Charles Chukwuemeka Dike, MD, MPH: The Path from Lagos to New Haven

The Early Years

Charles Dike was born on November 4, 1965, a day in the Catholic church calendar that honored St. Charles, apparently known as a loving reformer. Charles's mother's preference for the name of a sanctified church figure over more secular choices foretold how the parents would organize the household and structure its values. One can easily imagine bystanders already dressing young Charles in the vestments of an altar boy and encouraging him as he studies the Catechism in preparation for his first communion. It must have been a joyous time. Six more children followed baby Charles (he had an older sister), with the eight boys and girls evenly divided. The increasing family size may explain why the school-teacher mother soon decided to stay home and attend to her children, while father worked as an accountant and general businessman.

Charles was born and raised for a short time in Port Harcourt, a city in Rivers State, Nigeria. He grew up, though, in Lagos, a capital city located in southwest Nigeria. Although Lagos has been considered a region dominated by the Yoruba tribe, its urban flavor has long attracted members of other groups. The Dike family are Ibos. The father insisted that English be the language spoken at home, which reduced the children's fluency in their native Ibo tongue. The family head may have prioritized English because of his involvement in business. He may also have understood the status of language fluency in a broader political context. The British entered that area of Africa around 1884, took it over as a protectorate in 1912, and gave it independence in 1960. The Biafran Civil War (1967–1970), in which the Ibos played a central part, probably added some emphasis to the role that language skill would play in the future of Nigerian emigrants to Britain, the Commonwealth, and North America.

The Dike's family residence in Lagos was a three-bedroom apartment. When I expressed my curiosity about the use of home-space by ten family members, Charles pointed out, highly amused, that most of the time there were at least two other youngsters present. His parents regularly agreed to take in youth from their village to be educated in Lagos schools. That practice was a commitment commonly agreed to in Nigeria to assure that disadvantaged families could have their offspring educated. The contract was simple. Villagers asked city folk to take in a child and make sure that child attended school. Charles also explained that this practice was the backbone of another tradition that required him, once placed in a job as a young adult, to send money home for the education of younger siblings.

There was a flexible use of space in the apartment. Showers were mandatory before going to school or to church. This rule required that bathing rituals be brief so that everyone could leave home on time. There was no formal dining room for simultaneous use by the whole family. Yet, they learned how to eat at the same time while sitting in different places within the apartment. Other rules, installed and enforced by a careful father, were observed by the entire clan. Everyone was up by seven o'clock in the morning and back in the house by seven in the evening unless permission had been obtained before leaving home. There were also in-home jobs, assigned as a function of age. Charles described his having to wash cars on Saturday, inside and out, with little recognition expected from the parents. Work was a clearly defined expectation.

There is a frequent observation in tropical developing countries: the warm climate, limited indoor space, and large families push parents to let the children find their different ways of using leisure time and enjoying play. This habit is encouraged when there is little fear of anything happening to the children in the immediate vicinity of home. So, running and jumping and playing games with friends naturally emerged in our conversation. And unsurprisingly, he turned to discussing his skill in soccer. The neighborhood soon took note of his moves, quickness, and tricks with the ball. I laughed at my own familiarity with how soccer players look back and describe their exploits with unabashed precision and clarity. He began to be recognized as someone to be watched as a future player for the national team. His dad, looking at the future, snuffed out those dreams quickly. It made a lot more sense and was clearly more likely for Charles to obtain a university degree to be used in applying for a job than to make it as a player on a team in Europe. Tae Kwon Do, the Korean martial art, was another of his favorite activities. His talk about school, youthful play, popularity among friends, and closeness to parents summarized a joy of life in those elementary school years.

