Special Hearings — Mental Health Workshop — 1997-11-20

DR BAQWA: ...[inaudible] very importantly coming into and especially if one questions somebody as their knowledge and the concept of Sangoma's and our understandings of trauma and problems.  I have wonderful examples of how people from the third world - as we were called in Europe, have used metaforce of healing wherein psychiatry really was not the field - no psychology but rather probably going into religion and other forms of surviving and I think that's where your Sangoma's and other thinkings will go in.
 I'm looking at psychiatric interventions in Government Hospitals and Community Settings  - that is now how the future should be like, I think I'm talking of ...[indistinct] man of a sort of control that things are going as they should be in the sector of human and healthy mental health generally.
 And also there is a concept of community psychiatry as being practised now, recommendations for improving these conceptualisations.  When I was in Oslo, I was looking at what had come out of South Africa because I was excited coming down in 1995 and I saw a paper by Seedat which - I'm sure if it was the Seedat, it was an enquiry into the concept of community and I was very excited because that was one of the most progressive analysis I've seen.  
 And I tried to pick it out now to show him as to whether it is his paper and I saw I had one of Fogelman - which is not what I was looking for, so I put the wrong paper in my bag.  Is it you? - I don't know.  
 I'm was also going to look at recommendations in part 3 for curriculum changes at institutions - like Saths was saying again, and institutions of training of professionals in health care.  So, I would like to start this presentation with some quotations - they might appear rather dramatic, but I am also dramatic of nature.
"If we unearth his bones, the pain would come again"
Said Mr Tshwete - who's the father to Steve Tshwete who was one of the young freedom fighters who had been killed in combat with the State apparatus some time in 1985 and buried anonymously in a cemetery in Piet Retief.
"Here are the bones of the skull - the whole skull"
Said the Premier of Mpumalanga Matthews Phosa, as he carried high another plastic bag containing skeleton remains of one of the three young men whose graves had been identified by an investigator for the Truth Commission.
"They burn our children and have braai's at the same time"
Stung the words of Dumisa Ntsebeza, the TRC's Investigative Head.
"The families of the killed - the previously disappeared, looked on in grave numbness and anger at the scene - a reminder of the killings fields of the previous State's terror"
All this was seen on national television only a weeks ago - November the 7th, '97.
"...[indistinct] and braai's, cannibalistic rituals - will the hearts of the young warriors nurture the depraved hunger of their soulless killers, vultures, on the conscience of this ...[indistinct] democracy.  The violence is pervasive.
 The father who lies naked to his 8 month old baby girl and puts his finger into the babies vagina an act so incomprehensible in it's depravity, akin to a thousand raids committed by fathers on their daughters in a thousand squatter camps and a thousand gilded bedrooms in colonial mansions. 
 Is this a collective psychosis, a collective madness?  Was the answer - who can give the answer, how can the soil be cleansed?  Have the molecules in the air clustered into impenetrable condensations of venomous bile, devouring the heart of our nation and causing collective psychosis, unleashing a wrath upon itself that defies comprehension - like the self mutilation of a character lacking self definition, a nation without a character searching violently for it's identity.
 I watch in horror as a psychiatric nurse challenges a violent psychotic patient pointing his finger at the breast of this unfortunate patient who is frightened by his omnivorous power.  Another nurse yelling in reciprocal crescendo as argument continues with a patient who eventually screams: "I am not your insane child at the beck and call of the staff, I have my human rights".
You can imagine how I was smiling when I heard this - so it is sort of even reaching our mental patients in institutions, that there is a culture of human rights moving into our social circles and institutions.
 The scenario that I painted above is my introduction into the violence that has permeated our society before our political freedom in 1994 and after.  The need to analyse it, to acknowledge it's manifold permutations and sources, it ...[indistinct] information and recognition and finally, ways of intervention, is increasingly compelling and I also know their efforts already in our society doing exactly this so let's do our share here.
 The concept of organised violence has steadily been taking root amongst the professions and disciplines that work with health hazards or organised violence and abuses of human rights.  It's a relevant issue in the politics of health as it encompasses political, ethical, medical and psycho-social realities.  One may as it were, say that one is talking of intentional violence whether physical or psychological, by man to man, war, prison, concentration camps, torture, terror and harassment.
 But I wish to add another form of violence now, the type that results as an abnormal human reaction to the above-mentioned violence, the violence of a society brutalised by itself, a society traumatised, an indirect form of violence flowing from the erosion of the human spirit and moral norms.  In short, an almost state of anarchy, a regression to a more primitive mode of leaving the wild west of our times.
