The popular notion that mental illnesses such as depression, anxiety and post-traumatic stress disorder are the preserve of affluent, predominantly white suburban residents is as far removed from the facts as it is to assume that every outlying village is a haven of idyllic tranquillity.
Mental health problems in South Africa’s rural areas are not only as real, and as bad, as they are in our cities, but they are getting worse.
This is mainly because of the simple difficulty of getting treatment to sufferers. There are no psychiatrists treating patients in rural areas and most primary health nurses at rural clinics are ill-equipped even to recognise the symptoms of mental illness.
“There are no ethnic, racial or even environmental barriers to mental disorders. There are only the realities that affect our ability to treat them,” says Zane Wilson, founder of the South African Depression and Anxiety Group (Sadag), a non-profit national group currently at the vanguard of efforts to remove the lingering social stigma surrounding mental health problems. The group is also trying to help bring support and treatment to the millions of South African sufferers.
Working together with mental health professionals and government, as well as global organisations such as the World Bank, Sadag has embarked on a campaign to help fight mental health problems — especially in rural areas.
One of the worst-hit provinces is KwaZulu-Natal where tragic phenomena such as teen suicide, substance abuse and domestic violence often verge on the catastrophic.
Professor Dan Mkize, head of psychiatry at the Nelson Mandela School of Medicine in Durban, says that while the treatment of mental illness is difficult in urban areas in rural areas its management is made more complicated by numerous factors.
“We are now looking at how to integrate mental health care into primary health care. We have to train nurses, for example, to recognise when the combination of recurring headaches, inability to sleep and other symptoms may indicate depression and refer a patient to hospital. This is only one instance where the proverbial ‘take-two-aspirin-and-come-back-in-the-morning’ approach is both real and dangerous,” Mkize says.
“And while we continue to research mental health issues in rural areas to understand the problem, we cannot neglect the simple need to get the right medicines to the clinics where they’re needed.”
The sprawling Umlazi township less than 20 minutes drive from central Durban has the dubious distinction of the highest per capita HIV/Aids infection rate in the world. This township comprises both urban and rural areas. It is served by the equally sprawling Prince Mshiyeni hospital. But the hospital has no resident psychologists.
In addition, the hospital services 21 clinics outside of its precincts. “Three weeks ago there was only one vehicle to supply all those clinics,” says Mkize.
“And when we do get the odd vehicle to transport supplies to clinics, it gets here on Monday and has been hijacked or stolen by Friday.”
Now, with the help of Sadag, Mkize, who is also head of mental health for KwaZulu-Natal, is hoping to garner support from one or more of the security firms that transport pension payments to rural areas to add medicines to their payloads.
“On the positive side, however, rural communities have stronger social bonds than urban neighbourhoods. This means the social mindset is in place to provide vital support structures for sufferers,” says Wilson.
“There is a wonderful ease with which people, even in the smallest, least-sophisticated and most far-flung village, rally around to support people who they realise are having problems,” says Wilson.
“But support is only one aspect of the diverse and often complex therapy sufferers need if they are to get better. We now know that biological, psychological and other interventions have to go hand in hand in treating the entire spectrum of mental illnesses,” she says.
Despite support structures, Mkize believes considerable stigmatisation remains. As with HIV/Aids, this negative social phenomenon, still common in so-called sophisticated urban areas, is one of a battery of characteristics idiosyncratic to rural areas.
“We find men are referred to hospital more often than female patients ... Yet we know that throughout the world depression is twice as common among women as men. Yet rural women in South Africa are generally not referred to hospital as readily as men. Possibly because it is accepted more commonly among women, they are not referred to a professional mental health practitioner as readily as are men. But, by the same token, we find that when women are referred to hospital their condition is often more advanced and more serious than it might otherwise have been.
“This is only one instance where greater education of primary health caregivers at clinics and awareness among the communities may help ensure early and effective treatment,” Mkize says.
A common term has arisen in rural areas. “The amafufunyani [screaming] syndrome describes a grab-bag of symptoms covering everything from depression and panic disorders through schizophrenia to epilepsy, also underlining the need for greater communication in addressing the problems,” says Mkize. “Among us psychiatrists we prefer the term ‘hysterical psychosis’, more commonly called hysteria.”
Teen suicides have also begun assuming alarming proportions in rural areas where experts believe another battery of social ills and pressures are driving young people to kill themselves.
“The mind-numbing speed with which HIV/Aids has spread is just one of the factors, and recent research has shown that young people who are HIV-positive are 36 times more likely to take their own lives than other youngsters.
“Now add to this the breakdown of family structures, poverty, joblessness, crime and substance abuse and you have the makings of a very serious problem,” says Mkize, highlighting a recent study, which showed that of 6 000 high school pupils in the greater Durban area, more than 120 had used cocaine, a top-end, expensive and dangerous narcotic.
While concerned at the shortage of skills in mental health diagnosis at primary health level, Mkize says many nurses who have graduated with a certificate in psychiatric nursing — an additional year’s training on top of their four-year primary health care training — see themselves as “specialists” and are reluctant to “go back to cleaning ulcers and bedpans”.
Is South Africa producing enough psychologists and psychiatrists? Mkize shrugs wryly: “Up to 50% of the psychiatrists who will graduate at the end of this year plan to emigrate. So the answer is ‘No’.”
Despite the growing prevalence of stress-related and other mental illness across South Africa, businesses and corporations seem reluctant to shoulder their responsibilities in this regard. There is still, as one victim put it, a “crazy cousin in the basement” syndrome; implying some dark family secret to which no one will admit.
If this is the lingering attitude in the modern suburbs, how much more complex and perverse might the issue be in rural areas caught between ancient tribal systems and those of the 21st century?
Llewellyn Kriel is a communications consultant to Sadag. He suffers from chronic depression.