We’d rather retreat into process, protocol and spin or “we’ll discuss it next week during the debate”. Multiple headlines, trending tweets and spicy radio open lines later, one would think we’d salivate at the sight of the next tragedy. An investigative process led by Prof. Malegapuru Makgoba informed us that not 36 but 94 mentally ill patients died at the hands of unregistered fly-by-night NGOs, between March 23 and December 19, 2016. True to form, we went into a rehearsed display of inaction and concern, the South African way. The way we did after 34 people died mercilessly at the hands of the South African police and others at Marikana in 2012. It was a familiar outpouring of collective grief and shock; the way we did when our people butchered each other on trains, in huts and in ranks across our country in the early 1990s. We had seen this before, or had we?
Some patients were transferred directly from ‘sick bays’ to NGOs; others were transferred with co-morbid medical conditions that required highly specialised medical care (‘bedsores and puss oozing out of sores’ or medical conditions such as epilepsy and hypertension) into NGOs where such care was not available, and yet other frail, disabled and incapacitated patients were transported in inappropriate and inhumane modes of transport, some ‘without wheelchairs but tied with bed sheets’ to support them; (Makgoba report)
We thought Marikana was an inflection point that would encourage us to do things differently, in part because of the role that mining has and continues to play in shaping the political economy and fabric of society of South Africa. Four years later, the Life Esidimeni saga, reveals more than any other event, what the South African brand of neoliberal capitalism can do, to the most vulnerable. Those who can’t, in the picket lines demand their rights to life, and who in death can’t build an emancipatory politics through those who live. In brief: mentally ill patients aren’t as easily identified to place on T-shirts of idealistic lefties or in large murals of underground graffiti artists.
We knew of the 34 mineworkers in Marikana but we can’t count on one hand the names of the ones who died in fly-by-night NGOs, dehydrated, hungry and anxious to meet their maker. In a way this depersonalisation of their life (and their death) is a direct outcome of the system that made their condition and its attendant responsibility of care a commodity to be traded among different actors. Their lives much similar to an easily transferable and lucrative tender, in lieu of unaffordable tender love and care. The play with words aside, this matter exposed the systemic and intentional under-capacitating of the state that we’ve seen over the last few decades. So much so that the question is seldom asked, “why did the state not have its own psychiatric facility?”, or if it does have, are these able to absorb all patients at scale? If not, why not?
….some NGOs rocked up at LE (Life Esidimeni) in open ‘bakkies’ to fetch MCHUs while others chose MCHUs like an ‘auction cattle market’ despite pre-selection by the GDMH staff; some MCHUs were shuttled around several NGOs; during transfer and after deaths several relatives of patients were still not notified or communicated to timeously; some are still looking for relatives; these conducts were most negligent and reckless and showed a total lack of respect for human dignity, care and human life.
What has this got to do with neoliberalism, or the intellectual project of market fundamentalism or capitalism for that matter? Scholarship intersects with public policy in a manner that has a material bearing on the lives of people. It is not enough to divorce issues of life or death from their policy and ideological roots in the ivory towers and elite corridors of power. As Ta Nehisi Coates observes, the intellectual project often has real life implications;
“Remember that the sociology, the history, the economics, the graphs, the charts, the regressions all land, with great violence, upon the body.”
It is clear the economics of cost containment also landed with great violence on the bodies of the 94 patients. The Makgoba report acknowledged that such violence also went against the policy of the government;
“The decision to terminate the contract precipitously contradicted the National Mental Health Policy Framework and Strategy, the cost rationale could not be justified above the rights of the mentally ill patients to dignity and the state’s constitutional obligation to accessible health care”
The figures add some texture here, it costs R320 a day per patient at Life Esidimeni, compared to R112/day at the NGOs. The government, to answer why it doesn’t have its own facilities, we are told by Lisa Vetten, pays between R1,386 and R1,960 a day in its own psychiatric facilities.