 Psychological reactions are as much based on individual organisations as much as environmentally effected.   Explanations have been looked for - and some of them I like, socialisation - for example, problem solving by using violence, children emulating their violent environment, break up of families, refugee existence, alienation, discrimination, frustration, socio-economic conditions - the list can go on but I think for me, it is appropriate that I bring up a little bit about what mental health is all about.
 I think we have an idea already as we looked at the situation that I have depicted, though I promise you there is much more that I can say about the subject of mental health but I think the scope of this paper would not allow me sufficient probing into an enquiry into success at living, not idolisation of the beach god successor - that's a different thing, just to be successful at living  - what the hell is it all about?
 I'll just quote Marie Jahooda - I am not sure if she's an anthropologist or an anthropologist psychologist or sociology anthropologist psychologist, but I read about her when I was researching for my pilot project that I wanted to bring with me to South Africa for improving health services.  
 She says that mentally healthy people should be in touch with their own identity and feelings, that they should be oriented towards the future and should be fruitfully invested in life.  Their psyches should be integrated and provide them a resistance to stress.  They should have autonomy and recognise what shoots their needs, they should be masters of the environment.
 Now, this is not much psychiatry as is taught in our institutions but that's how mental health should be brought within curriculum changes that our psychiatrists should know about these things. 
 Let me move on to Part 2, which is the examination of conduct of use of psychological interventions - actually the abrupt ending to Part 1 is in essence what - I think, Saths Cooper has also said in a way that there is very little discrepancy except somewhere where he says: "Psychiatrists don't know psychotherapy but we'll talk about that later on and I actually think I have it in the paper here but he's created an atmosphere - a scenario, about what the problem is with our society and what the problem is in instituting changes and the panel there has also enquired into how we should go about it.  
 I've tried to sort of put it in the context of violence and a definition of mental health and sort of - you see threads that combine and make some sense - not cohesion at the moment, but there are threads that are coming, threads through our lives, through the violence, through our search.
 In Part 2, which is the examination of the conduct and use of psychological interventions by individuals and institutions in relation to the past, I will start by taking a look at practices in different psychiatric institutions.  I shall refer to the findings of the Mental Health Committee's investigation into psychiatric institutions and the abuses of human rights there.  
 A report was finalised in February 1996, the findings were classified in a number of broad categories.  I have given an addendum about their summaries and we might see where that goes in the workshop tomorrow.  Anyway, Re: 1 - their broad category was unacceptable health standards - I mean, we don't have to go into that too much, it is clear that our mental health tertiary institutions were asylums.
 Several facilities were found to be unsuitable for patient health care delivery and certain hospitals were mentioned.  What was common to those was the overcrowding of patients in wards, rows and rows of beds in one hall, neglect of patients akin to asylum like conditions of mental institutions depicted by Michel Fukou in is brilliant book: "Madness and Civilisation - Sanity in an Era of Rationalisation or Reason".  
 Let me give you an instance.  The forensic block of one hospital where I worked as a Registrar in Cape Town in 1994, it was so overcrowded that I was tempted to think of it as a prison rather than a place where people were sent to be observed for mental health - or what do you call it, for mental illness.  The patient composition in the forensic department - that forensic unit, was anything from what is called anti-social personality disorders - we don't have to go into definitions of these things, to severely ill functional psychosis - it's a broad spectrum.
 Young criminally charged youths were mixing with veterans who had killed and raped.  I tried to argue for the protection of the younger ones so that they can be roomed in solitary rooms, which of course had no proper locking mechanisms anyway.  I was told by a consultant there, that patients had a right to some enjoyment - some sexual enjoyment, in their miserable conditions.  I guess he thought he was being liberal minded in the human rights oriented context of the new South Africa but the issue was rape, it was not - I was not talking about consented sexual activities in a mental hospital, but another issue.
 There was little activity of the patients and the only free space was just a square surrounded by buildings housing these people referred by the courts for observation.  These people actually - when they were referred, it was either that they had stolen a banana or they were charged - and charged for stealing, and maybe they couldn't make sense in the courts, that's why they were sent by the police to the forensic department or they were referred for having raped and killed 9 year old school girls.
 I really wondered how they could all be clustered together and it made me think of how psychiatric services are organised in this country and it made me think of referral methods but I was told by some wise psychiatrist that of course we are a developing country - we have problems, and this is some form of picking up the people who are ill in the society - police are doing that work for us.
 I must in kindness, say that that hospital also had a football ground so that they could play football there but of course security was inadequate and that is another of the findings of the Health Committee that was investigating psychiatric facilities.
