‘Mental Health in an Unequal World’
Cape Town: Almost a third of the South African population will present with a mental disorder such as depression, substance abuse, anxiety, bipolar disorder and schizophrenia during their lifetime.
Yesterday, marked World Mental Health Day. It gives us the opportunity to reflect upon mental health, not only on the mentioned day but also during the remainder of the month. For 2021, the theme is ‘Mental Health in an Unequal World’. This theme is particularly relevant for a country like South Africa that has also been described as one of the most ‘unequal’ societies in the world. In this article, I would like to unravel aspects of this complex phenomenon and how it plays out within our local mental health context.
An unequal world?
How wonderful would life be if we were all born equal? Alas, inequality starts very early on. From birth, the human condition seems to be unequal! Some of us are born with genes that make us thrive and be resilient. Others are less fortunate. And beyond the womb, we are cast into an unequal world. Despite apartheid ending more than 20 years ago, many South Africans are born into poverty and other adversities. Material inequalities continue to grow: the wealthy becoming wealthier, and the number of poor people rising. How does this impact mental health?
Mental illness in SA
Arguably, mental illness and poverty are two sides of the same coin: on the one side, there are many people living in poverty, possibly unemployed and lacking adequate housing and basic amenities, who are at increased risk of mental illness. On the other side, people with a mental illness are more likely to drift into or remain in poverty because of reduced productivity or unemployment and increased health expenditures. A vicious cycle, indeed. The interplay between these inequalities within South Africa is complex and has detrimental consequences for mental health and appropriate healthcare.
Mental illness is rife across the globe, as in our country. Moreover, there is evidence that more than 40% of people living with HIV in the country have a diagnosable mental illness.
Women and children may also be at increased risk: one study showed that a third of mothers living in low-income and informal settlements in Cape Town suffer from postnatal depression, whereas almost half of pregnant women from KwaZulu-Natal present with depression. Estimates suggest that in the Western Cape, one out of six children have a diagnosable mental health condition. These rates are alarming and higher than the prevalence of these conditions in developed countries.
Mental healthcare in SA
There is consensus that there is no health without mental health. Indeed, mental, physical, and social health are essential parts of life, closely interdependent, with mental health being crucial to the overall well-being of individuals and society. However, it seems that South Africa, like many other countries across the globe, does not consider mental health a priority.
This is exemplified by the fact that fewer than 1 out of 10 individuals with a mental illness will receive the care that they need, despite the fact that many mental health problems can be treated at clinics and hospitals.
Evidence suggests that between 75% and 95% of people with mental disorders in low-and middle-income countries like South Africa are unable to access mental health services. And those that do have access are not necessarily receiving sufficient or appropriate care.
The recent Life Esidimeni tragedy, resulting in the death of 144 mental health patients and exposure of 1418 others to trauma and poor health outcomes in the Gauteng Province, has shocked the nation, casting the spotlight on mental healthcare and revealing some of the systemic inadequacies and inequalities in our society.
Even though neuropsychiatric disorders are ranked third in their contribution to the burden of disease in South Africa, after HIV/Aids and other infectious diseases, mental health remains the neglected child of the local healthcare system.
Although steps have been taken towards strengthening mental health care in the last 20 years, including reforming the Mental Health Care Act 2002 and developing a National Mental Health Policy Framework and Strategic Plan 2013-2020, the Department of Health spends only 5% of the total health budget on mental health services, leaving mental health under-funded and under-resourced. Such lack of investment in mental health, disproportionate to the overall health budget, contributes to the mental health treatment gap.
Furthermore, mental healthcare services are centralised in large urban hospitals, while rural communities are neglected. There also seems to be enormous inequality between provinces in the distribution of mental healthcare services and resources. However, the truth is that there is a dire shortage of trained mental healthcare professionals everywhere in the country and facilities in all provinces are stretched to the limit due to the current demand.
Covid-19 in an unequal world
In 2020, the Covid-19 pandemic hit an already unequal world, impacting us all, but perhaps more so the world’s most vulnerable through loss of lives, health, jobs, incomes, and education. Mental health has also been affected, with many people facing increased levels of depression, anxiety, insomnia, and alcohol and substance use, thus, increasing the demand for the already limited mental health services. Covid-19 has also interrupted access to essential mental health services.
In response, the World Health Organization has issued guidelines to countries on how to maintain essential services, including mental health services. It is their recommendation that countries allocate resources to mental health as an integral component of their response and recovery plans.
Where mental health is concerned, we continue to live in an unequal world. Nevertheless, we all have a role to play, indirectly or directly, to address these disparities. The month of October presents another opportunity to reflect on the issues that perpetuate mental health inequality and to educate our people and those in power about the value of mental health and highlight the importance of accessible, appropriate, and sufficient care for all.
Such efforts should not be limited to the month of October, however. In November, for example, it is election time in South Africa, and we all have the right to vote. This is an ideal opportunity to elect people that prioritise mental health and mental healthcare and who can take a stand against stigma and discrimination, to ultimately address the inequalities that hold back people with mental illness and their families.
*Professor Lochner is affiliated with the SAMRC Unit on Risk and Resilience in Mental Disorders in the Department of Psychiatry at Stellenbosch University.