11 The role of religion in suicide prevention work in Uganda

Central themes of traditional religious practice in Uganda have been the role of a creator, an understanding of life in an integral sense and maintenance of contact with the spirit world. Christianity was introduced to Uganda at the end of the nineteenth century and was associated with the colonial powers. Subsequent expressions of religious beliefs juxtaposed traditional and European beliefs. Present expressions of cosmology in everyday life mainly involve a strong sense of the collective and its responsibility, breakdown of which, and the subsequent loss of cohesion, plays a central role in suicide. Suicide has usually been seen as an uncommon occurrence in Uganda, but recent research suggests that this is no longer the case. The rise in suicide may be the result of substantial social changes and long-term strife affecting the population. Associated with this have been examples of mass suicide and internal wars, which have resulted in mass killings which may have their roots in traditional and non-traditional religious beliefs. An understanding and knowledge of the traditional world view of Ugandans may be helpful in developing strategies for the management and prevention of suicide in Uganda.

Contemporary Uganda is a predominantly Christian country, with a significant minority of Muslims. Traditional religions and practices dominate the private lives of many Ugandans, but are today often inseparable from Christian practices. Across the world, religion concomitantly serves social and political purposes as well as individual needs. In this chapter, we discuss the traditional religions, their evolution and social effects, which may assist in our understanding of the phenomenon and prevention of suicide. We then provide suggestions for research and suicide prevention that incorporates traditional notions of a meaningful, peaceful and worthwhile existence on earth.

Traditional religious practices have varied across Uganda, but a central theme has been that life has been understood in a holistic or integral sense, with a creator giving knowledge about life; how to promote it, transmit it and heal it (Byaruhanga-Akiiki 1995). Human existence on earth is in constant touch with the spirit world; humans do not pass away in death, but proceed to new life in the spirit world where ancestors and the great God, who is responsible for all that happenings on earth, live (Oguejiofor 2003; Onah 2003), and along with ancestral spirits, are adored regularly through prayers (Ndoleriire 1995; Nyamiti 2005).

Christianity was introduced to Uganda by Europeans at the end of the nineteenth century, and Islam was ascertained in 1844. The first British explorers, Speke and Grant, visited Uganda in 1862, and were followed by Henry Morton Stanley, who attended the court of the King (Kabaka) of Buganda. Stanley took a letter from the Kabaka, which later appeared in the Daily Telegraph, back to England asking Queen Victoria to send missionaries to Buganda in order to teach the people about the Christian religion and ‘Western knowledge’. This move to the British may have been prompted by the threat faced by the Kabaka from Egypt and from the neighbouring King of Bunyoro (Mutibwa 1992). The first Anglican missionaries arrived in 1877 and Catholics in 1879. Uganda became a British Protectorate in 1894, and remained so until independence in 1962. The early missionaries, and their respective African followers, were in conflict and this was fought out in the court of the Kabaka, giving it a political dimension, which resulted in civil wars in Buganda and the later dominance of the protestant faction. Protestantism became equated with the establishment and the colonial powers. In the colonial period, state and church were initially established as separate institutions: the Anglican church came to be associated with the Kingdom of Buganda, and the Catholic church with the democratic opposition in the rest of the country. After 1930, an African revivalist movement, the Balokole, arose and was critical of the established church hierarchies; subsequently establishing itself as the predominant church movement. The arrival of Christian missionaries transformed traditional beliefs and practices: out of the colonial invasion sprung transformed religious expressions juxtaposing indigenous beliefs with those from Europe (Behrend 1999).

