Only 5% of South Africa’s total health budget goes to mental health. Dedicated community mental health services are only available in Gauteng and the Western Cape. In shack settlements and remote rural communities, treatment for mental illness is inaccessible, unaffordable and not pertinent to the realities on the ground.
International best practice (and Life Esidimeni) show that governments should invest in community mental healthcare services and general hospital psychiatry, while continuing to support existing stand-alone hospitals, until community care is established and spending can wind down on stand-alone hospitals, said Professor Lesley Robertson, a psychiatrist who served on the expert panel for the investigation into the deaths of Life Esidimeni patients.
Although a National Mental Health Policy Framework and Strategic Plan 2013-2020 was produced in 2012 with the aim of providing accessible, equitable, community-based mental health care, to date there has been no funding to implement the plan.
“We are still practicing colonial-era psychiatry in South Africa. We fund our psychiatric hospitals more than any other aspect of care and these were all built before 1910,” Robertson said.
Poverty, violence, fragmentation and displacement are prevalent in communities that have poor access to healthcare.
Dr Alphonse Kanda, who runs rural mental health care clinics in the Magaliesburg area says where community mental health is available, it is not conducive. “My clinics are in containers, not in actual buildings, and the staff is not trained in mental health. The geographical location of the clinics means people who don’t have money to pay for transport can access services.”
Mental health has to be holistic and humanised, Kanda says. “This means not only the provision of medication but proper counseling and social services to address violence and poverty – and all these services have to uphold the dignity of the people being treated.”
The prevailing biomedical approach to mental health is also problematic because the focus is on medicating people as a way of dealing with helplessness and hopelessness because of poverty. ”We treat them with antidepressants or tablets for anxiety or to help them to sleep, but the main thing is poverty and poverty can’t be medicated.”
Poverty, inadequate investment by the government, inappropriate and inaccessible mental health services, and an apparent lack of political will to address the festering socio-economic conditions that fuel mental illness are in evidence throughout the country. Kanda and others are doing what they can to care for and support people who are struggling and suffering under untenable conditions.
In, Diepsloot, a stone’s throw from one of Gauteng’s most affluent suburbs – Dainfern, secured behind an electric fence and high walls – Nono Maseko manages the South African Depression and Anxiety Group (SADAG)’s counseling centre from a container. The two health clinics in the area don’t offer mental health services. “Patients with mental illness get admitted to Helen Joseph and then referred to us or sent to Sterkfontein,” Maseko said. Sterkfontein Psychiatric Hospital, which has been in existence since 1943, admits most of its patients from Gauteng.
Maseko runs several support groups, one (#rapeptsd), for women aged between 18-35, who are struggling with depression and post-traumatic stress disorder (PTSD) as a result of rape and domestic violence.
The container is located on municipal land, collaborates with – Lawyers Against Abuse (LvA) and the faith-based organisation Family Africa. As part of employment-creation, eight women grow vegetables alongside the container. The vegetables feed the women and their families and are given to two crèches on the property – one for HIV orphans and one for the children of parents with low incomes. What remains is sold to the community. Shoprite, who sponsored the container, has undertaken to buy the winter harvest. “We try hard to create employment,” Maseko says.
About 80% of the community is living in poverty, according to Maseko. “The challenge is that we have people from many nations living here and NGOs don’t cater for people without South African IDs, so they depend on SADAG, Family Africa and LvA.”
Depression, mental illness induced by substance abuse, PTSD – particularly as a consequence of rape and sexual abuse, which is pervasive in Diespsloot, is the same all over the country, Maseko says.
Sibusiswe Gana, a volunteer, lives in one room in Extension 13 in Diepsloot, where there is no electricity, with her partner and baby. She says depression goes with poverty and gender-based violence and “9 out of 10’ are suffering. “There is also alcohol and drug abuse – mainly Nyaopi – and there are new drugs in the schools,” she says.
Drug dependency is increasing. “We can’t see it getting better,” Maseko says. “Most kids taking drugs stay in a one-roomed shack and there are maybe 14 family members in the shack – and sometimes there is no food. We take them to rehab but when they come back the situation at home is still the same: mother and father unemployed and the whole family living on the grandmother’s SASSA grant.”
Youth on drugs are often HIV positive, Maseko says. “They come to me for counseling and then go across the yard to Family Africa for HIV support and food parcels.”
Maseko said teen suicides are on the increase in Diepsloot. “It is to do with poverty and unemployment,” she said, adding that many of those who take their own lives are learners from Diepsloot West Secondary School.
Professor Stoffel Grobler, a psychiatrist at the Elizabeth Donkin Hospital in Port Elizabeth, says mental health problems in the areas he serves cannot be resolved unless substance abuse is addressed.
He says that in his experience, abuse may begin with cannabis at around the age of nine or ten; then methamphetamine by age 14 or 15, and by 18 drug abusers are likely to have their first admission to a psychiatric hospital. “By 23 they will have had three or four admissions, and then you change the diagnosis from substance-induced psychosis to schizophrenia because the brain starts functioning in a different way.” Up to 90% of admissions to the Elizabeth Donkin psychiatric hospital are young males aged between 20-25. Grobler was unable to share exact numbers of patients admitted because of drug-induced mental illness currently in the hospital because of professional ethics. However, he said the overall patient load is lower than usual because a ward has to be left free for Covid emergencies.
“Rural health clinics that I work with in the Nelson Mandela and Sara Baartman Districts have amazing nurses who do their best with very limited resources. Substance abuse is where they falter. There is virtually no support that I know of for people who abuse substances…In terms of rehabilitation there is very little available in the whole country.”
Sister Maronese Davids manages the Graaff Reinet Healthcare Centre in Asherville. The clinic is open from 7 to 7 and staffed by six professional nurses and two assistant nurses, who see thousands of walk-in patients daily.
“We are poverty-struck here in Graaff Reinet , Davids says. “It is really difficult with psychiatry being integrated into Primary Health Care. We need a separate facility. We don’t have a psychologist or a psychiatrist here.”
Patients with symptoms of drug-induced mental illness are kept in hospital for 72 hours observation and then discharged. “They can’t be admitted because there are no beds for them. We feel so helpless,” said Davids.
In Diepsloot, Maseko works with traditional healers and churches, because both have a significant influence in the community. Clients who think their depression may be related to an ancestral calling are encouraged to see a psychologist and take medication and then to see a traditional healer to find out if they have a calling. “It works to use western medicine and traditional healing together,” Maseko says. “Some people feel comfortable going to a traditional healer and to a psychologist. This is the motto I am using and so far it is working.”
One of Maseko’s patients, Lillian (not her real name) suffers from severe depression. Her harrowing background includes abuse by her policeman stepfather, being raped four times (the first time, when she was abducted at the age of 15), and domestic violence at the hands of the fathers of her three children. Two of the men died; one was ill and the other took his own life. Thirteen years ago, she developed debilitating spinal pain, which crippled her. Medical tests for a physiological cause were negative. Finally, a neurologist diagnosed ‘conversion disorder’, a physical condition with a psychological/emotional cause. “I suffered rejection, disappointment, loss of loved ones, rape and abuse, and finally I slipped into depression,” Lillian, said. “I am taking medication and every week I meet with a psychologist.”
Maseko has applied for a disability grant for Lillian, and aims to assist her to leave her abusive partner.
Lillian’s grandmother is a traditional healer and members of the family believe her illness is caused because she has not respected her calling to inherit her grandmother’s gifts as a spiritual healer. “It is confusing because my condition can be viewed from two perspectives,” Lillian says. “I am encouraging people to seek more knowledge about mental health and assisting women who have been abused by sharing my story.”