The invocation of the Disaster Management Act (2002) has enabled the South African government to ramp up its efforts in the fight against the current pandemic in which we find ourselves. According to the Johns Hopkins University, Covid-19 has thus far claimed more than 70,000 lives and has infected more than one million people around the world.
While governments all over the world are ferociously fighting against this virus, South Africa’s efforts to lock down the country, accelerate testing and treatment in order to contain Covid-19 have been highly commended, despite some challenges that remain. Nevertheless, it is disappointing, but not at all surprising that in its approach, South Africa has not integrated emergency psychological crisis interventions to reduce the negative psychosocial impact of the pandemic on public mental health in the country.
What then does this pandemic reveal about the state of mental affairs in SA and what could be the short-term and long-term considerations that the government could take?
Pandemics and mental health
In his prognostic book titled “Psychology of Pandemics”, Steven Taylor, a professor and clinical psychologist in the Department of Psychiatry at the University of British Columbia (Canada), maintains that psychological factors influence the spread of pandemic infections and the associated emotional distress that comes with them.
In essence, the footprint of Covid-19 is not only seen among those who are sick or succumb to the virus, but it is also entrenched among those who experience the consequent stress, anxiety, anger, fear of death and fear of losing loved ones, among other psychological discomforts.
Previous pandemics such as the 2003 Sars and the 2014 Ebola virus outbreaks show us that generalised fear and fear-induced over-reactive behaviour were common among the public. During this current pandemic, these psychological reactions will definitely be worse.
In this bloodless war against an invisible enemy where human beings are the transporters, receivers and ultimate casualties, it is also commonplace that the general population could already be self-diagnosing themselves – possibly from a mild hypochondriac hysteria where people are constantly anxious about their health, especially at a time of seasonal flu in SA.
These days, a simple cough or sneeze could invoke a lot of anxiety for an individual and those around him or her. The sudden and severe disruptions of routines, separation from families, wage losses and social isolation are undoubtedly fuelling the fire.
For healthcare workers, the risks are heightened as they are on the frontlines of the battle and thus exposed to contracting the virus, possibly losing patients and overworking themselves, which could lead to burnout.
There are also those who have pre-existing psychological ailments such as anxiety disorders (panic disorders, obsessive-compulsive disorders and phobias), mood disorders (depression and bipolar), personality disorders or even post-traumatic disorders and their conditions could be worsened by this pandemic.
The recent reports of a rise in domestic violence are also very concerning. Coupled with all of these challenges, there is an overabundance of misinformation on social media and elsewhere about Covid-19, and ways to prevent/cope with it and these can impede infection control.
The measures the South African government has taken to try and prevent further infections have taken centre stage. Work has been halted unless it is essential, physical distancing is the new norm and many find themselves spending more time alone. Boots are on the ground, the behaviour is closely monitored, violence is erupting (almost reminiscent of old times) – with little acknowledgement of the psychological consequences of all of these matters.
Suffice it to say, if we’re not careful, a mental health pandemic could be on the horizon. Taylor reminds us that pandemics are psychological phenomena – they are caused and contained by human behaviour. The implementation of non-pharmaceutical interventions such as physical distancing, better hygiene, the banning of large gatherings, school closures etc. have been seen as the leading ways of preventing further infections. However, even with such measures in place, people are already experiencing different types of psychological distress at varying levels.
In the UK, a man committed suicide after “being pushed over the edge by coronavirus loneliness”. In another suicide case, a German state minister killed himself after becoming “deeply worried over how to cope with the economic fallout from the coronavirus”. In the US, there have been reported increases in 911 suicide-related calls in some states.
While these consequential events could be seen as far from our immediate reality, it is possible that they could already be taking place here in South Africa. It is therefore important for the government to proactively assist South Africans to cope with not only the containment of this virus, but also the potential psychological consequences that it presents. This pandemic needs to be understood as a psychological problem as much as it is a medical one. We are trying to protect ourselves against Covid-19, but how are we protecting ourselves against the psychological distress it wreaks?
South African mental health crisis exacerbated by the pandemic?
The exclusion of mental healthcare interventions in the government’s emergency response was not completely unexpected. South Africa’s silent mental health crisis has been brewing for decades. Underfunded, under-resourced and misunderstood, the mental health field finds itself in a precarious space where its relevance and extent of influence is not appreciated.
Moreover, the inequality gap in SA becomes even more apparent when we confront the issue. Perhaps this pandemic has the potential of changing all this by providing the country with a friendly reminder of the importance of mental health where it matters most.
South Africa has two specific policies on mental health. The Mental Health Care Act 2002 (Act no. 17 of 2002) and the National Mental Health Policy Framework and Strategic Plan of 2013/2020. The former replaced the apartheid-era Mental Health Act of 1973: However, it was rudimentary and focused more on the care of the mentally ill, without a comprehensive approach of making mental health access a priority for everyone in the country.
The Policy Framework and Strategic Plan 2013-2020 is more comprehensive and “identifies key activities that are considered catalytic to further transforming mental health services and ensuring that quality mental health services are accessible, equitable, comprehensive and are integrated at all levels of the health system, in line with World Health Organisation (WHO) recommendations”.
Despite the latter being a formidable policy, the mental health system of the country continues to suffer due to other health priorities such as HIV/Aids and a shortage of qualified mental health professionals. In South Africa, there are 1.58 psychosocial care providers per 100,000 people and to put this into context, there is one psychiatrist per 357,000 patients. This means that out of the 17 million people who suffer from different types of mental illnesses in SA, 75% of them will not get any kind of needed help. South Africa has a severe shortage of psychiatric institutions and the situation is even direr for children and adolescents as only 1% of the beds are reserved for them in psychiatric wards.