Education and Clinical Training

The family wanted to enroll Charles in a Catholic high school that turned out to be too far from home. The next choice was a prestigious government school. Government bureaucracy led to the decision to transfer a group of new students, including Charles, to the less celebrated Lagos City College. His family were upset and disappointed, but Charles stuck it out. He was named a prefect, a desirable leadership position known throughout high schools in the British Commonwealth. The reward confirms that students have established themselves in the competitive school environment. This position is traditionally accomplished through sustained commitment to the school's academic and sports missions, distinguished deportment, and evidence of leadership. It was eventually time to apply to university, and Charles opted for the onerous pathway to medical school. It was a seven-year journey that he started at age 15. The principal supervised the application process himself, leaving little to chance. The outcome was Charles's admission to the institution now named Obafemi Awolowo University, located in Ife. The course of study involved four years of a preclinical curriculum, successful completion of which was rewarded with a bachelor's degree in health sciences, followed by three years of clinical work. Having completed his undergraduate medical training, the next steps were the usual one year of a rotating internship and another year in compulsory national youth service.

With those requirements completed, Charles returned to Lagos and spent another two years working in group practices delivering obstetric, gynecologic, and pediatric services. Although the clinical experiences enhanced his confidence as a young physician, he realized that he was not advancing toward completing a medical or surgical specialty. Furthermore, the economic climate in Nigeria had become uncertain with the changes from civilian to military leadership. What may have made things a bit worse was that the university where he did his training had developed a reputation for militancy and political protests. Charles began to contemplate ways of emigrating to England or the United States.

An unexpected opportunity to attend a medical education conference in England presented itself. Charles has long seen this chance as a direct gift from Heaven. The opportunity included, best of all, a travel visa that permitted him to stay in the country to seek a formal training slot. He arrived for the conference in mid-1994 and immediately started studying for the required examination that permits foreign-trained doctors to engage in medical activities. He passed that examination in February 1995 and immediately applied for a temporary placement; the only one available was in psychiatry. The financial pressure forced him to take it. The temporary placement, located in Birmingham, was a success, enabling him to qualify for a residency position in psychiatry with the support of his supervisor. Charles persisted in his efforts and ended up gaining Royal College specialty qualification in psychiatry. During this period, he was still considering emigration to the United States for American training.

While pursuing psychiatry training in the United Kingdom, he had taken required U.S. examinations of the Educational Council for Foreign Medical Graduates (ECFMG) and still had Part 3 to complete. That portion could only be done in the United States, which meant that he had to obtain an American visa. His first application was rejected, and it hurt. He wrote a letter to U.S. officials and insisted that the rejection could only have been based on race, as he had met all the requirements to obtain a visa to take the examination. Charles stated that the reply letter agreed that an error had been made. The rejection had been so deeply painful that he took another year and a half to reapply. In the autumn of 1998, with the Part 3 ECFMG examination completed and an acceptance offer in hand from the University of Illinois at Chicago, Charles started his American training. He had two and a half years to complete rotations in medicine, neurology, emergency medicine, and psychiatry subspecialties. His performance was so strong that he was offered a place to continue training in internal medicine. This opportunity brought up once again the subject of how solidly rooted his choice of specialty was. He reflected on this time, recognizing that he had a good sense of what psychiatry meant in clinical terms. He also recognized that he had confronted all the training requirements and overcome the difficulties. Supervisors had also given him high marks as a trainee. This time he felt he was well suited. He turned down the internal medicine offer and turned to thinking more seriously about the subspecialty direction in psychiatry.

Charles discussed his interest in forensic psychiatry with colleagues and advisors. They supported his decision, and he gained admission to the Yale School of Medicine forensic psychiatry program for the 2001–2002 academic year. During his stay in Chicago, he had met a young woman named Ulari Maduekwe who was studying at Indiana University. Their marriage in 2002 underlined the decision that he stay in Connecticut. The university city of New Haven became the place where he and his wife raised their two children and where she established and sharpened her own professional identity in nursing.