An example of this transformation can be seen among the Acholi and Madi in northern Uganda. Spirits (Acholi—jok, plural jogi, in Madi ori) played a central role in the Acholi and Madi cosmology and religion (Behrend 1999). These jogi were mediated through mediums called ajwaka (Acholi) or ojo (Madi) and operated in the public or private arena. Traditionally, the jogi of chiefdoms and clans were responsible for the collective welfare of man and nature, and war as well. In addition, ‘free jogi’ could be used privately by ajwaka for good or bad purposes. With colonialism and consequent reduction in the power of the chiefdoms, these ‘free jogi’ predominated; often incorporating terms and forms taken from foreigners (Behrend 1999). External influences, such as the Christian belief of duality, of good versus evil, gradually altered the worldview of the Acholi and Madi, and produced a variety of spirits that could be used for witchcraft. The previous cultural system had ensured that all spirits lived in harmony with their relatives still on earth. The revivalist Balokole movement reinforced this, but introduced the ideas of salvation, which were previously unknown in Acholi and Madi religion. These newer ideas created the possibility of prophesy, which predicted the end of the world. Newer Christian spirits emerged in the 1970s and 1980s at a time of crisis and conflict for Uganda. The tipu maleng (holy spirits) and their mediums (nebi, the Alur ethnic group) were different in nature from the ori, jogi and ajwaka. These new spirits were unambiguously good; the nebi healed and did not bewitch or take revenge. These developments of prophesies and tipu maleng may have been influential in key movements in northern Uganda led by Alice Lakwena and Joseph Kony (see below). Both movements, like the Balokole movement, were concerned about evil and sin that threatened salvation and life after death; both movements sought to restore purity, hope and salvation from eternal destruction.

In Uganda, it is widely believed that ancestral spirits, and the spirits of other dead relatives, live among the living and special shrines or huts are constructed for ancestors to live in. Among the Madi of north-western Uganda, every home has a guard post (tumi) for ancestral spirits to guard the entrance to the home of the living, protecting the residents against the intrusion of evil spirits and other malevolent forces. For the good health of the living, ancestral spirits are kept happy by timely offerings, paying homage and prayers, leading morally upright lives and strict observance of taboos by everyone. Clan and cultural leaders, and chiefs who represent the dead on earth, are supposed to lead exemplary lives. They are a source of inspiration in bad times, intercede with ancestors on behalf of the living in case of trouble, make rain, bless clan warriors in times of war, and provide treatment in case of ill-health. Elders at family level provide training in all spheres of life for the young, and ensure that the young shoulder the past burdens of the clan and family, and propagate and protect the past glories and successes of their ancestors. The roles of ordinary people are to respect chiefs, clan leaders and family elders; lead morally upright lives; meet personal obligations and responsibilities to the community and clan; take care of the needs of ancestral spirits at family level; provide for the welfare of the community and group; and protect the general interests of the clan and family.

The traditional cosmology of Ugandans may be summarized as a collective recognition of the universality of the human condition: what happens to one person will ultimately happen to the next. What happens in a person's life may be traced back to their own roots and past history, or may be due to the malevolent intentions of their enemies executed by evil spirits or through acts of witchcraft. Ill-health and other forms of personal or group misfortune may be understood in terms of personal or collective group failure. People are expected to endure the human condition, seek help from the relevant agents, submit to group expectations and admit any acts of wrong-doing in reconciliation and repentance. In this way, people become rooted in the larger group, and experience the value and meaning of a full life in relationship to the value systems of the larger group. Individuals contribute to, and receive from, the larger group in a reciprocal manner, making life on earth worthwhile and making suicide, due to general psychosocial difficulties, irrelevant for most people. The occurrence of suicide has usually been observed in relation to individual or group failures in the observance of cultural norms, values, regulations, taboos and fulfilment of personal roles and obligations that severs interpersonal relations and makes susceptible individuals vulnerable to self-destructive behaviour. Interviews with various community groups and suicidal individuals reveal the significance of group cohesion and personal sense of belonging to the larger group, the recognition by group members of the value of each member in the group, and respect for each group member by members of the larger group. The sense of belonging is particularly strong among the elderly when they persistently express the wish to die and join the company of their dead colleagues whenever they face the challenges of social isolation in old age in contemporary society in rural Uganda. Suicidal women value the respect that their own offspring ought to accord them in old age, in recognition of their suffering and sacrifice in the upbringing of their offspring. Young women of active childbearing age derive tremendous value in being able to bear children and being able to fend for the children and their fathers. Children and adolescents become suicidal if their parents or guardians fail to educate them, and/or protect them from physical and psychological harm, as occurs in child abuse and neglect.

