a fundamental finality in Nature : nothing ever happens entirely by chance". It is also said: "Africans don’t believe in luck". In the magic mentality is integrated animism, the cultural African religion in which "everything has a soul". There is also the whole series of rites, taboos, and symbolic behaviour that one believes susceptible of reacting efficaciously on beings and objects, in the order of "Mana". This Oceanic term dear to ethnologists signifies a "primordial force radically distinct from every natural force" (P. Giudicelli*).

On the other hand, according to Collomb, getting to know these healers reminds us that medicine is a branch of humanism. Among the Blacks, "it conveys values which the west no longer recognizes" (1976).

Let us consider, as an example, a very important moment in medical procedure : diagnosis. The European psychiatrist (or the African trained in European methods) is content to identify the symptoms and the variety (the "how") of the disease : depression, schizophrenia, a maniacal fit... On the other hand, it is of little importance to the healer if the patient has feelings of anguish or hallucinations. His diagnosis must identify the "why" and the aggressor : a sorcerer ? a "rab" ? And he must solve two problems :

– How to put an end to this aggression (and make the aggressor let go of his prey)?
– How to restore the sick person back into his group ?

These considerations show a radical difference between the western procedure, where the mad person is separated from others, "alienated", and the African procedure which seeks to end the separation from others and helps the mad person to find once again his place in society.

THE APPLICATION OF THE DOCTRINE IN THE DOMAIN OF THERAPY

In Dakar, Collomb* stigmatizes the old opposition science/superstition and breaks away from the narrow colonial mentality according to which "Whites have everything to teach and nothing to learn". In 1977 he says: "We must accept the fact that at the moment healers have more success in treating mental diseases… The roles are being inverted, it’s the psychiatrist who listens to the healer; he doesn’t teach any more, he learns". Suddenly, ethnopsychiatry, a speculative or cognitive science, is going to acquire a therapeutic component that is pragmatic and specific to the society in question.

Collomb’s genius consists in the fact that, after having stated and published this observation, he begins to put into practice the collaboration between European psychiatry and traditional African psychiatry. This syncretism is appreciated by the patients because, for black people, "In the hospital they calm you down, but only the traditional practitioner can cure you".

When Collomb arrives in Dakar, the first attempts in this field have just been realised by T.A. Lambo, a professor of psychiatry trained in Great Britain. Returning to his native Nigeria, he has just founded in Abeokuta the first "therapeutic village", trying to use in appropriate fashion both modern psychiatry and African psycho-sociology. The two colleagues appreciate each other and begin a fruitful collaboration.

In his service at the Fann hospital, room to room visits and medical prescriptions by the boss are brought to an end. The two great innovations are the intervention of the healer, more a religious figure than a therapist, and the overwhelming role of families.

Once a week, in the shady courtyard of the service, there is a general assembly, the "Pintch", a sort of reconstitution of the interminable discussions in African villages. All the patients and their relations are present. One of the patients is elected on the spot as the president of the meeting. The debates and exchanges take place as in the village in the vernacular tongue. Doctors and staff are just simple participants like everybody else. The healer does his work and intervenes as much with the patients as with their families. Women prepare the meal which will be eaten together. Sometimes there are traditional dances to the rhythm of the tom-tom beat.

Thus receiving treatment from the group and in the group, with the possible administration of western medicine, the mental patient, after an interval more or less drawn-out, finishes his convalescence in the bosom of his family.

THE APPLICATION OF THE DOCTRINE IN THE INSTITUTIONS

In what concerns psychiatric assistance, the establishment of asylums and psychiatric hospitals is called into question. At Thiyaroye, close to Dakar, in 1958, the building of an asylum for 200 patients is planned. After the construction of the first section of 80 beds, the project ends, undoubtedly on the advice of Collomb.

The new formula is the therapeutic village. Patients are admitted with their families and work in the fields. Healers practise there side by side with the nurses; psychiatrists trained in the west arrive periodically. These settlements function in a manner similar to that of therapeutic villages intended for people suffering from sleeping sickness and for lepers.

Almost all the French-speaking psychiatrists in West Africa are students or adherents of the Fann School. They are altogether convinced of the efficiency of its methods. But, for budgetary reasons, only some of them have been able to put them into practice.