Career Development

Charles started his first job as a staff psychiatrist on a unit at the Whiting Forensic Institute, Connecticut's secure forensic psychiatry facility. At that point, he did not appreciate the implications of the decision. He knew that a forensic hospital generally served difficult patients. He did not understand what “difficult” really meant. Neither could he have fully grasped then how oppositional the logic of clinical care and the principles undergirding patient choice could become. He had never confronted so starkly before the task of integrating ethics into clinical decision-making. These matters confronted him within the first month when he realized that restraint use on the unit and the use of continuous patient observation were out of control. Charles decided that these two problems were urgent matters requiring quality improvement strategies. He said it took about four years to improve practice in these domains and stabilize the changes so that one would consider the results to be a natural part of the unit's culture.

Change in this context is always hard. Staff are rightly concerned about their exposure to danger and wish to control their own safety. The task was to develop together ways to manage safety on the unit without an undue reliance on restraint and seclusion, and to gather and share the data that such new approaches did not, in fact, increase violence on the unit or staff injuries.

Charles spent four years on the unit between 2002 and 2006, before being promoted to serve as medical director of Whiting from 2006 to 2012. He became Whiting's director in 2012 until he moved in December 2014 to the central office of Connecticut's Department of Mental Health and Addiction Services (DMHAS) as deputy medical director. (He succeeded me as medical director when I retired in 2016.)

Charles saw those 12 years of experience in a forensic facility as “difficult and tough.” Part of the task was to provide clinical care to patients with severe and chronic illnesses, while managing the pressing concerns of legal (and other) advocates and navigating the confluences of union and government rules active in state psychiatric institutions. There was also the problem of violence and dangerousness among the patient population, much of which was further complicated by a lack of control over admissions and discharges, which at times required some extraordinary efforts to reduce the risk of harm to staff and patients. So, change and improvement did take time. Charles settled into a daily rhythm of patience and persistent pursuit of excellence in care, seeking the right balance between care and safety and security, while striving to maintain the dignity of both patients and staff in the context of a forensic hospital.

In 2002, when he took up the staff psychiatrist post at Whiting, he also kept his ties to Yale's School of Medicine. He attended the academic activities of the department of psychiatry's division of law and psychiatry, which allowed him to stay abreast of the forensic psychiatry literature and to make good use of interactions with Yale colleagues. He became active in the American Psychiatric Association (APA) at the national and local levels and cultivated contacts with other forensic psychiatrists in the American Academy of Psychiatry and the Law (AAPL). This engagement made it easier for him to seek advice and to structure a way of thinking about his work. In retrospect, it seems almost self-evident that he wanted to follow a career pathway that was multipronged. There was the clinical care of patients housed in a forensic hospital; the management of complex units and then administration of a facility; there was also the skill of integrating clinical work and ethics principles. In addition, he wanted to garner experience in evaluations and court work.

Time and experience are important elements in the acquisition of clinical and administrative expertise in all medical specialties. Somewhat more complicated is the simultaneous development of praxis in the academic context. Charles's involvement in the Yale forensic psychiatry program assured his development as a clinician-educator and scholar. I reread five of the group of peer-reviewed articles that Charles published with colleagues since 2015, as I wanted to understand what model he had used in melding the different strands of his activities. The first article,³ which focused on the transport of forensic psychiatric patients, explored the safety and custody challenges attached to the movement of these individuals outside the confines of a forensic psychiatry facility. The second,⁴ published in 2016, addressed the management of forensic hospitals. Then came a piece about a program to diminish restraint and seclusion use in a state hospital.⁵ The fourth publication⁶ discussed ethics in systems of care, and the last one⁷ concerned a U.S. Department of Justice investigation of Connecticut's state hospital. These five articles thoughtfully addressed forensic topics within the public sector, focused on practical leadership dilemmas requiring the attention of managers within the system.