Cultural and traditional religious beliefs and practices, even when incorporated into Christian systems, are reflected in Ugandan social life in which collectivism predominates. Social networks are established using all available forms of social processes aimed to enlarge individuals' social support systems. Marriage between clan relatives is discouraged in order to widen and strengthen social networks, and equitably share wealth in the form of bride price. Homogeneity in religious affiliations is encouraged to strengthen social bondage between individuals. Alliances in political affiliation are sought after to strengthen the sense of belonging, social security and group dominance over others. What belongs to one person belongs to the group or family, community or clan on earth and to the spirits in the invisible world. Personal success, joy, possessions and other forms of wealth are shared, but so are all forms of loss, misery, sorrow and costs. Urban city dwellers, whether from the same clan or tribe, set up their own microcosmic worlds in order to retain their sense of social cohesion against potential adversity, and these in turn, keep in touch with their primary rural communities and keep their loyalties of extended family and village ties that hold them together (Leopold 2005). People frequently return to their villages from their residence in the cities to join members of their village community in solving family and clan issues, take part in funerals or celebrate important traditional rituals and cultural events like naming and christening a child, initiation, marriage ceremonies or other festivals. Elders from the countryside visit relatives in the city to discuss clan and family matters. City dwellers send financial assistance to their rural home communities to support various development projects or to pay for the education of children from financially less capable families. In this way, people of the same lineage provide support to one another at all times in the face of harsh conditions of living.

Orley (1970) suggested that suicide was uncommon in Uganda, but more recent studies suggest that this is not the case (Ovuga et al. 2005a). Social changes over the past 100 years have altered traditional Ugandan society, and with endemic poverty, the advent of AIDS, perennial political strife and continued conflict leading to the internal displacement of more than 1.8 million people in northern Uganda alone and hundreds of thousands of refugees living in Uganda, the conditions are ripe for an increase in the rate of suicide. People struggle with little success in establishing new social alliances and groupings in which they might be able to fit and derive meaning for life. Poverty and unemployment levels are high. Alcohol abuse is common among the rural poor and other population groups resulting in significant social, economic and occupational impairment (Ovuga and Madrama 2006). People in some areas of Uganda currently have no ready access to the universal community support that individuals enjoyed during the first half of the twentieth century and earlier. Under such circumstances, people feel uprooted from the core of their existence, abandoned, and lack of meaning and purpose for existence. Life no longer seems worthwhile under the psychosocial strain that they might experience, paving the way to an escalation of suicide rates and the emergence of cult movements (Dein and Littlewood 2005). Sociopolitical and consequently economical changes, which could eventually have an effect on these phenomena, can hardly be foreseen in the future.

In African cultures, mental illness is equated with madness. Less severe forms of psychological disorder may be labelled as ‘stress’ or a ‘psychological problem’ in an effort to grapple with the reality of emotional ill-health and its associated shame, stigma, fears and the eventual threat of discrimination. Mental illness can be conceptualized as a broad spectrum of ill-health, ranging from general symptoms of psychosocial distress to chronic psychotic behaviour that predisposes the affected person to social neglect and eventual death. Figure 11.1 illustrates a hierarchical concept of mental illness in Uganda. This figure is based on work carried out by the two authors using focus group discussions in two areas of Uganda, and field work in Adjumani and Gulu districts (Ovuga 2005; Ovuga et al. 2005a, b).