 Let me just jump to Re: 2, the second part which says: "Management Issues".  Discriminatory practices including racial discriminations were and are probably still rampant in 1995/'96 and '97 in several psychiatric hospitals.  Doctor Zolly Lengam, a Registrar at ...[indistinct] Psychiatric Department, describes in a clear impassionate manner of the practices in Pietermaritzburg's two hospitals in 1994 when she was working there - they are called Townhill Mental Hospital and Fort Napier.
 The discrepancies between the original planning and architecture of these hospitals:  Townhill was traditionally planned for the White patients and Fort Napier for Black.  Fort Napier - as the name implies, was converted from a fort into a mental hospital.   I don't know if you want to go what that Fort's function was some time during the colonial wars.
 Anyway the acute section of that hospital - Fort Napier, was built from stables, so already in the planning you see the discrepancies and they are still existent today, we don't accept changes - I mean, we don't expect changes like magic but the situation still exists.  The acute section of this hospital is dark and dingy - those are her words, and she says coldly and quietly: "Rows and rows of beds", whilst Townhill - I don't have to appeal to your imagination, in contrast had beautiful grounds and psychotherapeutic wards with all the amenities.
 Allegedly, Black were always too crazy or unsuitable for psychotherapy - which is also an idea or a thought that I found very strong in Europe, they call Blacks ...[indistinct] or that they were too busy surviving to have any introspection into their feelings - anyway, that's another issue too.
 Doctor Lengam tells of a Black female psychologist, Maureen Mbensa who battled a lone war for several years to have a psychotherapy unit installed in Fort Napier.  There was also existent in 1994, a subtle racist discriminatory practice that would create a barrier or an impediment for Black patients to be admitted to Townhill, a criterion: ability to speak English so that you'd only have your sprinkling of middle-class Blacks who could mingle with the White neurotic element of the psychotherapy wards of Townhill. 
 In essence really, this was not much different from the practices I saw in Cape Town.  Medication was also along class racial lines - second generation anti-depressants - I don't know if any of you know about these things, you see anti-depressants are first generation classical ones with very, very horrible side-effects and then the second generation don't have those side-effects but they are very expensive and other types, newer types.
 The psychopharmacies - what do you call - psychopharmacies yes?, they are flooding us with all these new medications, giving us samples, wanting us to move on and on and they're bribing us - East and West, and in South African we are easily bribed, it's shocks my ethical sense that it goes so easy here - one day I'm going to ask for a car.
 I must admit these medications are expensive  as compared to your classical anti-depressants that are coded in our hospitals today.  Actually all new drugs - all new anti-psychotics, with lesser unpleasant side effects would find their way to Townhill.  The crumbs from the rich White table were a new drug called: "Cosapin" which came into use quite late in the '70's but it is quite good as compared with your classical ones but it has an unfortunate side-effect, it's a blood discracia and it necessitates very frequent blood testing - as much as once weekly for the first 12 weeks of therapy, this was allowed in Black hospitals.
 I happen to also have researched on this Closapin, how it was introduced and experimented in South Africa as long ago as '73, when countries like Finland and China were very cautious as to it's fatal side-effects.  The ethical consideration on testing clinical drug trials here in South Africa, were waved aside or deemed not relevant but Doctor Lengam, cool as she always is throws a punch and she says: "Well, Black patients had to be manageable".  
 She also comments on the staff at Fort Napier, that was comprised mainly of frustrated Rhodesians who had dispersed at the onslaught of Chimorenga.  Now,  that was that time but now they are confronted by another Black wave of doctors from the continent who came in with the 1990 ...[indistinct] door opening to let in life and purify the air.
 Recreation facilities at these hospitals have always been a sore point with committed staff.  Townhill grounds, havens of opportunities for braai's and walks when families visited.  Even at my hospital now in Ga- Rankuwa here in Pretoria - which fortunately evaded the sort of investigations of 1996, there are no facilities for leisure or rehabilitation except for some decrepit old teethes or occupational therapy unit.
 I want to go back to Cape Town as well, where a stiff backed suite clad consultant yelled at me in almost infantile rage for what he called: "my attitude to work" as I maintained a passive aggressive attitude for his orders to me to perform pre-arranged and scheduled ECT's - that is your electro convulsive therapies, without prior discussion and examination of the indications as one would expect.  
 His outbursts may have been an indication of what was to follow two years on - emigration, which I hear is immanent.  I wouldn't even talk of that ECT machine which I think was a relic from the second world era - I mean, Second World War.  Another factor that I'm looking at: "The Management of Patients", there's also ...[indistinct] of family involvement in the treatment of our mentally ill patients and that is classic - I mean, it's all over South Africa.