The publications illustrate the importance of keeping forensic trainees aware of the burgeoning literature and the strategies that are intended to resolve problems. The collaborative approach is characterized by interdisciplinary reflection and problem-solving, which are especially useful in this genre of work. Solitary scholars in this arena tend to tire quickly, but Charles obtained substantial recognition for this emphasis on collaborative discourse. This recognition is why his publications have led to speaking invitations from universities, community agencies, and academic centers. The sophistication, maturity, and practical nature of his scholarly inquiry have gained him international notice. He was recently promoted to the rank of professor of psychiatry at the Yale School of Medicine, and the department of psychiatry also presented him its prestigious Stephen Fleck Physician Award. The Substance Abuse and Mental Health Services Administration (within the U.S. Department of Health and Human Services) named him to its national advisory council.

Influence of Religion

Religion came up in our discussions as we explored how Charles had developed a support system for staying strong in the face of adversity and conflict within his workspaces. He pointed out that religion has long made a difference in his life, and he has made use of faith groups to sustain his efforts in pursuit of excellence in different activities. He acknowledged needing God's help to assist him in resolving conflicts. Inviting God to participate makes him perform with more confidence and effectiveness; it also enhances his melding of honesty and fairness as he contemplates decision-making. He understands the political side of administration, but also finds it helpful to determine what God wants from his efforts. Charles is careful, as he explained his thinking, to make sure that he does not proselytize at work.

The presence of religion in his life has also introduced a certain patience in his style of coping with the subject of race-based contrariness in mundane matters. Race is an everyday ingredient in all that happens in a racialized university like Yale. Race rears its head in public sector transactions because minoritized groups are often among those lacking resources to access health care, education, and other economic benefits. Race also matters in decision-making within professional medical organizations like the APA and the AAPL. Charles spends a significant amount of time with these two influential systems trying to influence development of public health policy. In both spaces, he has served on important committees. He is currently chair of the APA's ethics committee; he is also president of the AAPL and chair of its diversity committee. There is now an eponymous Charles Dike Scholarship awarded annually by the AAPL.

While chatting about religion related to work, we noted its place in his dealing with the COVID pandemic. I was aware of the preparations that engaged the university as it confronted its obligations to patients, students, staff, faculty, and the broader community. Charles informed me of his involvement with this pandemic in the university context and made clear how he had major responsibility for state activities that concerned general psychiatric patients and the forensic group. There were activists agitating for discharge of patients, without appreciating the legal, political, and health implications. Resolution of this debate required careful reflection and consideration of the available solutions, while Charles did his best to respect individual dignity and the public health. Charles was pleased that he could rely on experience and training acquired some years ago during his studies for the master's degree in public health, obtained in 2004 from the University of Illinois, Chicago.

Reflections on a Career

It is a common practice for senior professionals in any discipline to look back and use some measuring rod to evaluate past contributions and contemplate whether there is enough time to conquer new ground. Charles said he was pleased to have contributed to the quality of care received by his public sector patients, especially those who were in the forensic arena. He also emphasized the coordination of that treatment. On his watch, the state's health system has now turned to including substance use and other medical services within general psychiatry, which is another try at whole-person care offered some years ago. Consideration of housing is now a formal dimension of each person's treatment plan.

We reviewed the obstacles encountered in trying to extend these examples of creativity to the psychiatry residents' training curriculum. Particularly in the forensic arena, trainees have difficulty understanding the importance of housing in the whole-person evaluation of an individual's needs and the inevitable connection to employment. We also agreed that expanding this attention to forensic patients always leads to recognition of the fiscal costs of such planning. There is also realization that supporting these individuals in the community requires leaders with political skills and increasingly broad public health knowledge. Charles feels the existence of a chasm between the needs and demands of forensic patients in the public sector and the kinds of forensic services offered to wealthier clients. He acutely senses this difference between the two types of forensic work. And he does his best to explain that the public sector and its private equivalent on the Yale campus should be bridged more effectively. He is not sure that university leadership appreciate the rationale that undergirds his commitment to public sector service delivery, which must include the forensic system. Still, he is pleased that at the end of the tortuous path from Lagos to New Haven, he leads, with other colleagues, a system that frames public psychiatric care for a needy swath of the population. He wants Faith Ringgold to know that he understands he is making history.