Kathryn Strachan
JOHANNESBURG, Apr 29 2008 (IPS) – Each psychiatric patient leaving Tower Hospital in the Eastern Cape Province under a new project to integrate patients into the community is sent home with two piglets. While at the hospital, patients are trained to raise pigs, the hope being that they will use the piglets for breeding to develop a sustainable source of income once discharged.
But in following up with these patients at their homes in the surrounding hills and villages there is not a single pig to be found. They have all been eaten or stolen, says Tshedi Tshabalala, who runs the local community rehabilitation centre. And sometimes there is no food for the pigs.
The fate of the piglets highlights the challenges in transforming South Africa s mental health system.
There is a need to get stabilised psychiatric patients out of hospital and into the community, in line with international standards and newly introduced legislation.
However, patients are vulnerable when sent back to areas where there is deep poverty. Unless deinstitutionalisation is done hand-in-hand with supporting and caring for patients in the community, efforts to have them exit hospitals could do more harm than good.
An overgrown patch of land at the centre, which lies within the walls of an old fort, provides another illustration of the difficulties that surround patients re-entering society.
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Intended to allow the patients to cultivate vegetables as a therapeutic activity, it is now choked with weeds. The patients expected to get paid for working in the vegetable garden, and lost interest and stopped coming when they realised there was no payment, Tshabalala says.
Given the lack of support in communities, patients soon relapse and are readmitted for care.
The situation we are sending them back to is the situation that we got them from. Maybe it is the family that is the problem, but we don t work with the family, only with the patient, says a nurse at Tower Hospital. But just because it is not working doesn t mean we shouldn t keep trying.
Tower Hospital, situated on the outskirts of the small town of Fort Beaufort, was chosen as one of two pilot sites to test the new system of sending stabilised psychiatric patients to live in the community. The other site, Madadeni Hospital, is located outside Newcastle in the south-eastern KwaZulu Natal Province.
The facilities were selected because they are both in very poor settings: the thinking was that if the plan was a success in these places, it would be comparatively easier to get it working in better resourced areas.
The link between mental health and poverty is of concern throughout Africa, and is currently the focus of a project spanning four countries on the continent. The initiative is funded by the UK s Department for International Development, in collaboration with the World Health Organisation.
Researchers from Ghana, South Africa, Uganda and Zambia have joined together in a five year study to unravel the complex interaction between mental wellbeing and poverty, and suggest policies and programmes that can break this cycle.
It is recognised that when people become mentally ill they are more vulnerable to poverty as a result of loss of employment, reduced productivity and the cost of health care. Financial stresses can, in turn, exacerbate mental illness: the social marginalisation, lack of a home base and malnutrition that accompany poverty may further undermine mental health.
The four countries were selected because they represent a variety of scenarios in their mental health programmes and in their national levels of development. Lead researcher Alan Flisher says his team anticipates that if it can come up with a model of intervention which takes into account the differing levels of health provision and financial resources in these states, that model could be widely applied to other developing countries. Flisher is based at the Department of Psychiatry and Mental Health at the University of Cape Town in South Africa.
Despite a growing burden of mental disorders, poor countries are ill-equipped to deal with mental health needs, he adds. This is particularly true in Africa where many states have no mental health policy at all. Countries which have policies still face major difficulties with implementation.
The first phase of the study, which involved analysing resources and policies in the four countries, is now complete, and researchers are embarking on the second phase that of designing a comprehensive approach to addressing the interaction of poverty and mental health. Interventions are needed in sectors as diverse as housing, education and labour, says Flisher.
What the researchers have found in South Africa is, according to their report on the first phase, evidence of a vicious cycle of poverty and mental ill health, which is poorly understood and inadequately addressed in policy and service delivery.
The analysis of the situation in South Africa indicates the need to move away from an outmoded system of mental hospitals a system which is vulnerable to human rights abuses and stigmatisation of patients and to develop local mental health services which include residential care, day and outpatient services.
For deinstitutionalisation to be successful it needs to be accompanied by community-based rehabilitation programmes, says Flisher. But, Shifting the burden of psychosocial care for these patients to the community without supportive programmes is irresponsible and could result in the violation of human rights.
Insufficient commitment from government was identified as the main obstacle to progress in South Africa. The Department of Health has not formally adopted a national mental health policy, and where there are reforms such as the introduction of the Mental Health Care Act of 2002 there is a lack of political will and of resources to implement these reforms, states the report.