Mental ill-health occurring at the lower levels of the hierarchy may present with symptoms of dissociation or spirit possession (Ovuga 2005) for which therapy may be provided by a traditional healer. Symptoms of general psychosocial distress, including suicidal behaviour, may initially be handled by family, clan elders and close friends. Less severe forms of illness experience are explained and interpreted in terms of social cultural and existential experience and pain. Eighty per cent of traditional healers in one Ugandan district reported a personal history of mental illness (Ovuga et al. 1999) before they were trained as healers. In this context, African societies respect individuals who develop mental illness; affected persons who go on to become traditional healers enjoy high levels of respect, fame and prestige in their communities for having found favour to become mediums for ancestral and other spirits.

Once intercessions by recognized traditional healers fail the phenomena of social neglect, stigmatization and discrimination ensues as this signifies punishment from the spirit world. It is, however, important to recognize that African societies and cultures do not just neglect, stigmatize or discriminate against their kin who develop severe mental illness. This terminal phase in the evolution of mental illness to death signifies that the causes of the illness are simply too powerful for the family and traditional healer to tackle.

Problems in living, such as loss, disputes, unfulfilled rites of passage, problems of sexual unfaithfulness and poverty give rise to general symptoms of distress. Resulting cognitive evaluation of this paves way to the experience of ‘stress’ and fears over personal security safety and survival within an individual's cultural milieu. Persistence of distress leads to worries and brooding that result in ‘depression’ (equated with severe mental illness). When presented with vignettes depicting typical non-psychotic major depressive disorder, participants in Uganda interpret the symptoms as evidence of severe mental illness. Depression is invariably believed to lead to mental illness (seen as a form of chronic deteriorated psychotic illness) whose ultimate end is death. Depression as defined by existing diagnostic systems does not exist. Instead, this form of illness is explained within the context of social, cultural, and individual experience of real or imagined social adversity, crimes against social and cultural institutions, and the neglect of the welfare of the spirits of the dead. The spirits of relatives draw attention of the living to their welfare needs or anger over crimes committed by their relatives on earth by precipitating an episode of acute psychotic disorder. The spirits of the dead who have no living relatives may seek shelter from the family of an affected person through similar mechanism. Granting the wish of the spirit through the medium of a traditional healer leads to cure and the attainment of health for the affected person. Thus, African religion and ways of life foster harmony between the living and the dead, and the development of mental illness would suggest problems between the individual and the world of the dead, living and the gods. Health is restored with therapeutic strategies that seek to restore harmony between the affected individual, their family and the world of spirits.

Suicidal behaviour in Uganda is a crime and attracts shame, fear and avoidance, leaving behind a mark of impurity on the families of those who kill themselves. Attitudes toward suicidal behaviour are characterized by fear, shame, denial, stigma, avoidance behaviour, rejection and revulsion among friends and family. Suicide is a taboo subject liable to criminal prosecution and conviction. According to the Uganda constitution of 1995, suicide dehumanizes the individual, undermines the individual's dignity and right to life, robs the state of human capital and usurps the power of lawful killing from the state. The children's statute of 2003 criminalizes adult suicide on grounds that the suicidal person abdicates their responsibilities to provide for the needs and welfare of children under their care. Suicide is simply unlawful according to the Uganda Penal Code.

Suicide in Uganda is thought to arise from inheritance based on the observation that members from certain families seem to be at high risk for suicidal behaviour. It is believed that suicide behaviour may be the consequence of bad omen, witchcraft or the result of previous ancestral wrong-doings. Cultural explanations for suicide are similar to those for mental illness. Poverty, poor interpersonal relations and alcohol abuse have emerged as additional contributions to suicidal behaviour, particularly in the post-conflict of northern Uganda. Family, friends and clan elders provide initial counselling services to suicidal persons. The services of traditional healers are sought once the efforts of family and clan elders fail. Proximal factors that lead to suicidal behaviour include disputes in interpersonal relationships or the lack of material resources (poverty) necessary to support basic human needs and allay emotional distress.