The Department of Health spends approximately 4% of its budget on mental health, which is not enough. To make matters worse, Dr Melvyn Freeman, head of noncommunicable diseases at the Department of Health, maintains that 85% of psychologists are in private practice and are servicing 14% of the population as the private sector offers are far more competitive. This is unfortunate because most of those suffering from mental illnesses are often poor and cannot afford the more expensive services the private sector has to offer. The Life Esidimeni tragedy (whose memory still haunts us), is a stark reminder of this. The poor are the ultimate victims of this crisis and this shows that even under normal circumstances, South Africa is in the throes of a mental health crisis.
What should be done?
This enduring mental health crisis has followed us into this pandemic and in these times, most people find themselves anxious and scared as to what the future holds. To date, we still do not have a mental healthcare resource centre or guidelines to assist our people to cope, especially those who are most vulnerable and have pre-existing mental health problems.
This is not a gamble we should take lightly as our country is already losing R28.8-billion in earnings as a result of mentally ill adults annually. As the National Mental Health Policy Framework highlights “it costs South Africa more to not treat mental illness than to treat it”. Thus, it would be better for us to begin with the preventative and remedial measures sooner rather than later.
To counter the mental health conundrum that this pandemic poses, the government needs to be proactive in formulating short-term and long-term solutions. To this end, we might need to formulate an intervention workforce that comprises outreach teams led by psychiatrists and other mental health professionals, and psychological support hotline teams.
The South African Depression and Anxiety Group (SADAG) provides telephonic support, but their resources are strained and there aren’t enough qualified mental health practitioners to heed this demand at all times. It would therefore be beneficial for the government to partner up with universities (who have qualified professionals and students who have varying levels of qualifications and experience), to formulate a mental health resource centre which could comprise online materials for coping with stress during Covid-19 and an interactive interface where people can interact and get more information and help if needed – similar to the WhatsApp innovation for Covid-19, which has already been implemented.
The World Health Organisation (WHO) has published mental health and psychosocial considerations during the Covid-19 outbreak, but they are not exhaustive, lack contextual relevance and are devoid of socioeconomic class considerations. A better resource for the mobilisation of a mental health workforce would be the publication from the Inter-Agency Standing Committee on addressing mental health and psychosocial aspects of the Covid-19 outbreak.
The long-term solutions to the mental health crisis in South Africa are not new and have been raised time and time again by academics, mental health practitioners and organisations. They have always been urgent and their avoidance has led to the further deterioration of our mental health system.
Firstly, mental health awareness is key. This is an urgent solution because it will assist in the mainstreaming of the subject in schools (perhaps by incorporating it into the life orientation subject), communities and society. The general population needs to be able to articulate what they are feeling/experiencing and therefore need to be given those tools of articulation. Consequently, they will also know the resources and facilities available to them when help is sought. Sensitising the population to mental health matters also holds the potential of easing the stigma among those who are mentally ill.
Secondly, we need increased preparedness and service provision. More investment has to be made in the health budget allocation to mental health.
Thirdly, mental health research funding should be prioritised. There are nearly 200 National Research Foundation chairs across our universities and none of them is a chair on mental health, psychology or psychiatry. This needs to be corrected. With more funding on mental health research, there could be more robust research, which could better inform the pedagogics of mental health, priority areas and policy targets.
Fourthly, the systemic barriers that continue to impede the qualification of mental health practitioners must be lifted in a quality-assured way. The average number of master’s degree candidates in counselling and clinical psychology at a university is less than 10 a year – for each. This is a huge obstacle that needs to be overcome.
Fifthly, mental healthcare needs to be decentralised and restructured to take a more community-based approach. As noted by Janine Bezuidenhoudt, we need to “strengthen and expand community-based care to include mental health aspects”. Community-based care workers are at the frontlines of our mental health crisis and are best to make value judgements on who needs psychological help.
Lastly, the barrier between public and private mental healthcare must be thinned. Collective solutions to this crisis cannot be formulated with these two sectors on opposing sides. Thus, more partnerships are needed. It is only with a robust mental healthcare system that SA will be able to integrate public mental health interventions in its emergency responses to future pandemics or disasters.
The Covid-19 pandemic has overwhelmed the South African government as it has other countries. While containing this virus and flattening the curve take precedence, we also need to find ways of communicating mental health interventions to build resilience among our people. The medical aspect of this pandemic reigns superior, but ignoring its psychological implications could worsen the current mental health crisis in the country.
Post the pandemic, we will be bumping elbows and relentlessly reaching for the hand sanitisers every 30 minutes. People will no longer be sharing beers and cigarettes, and we could all display symptoms of Obsessive-Compulsive Disorder one way or another. It will be business unusual.
Unfortunately, these will not be the only Covid-19 burdens we will carry. We will be scarred; we will be grieving, and crowded spaces may irk us. Others’ mental illnesses would have been worsened, while still others’ would have been triggered. Many will indeed be in need of psychological help at varying degrees. The South African government therefore needs to acknowledge and recognise mental health needs in these trying times and take proactive measures to avoid an imminent mental health pandemic. DM
Kgaugelo Sebidi is a Johannesburg-based researcher for the Oxford Poverty and Human Development Initiative and a psychology student at the University of Johannesburg. He has an MPhil in Development Studies from the University of Oxford.
Ring of Fire as performed by Johnny Cash was actually written by June Carter.