If these numbers are to be believed, then a complexity emerges here; government management of psychiatric facilities is as unsustainable as private care is, and the outlet of delivery then becomes a competitive market of under-resourced and scantily subsidised NGOs. The market is not only the private sector, as we often believe, but since the early 1980s (and even earlier in care work in South Africa since 1937), the market has consisted of a combination of NGOs, welfare societies and other organisations of different kinds.
Cambridge-based economist Ha-Joon Chang argues that under neoliberalism the “increasing privatisation and deregulation” of sectors providing basic services to the poor, has “meant that the poor have seen a disproportionate increase in the exposure of their consumption to the logic of the market”. As Lisa Vetten shows, often the NGO or care work segment of the market is not as valued as their counterparts in the private sector;
What needs to change urgently is the low value attached to those who need care, and the equally low value placed on those who offer care.
Furthermore, and related to the numbers above, there is also a sense of viewing preventative interventions as solely confined to the individual and thus the costs are seen as a “nice to have”, to be reluctantly funded if “resources allow”, as Luigi Esposito and Fernando Perez wrote, this “downplays the role of the social realm” or uses it when care can be shifted in the name of “communal or familial” care;
…this obsession with medicalisation and the tendency to treat “mental illness” as a problem within the individual continues to be supported within the prevailing neoliberal logic that downplays the social realm, treats individuals as self-contained agents, and pathologizes thoughts and behaviours that deviate from what the market defines as functional, productive, or desirable.
This act of pathologising experiences, behaviours and thoughts that are seen as deviant is rather commonplace. It denies the role of public policy in creating externalities through exclusion that manifest in mental illness, addiction, displacement and alienation. Watch any episode of Khumbul’ekhaya and you will see how many stories of loss, migrancy and broken family fibre in an apartheid context are presented and packaged as “dereliction of duty” and carelessness.
This emphasis on the individualisation of care dovetails with some of the policy shifts that have occurred in the sector, in particular the shifting of care and capacity away from state health facilities to a combination of households and non-profit organisations. This, as Lisa Vetten argued, has significant resourcing issues and at times undermines the level of care enjoyed;
… it simultaneously shifted from professional health staff, to volunteers and HCBC (home and community based care) workers – with concomitant changes to the costs of the service, as well as who bears those costs…… this sort of downward task-shifting by the state, couched in the language of communitarianism and familialism implicitly depends on women’s unpaid, or underpaid, care work…
The task-shifting from private and state provided care, without requisite full subsidisation of services (including the decent remuneration of community-based care workers) is more like a hospital pass than international best practice. We are told that in many NGOs (especially those who can’t secure funds to top up government subsidies), some workers earn less than the R75 daily rates of the Expanded Public Works Programmes (EPWP). In effect, what has been created is a two (or even three) tiered system of care, with an often predatory relationship between the different tiers. When costs need to be cut in the state or state contracted private sector, the NGO, community or home-based sector kicks in, without an attendant rise in subsidies or personnel support.
‘He shouldn’t have died like that’
Depression sufferer Freddie Collitz (61) passed away in the care of the Mosego Home in Krugersdorp, an old age home for psychiatric patients. He apparently had a wound to the head, blisters around the ankles and a sore on his nose. He had earlier been moved from the Randfontein LE Institution to the Krugersdorp NGO.
Collitz’s story is one of those mentioned in the Makgoba report. It is a real-life example of the cost of “dereliction of duty” to provide accessible healthcare to those who need it the most. We are often tempted to individualise the issue in the name of the public authority (the buck stops with the MEC, right?) or we’ll easily blame the NGOs for negligence. We often do so at the expense of shining a light on the “systemic” drivers of this failure to respect life. Frankly, we often conceal in log-frames, strategy documents and cost rationalisation programmes their true meaning.
This often means, for those who receive the can kicked down the road, lower wages, fewer heaters, bakkies replacing ambulances and a lot less food on the plates of those entrusted to their care. We shouldn’t then be surprised when people die not because of their mental ailment (care is not about pills alone), but because of being a blanket too short or a glass of water too far. DM
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