Written accounts of traditional attitudes towards suicide are uncommon, and it remains unclear as to the influence of the colonial powers who introduced the laws on suicide. It would appear that suicide behaviour remains unaffected by the laws that seek to prevent them. Orley (1970), in his monograph of mental illness in Uganda, suggested that suicide was considered a ‘most terrible act’ among the Baganda. The body of a person who committed suicide was feared and suicide treated as contagious; no one of the same clan should touch the body as its ghost may enter him, causing the person to be tempted to kill himself (Orley 1970). Social responses to suicide include the performance of cultural rituals involving the sacrifice of animals. Among the Madi, rituals were performed to cast out the perceived evil for suicide and the tree from which a victim hanged was hewn down and burnt to ashes to prevent the act among surviving members of the victim's clan. The body of a suicide victim is hurriedly buried at the site of death without religious ceremonies or the enthronement of an heir. With the coming of newer religions, prayers and biblical teachings are used in the therapy and prevention of suicide behaviour.

On March 17, 2000, Ugandans woke to the news of the world's second largest cult suicide involving some 500 people, mainly women and children, burned to death in their chapel at Kanungu in the remote poor rural south-western Uganda district of Rukungiri. In the weeks that followed, 500 more bodies were discovered buried under the concrete floors of several houses belonging to cult leaders of the Restoration of the Ten Commandments, led by Joseph Kibwetere (Atuhaire 2003). Details of the cult remain obscure, and a planned government commission of inquiry to investigate it was never inaugurated to do its work, but its origins lay in the claim by a cult member of visions of the Virgin Mary and Jesus Christ. The cult prophesized that the cure for current hardships was the restoration of the 10 Commandments, and failure to do so would mean the end of a generation and the beginning of another one through a series of chastisements foretold by the Virgin Mary. They believed that only a quarter of the world would be saved. The power of this prophesy may be the mixture of the background context of a country afflicted by conflict, HIV/AIDS, poverty and the universal phenomenon of apparitions of the Virgin Mary, which may be seen to have a continuity with the older beliefs in the spirits.

On 2 January 1985, an Acholi woman, Alice Auma, was possessed by a Christian spirit, Lakwena (meaning ‘messenger’), for which she became a medium (Behrend 1999). This later resulted in Alice Lakwena, as she became known, creating the Holy Spirit Movement and an army, the Holy Spirit Mobile Forces (HSMF), to wage war against evil. The movement purified Acholi soldiers returning after fighting with the National Liberation Army (NLA), the army of the new government, and took them into the HSMF. Lakwena's aims were essentially moral and peaceful, aiming to create ‘new humankind’ and ‘a new society … full of love and humility, all expressed in unity’ (Behrend 1999). Other spirits possessed Alice, and the army that was created, had highly ritualized preparations for battle, including being sprinkled with water, ‘loaded’ with the Holy Spirit, and coated with shea butter oil to make them bulletproof. The HSMF won a series of battles with the government forces and marched from northern Uganda to Kampala, only being defeated at Jinja, not far from the capital. Joseph Kony, who founded and leads the Lord's Resistance Army (LRA), which was created out of the remnants of Lakwena's and the Uganda People's Democratic Army (UPDA) forces, has continued the war in northern Uganda for two decades. Kony claims to be a relative of Alice, and also acts as a medium for similar spirits.

These two examples of powerful figures leading fighting movements, the latter of particular brutality, combine aspects of examples of the dynamic bidirectional transition of traditional religious ideas into, and from, Christian beliefs in the setting of long-held cultural beliefs and continuous strife that has disrupted social relationships between the living and the dead, and promotes the potential for psychosocial distress, self-destructive behaviour and this particular type of war as an externalized equivalent of mass suicide. Like Alice Lakwena's HSMF, the LRA claimed that its mission was to create a new and pure Acholi society and to replace the impure, sinful and corrupt government of the day with one based on the teachings of the Old Testament. In an apparent attempt to fulfil its prophecy, the LRA set out to use brutal force to recruit personnel into its ranks, intimidate the populace and turn young abducted girls into wives to recreate a new Acholi society. Under the circumstances of war and violence, the communities were caught in between two opposing fighting forces with no protection from anywhere. Even though the government subsequently began moving whole communities into internally displaced persons' (IDP) camps, the populations initially resisted as this would undermine their cultural and traditional identities and ways of life. The communities in northern Uganda thus preferred to wait for every one of them to die in the course of the war, having surrendered into a state of helplessness and hopelessness.