 This had adverse prognostic effects for the patients and this adverse is quite opposite to the popularly held notion I heard when I was in Oslo, that ...[indistinct] patients in the third world - in developing worlds, fed better because their communities and families were more supportive and those communities were less inclined to highly emotionalise - to motionally verbalise criticisms, it's a concept that's called high emotions.  
 The societies up there are looking at your individuation, at your improvement, at your - what I can I say, individuality.  You are not so much part of the whole as you are your own, you are a tree in a big forest ...[indistinct] than extended family trees in a big forest, so that they look at you and if you are 18 and have not left house by then - because at that time, when you're 18 you can buy liquor, you can buy anything in Northern Europe and you can move out, you can marry, you can vote - you know, you are now free, you're free of parentation in that sense.
 But now, in those societies they tend to verbally criticise because of this sensitivity and they used to say that we are much better off but I am wondering because we are not doing those investigations - as Cooper had also said, that community extended thing, the supportive network element so we have to bring families in but that will come in another part.
 Re: Point 3 - I've jumped: "Management Issues" because there are so many and I wouldn't want to use all this time, Point 3 is some anti-ethical views to human rights and human dignity at psychiatric hospitals.  I said, just let us suffice to say that the legal rights of patients are not upheld, it's a very broad statement and we may wonder what it means and probably that we will deal with at the workshop.  
 We are still waiting patiently for the new Mental Health Act to find it's way from the National Mental Health Directorate to mental health institutions, three years into our democracy and three years from the end of the millennium.  ...[indistinct] psychiatry 2000, I ask.  You know, things like toothbrushes, washing rags, towels, shoes in winter ...[indistinct] and I'm asking a question: "Have you ever seen a psychotic patient in an institution"?
 If the society was invited - which I would like to do, in changing our perceptions and services, to get the people to come into mental hospitals - not just visitors, families - the few that that can, but to open up and let this mystery disappear and let the people decide how things should be done, especially now that we are de-institutionalising - that we are moving towards primary health care.
 Now, another interesting element, recently there was a battle of wheels unfolding between Pretoria West General Hospital - I hope there's somebody from there but there obviously isn't, and Madunsa - Ga- Rankuwa psychiatric department.  After that debilitating Westfort Hospital had been fingered by the report on psychiatric hospitals, was closed in 1997, about 40% of the chronic patients from Westfort were transferred to Pretoria West General.  It his here that Ga-Rankuwa's psychiatric department should transfer their patients for further rehabilitation, treatment when their acute psychotic illness has settled down. 
 But the Pretoria West people or the people at Pretoria West who had originally catered for the White working class of that area, again erected obstacles to this process just like you saw in Pietermaritzburg and the directives from the Director General of Justice - that is the legality part of it, are also very hazy on this matter so that confusion abounds and patients are caught in the middle.
 Even patients who are discharged from that hospital are not allowed to stay in three days after being discharged.  If no-one claims them, they are just thrown in.  There are no social workers in that unit, there is not community involvement again.  What perceptions emerged from this unfortunate situation is that burials are being erected in the name of legality where really, a general hospital has a duty to admit ill patients.  But also the facilities for car of these patients are lacking, these patients cannot even stroll the grounds as they are situated on the fourth floor.  
 Conditions of a shift now towards primary health care - without infrastructures in place, can be socially devastating for a very vulnerable patient group - unqualified change does not necessarily mean progress.  Academic psychiatric planning for the teaching of medical students and registrars is mechanistic in it's approach, their realities of South African society and analysis thereof are not brought on board.  There is not proper psychosocial orientation in the management of patients, concepts like supportive social network are not integral in the thinking of the registrars and students.
 Apathy and even lack of interest in these socio-economic variables abound.  I've heard Black doctors that family histories in psychiatric patient examinations are irrelevant and that poverty's not a social stress.  The facts of unemployment and chronic violence and refugee status are not discussed, there's almost a schismatic split between the patient and his or her persona.  Instead, students and registrars are ...[indistinct] at diagnosing the disorders of post-traumatic stress and drug abuse and related disorders therein without a comprehensive and cohesive approach, it's quite a two dimensional view - how unfortunate.
 Psychotherapy Dear Doctor - says Cooper, is almost an ...[indistinct], except for the tolerance, the tolerance of the presence of some of us overseas trained psychiatrists who almost an exotic element.  The reasons given are usually that psychotherapist ...[indistinct] or that the numbers of the population in demand are huge and that there are a few psychiatrists or that it is the domain of psychologists.
 There are psychotherapies that are modified to suit the realisations that I've listed - like you said, the one to one doesn't go.  Torture is seen through the windows of the definition of trauma and understanding and treatment thereof is rather absent through the lack of direct relation to the victims and their communities - like you were talking, one degree up, one degree down - families with the victims.