Approaches to the management and prevention of suicide may need to be revised in order to incorporate the traditional world views of individuals and communities. In this way, the applications of scientific research will perhaps bear significant impact on suicide management and prevention in situations of chaos and helplessness. Current efforts in suicide prevention place too much reliance on biological, epidemiological and statistical data that bear no relevance to individuals' life circumstances or their evaluations of these (Onah 2003). For instance, the desire of an 80-year-old man in rural Uganda, without significant social support from his sons and daughters, to end his life by suicide in order to join the world of his peers who have long died may not be predicted solely by detecting traditional risk factors. It is necessary to additionally define his view of the world and quality of existence, in addition to an evaluation of risks for suicide in the usual clinical sense. Management might then require the provision of social services relevant to his situation.

The review of traditional religious practices in Uganda would seem to suggest the need to create social, political and health care systems that protect and strengthen traditional linkages within kinships, as a major collective contribution toward suicide prevention, by promoting overall health and social welfare. Concrete steps in creating this system, and which have proved effective in Adjumani district of Uganda, comprised training village representatives to recognize early warning signs of psychosocial distress, make thorough psychological assessments within the cultural belief systems of communities, provide opportunities for distressed persons and their families to narrate their difficulties in a therapeutic atmosphere, arrange for family group meetings to settle conflict issues, and to refer individuals with more complicated mental health problems to health care providers in the community. The training of village representatives, known in the context of Adjumani district as village helpers (VHs), was based on four culturally recognized common causes of psychosocial distress in the community: loss (most commonly in the form of bereavement), disputes (with fear of witchcraft), unfulfilled rites and poverty. Identified mental health problems are discussed based on an understanding of the emotional, cognitive, relational, and behavioural impacts of the causes of distress on an individual and the immediate members of their social group.

Following the institution of this approach in 2004, in Dzaipi, a subcounty in Adjumani district, the rates of completed suicide decreased from 206 per 100,000 in 2004 to 105 per 100,000 and 91 per 100,000 in 2006 for a base population of 18,612 inhabitants. Likewise, the rates of attempted suicide dropped from 452 per 100,000 in 2004 to 370 per 100,000 in 2005 and 270 per 100,000 in 2006. Thus, appropriate suicide preventive measures at population level might aim to improve social rootedness, and revitalize and sustain social and cultural practices that made life meaningful for the ordinary person in society. Advances in agricultural modernization, economic development, and democratic governance should aim to provide for the needs of individual members of society, as well as the protection and welfare needs of group entities within the national borders of individual countries. Research to develop interventions for the management and prevention of suicide from this perspective is recommended.

We recommend that the channels of communication be opened between biological and social sciences in the field of human health, with the aim of fostering close collaboration between the two groups. These disciplines have a vital input to make, and these contributions may be maximized through mutual respect for the understanding provided by the other in the field of suicide prevention and the promotion of health.

Rates of suicide appear to have increased in Uganda in line with social changes and continued events that threaten the physical and emotional integrity of the population. An understanding of the traditional world view of Ugandans, and its adaptations in line with the introduction of Western religion, along with the known international literature on suicide, can help inform the management and prevention of suicide in Uganda. In particular, the emphasis placed on the collective nature of Ugandan society and the importance of kinship links can inform possible preventative approaches to suicide prevention as well as the treatment of the disorders underlying suicide.