Mental health care, either as a concept or as a practice, is not part of South Africa’s cultural zeitgeist. Like other developing countries, South Africa has severe mental health disparities. Between 75% and 95% of people with mental illness in South Africa have no access to mental health services. The Department of Health spends just 5% of the total health budget on mental health services, and mental health is underfunded and underresourced.1 There are simply not enough resources to address basic health issues, let alone complex and chronic mental health diagnoses. As in other low- to middle-income countries, mental health is severely under-reported, under-funded and under-represented.
But the underlying problem isn’t necessarily underfunded mental health services: even if by some miracle Scandinavian-level mental health services were available across South Africa tomorrow, most people wouldn’t use them.
The main problem is that the language, values and theories used to describe and explore mental health are based on entirely different cultural foundations. Introducing a Western-oriented mental health system into a developing country with a completely different cultural environment has proven problematic. As a result, mental health is a concept that has yet to penetrate the South African national consciousness.
Mental health is a very ambiguous term that is contextual. What is “normal” in one culture is foreign to another. Our “normal” is shaped by our culture, language, and education. These are the lenses through which we understand the world, especially when it comes to mental health.
Clearly, all racial and cultural groups are affected by mental health issues. But culture has an intangible impact on what a demographic understands as the causes and treatments of mental health issues. The intersection of mental health and culture is important, especially in developing countries.
This is not to say that there was no understanding of mental health in the South African context, but rather that South African conceptions of mental health, or health in general, have never had the space to develop in the same way as the Western medical model.
The field of psychology carries a heavy historical and conceptual baggage. Western Europe and North America claim responsibility for the origins and development of modern psychology. Since then, biomedical concepts have dominated discussions of mental health, both internationally and in South Africa.2 But psychology did not just begin in the West: in Asia, there is evidence of research into what we might now interpret as mental illness as early as the 1880s.3 In 1916 the Institute of Psychology was established in South America.Four Unfortunately, much Indigenous psychology research is oral, unpublished, or published in languages other than English.Five Most African universities did not have psychology departments until the late 1980s, and those that did exist used primarily Western theories and terminology. Instead of exploring indigenous principles, scholars have attempted to fit African patterns of behavior into Western molds.6 As a result, in South Africa and many developing countries like it, it has taken centuries for a concept of mental health defined by external standards to become embedded in the public consciousness.
Even basic principles get lost in translation. Take, for example, the biomedical notion of a separation between the “mind” and the “body” that constitute the self. It has been argued that the boundary between mental and physical disorders is itself a cultural construction that underlies our classification of illnesses as “mental.”7 Within this framework, mental health has been viewed as a physical illness that is confined to the body and can only be cured through medical intervention.
Compared to the South African health model, the separation of mind and body is somewhat arbitrary. Instead, health is holistic, uniting body, mind and soul. Physical illnesses can be linked to imbalances in an individual’s social life and relationship with their ancestors.8 A study found that in four developing countries, including South Africa, mental illness is often attributed to supernatural or spiritual causes.9
In many South African communities, mental health problems are understood to be caused by “witchcraft or demonic possession”.Ten People turn to traditional healers in their communities, who often provide a range of services for people living with mental illness.11 They identified three potential causes of mental health problems: biological, social and psychological.11 This doesn’t necessarily negate the medical understanding of mental health, but it does provide a fundamentally different understanding of the causes of mental health issues, and therefore how to treat them.
Given South Africa’s history of discrimination, seeking help from more traditional community outlets is clearly preferable to relying on the health system. For centuries, the South African health system has been used as a tool to marginalize and exclude people of color. “Black” hospitals were often overcrowded and understaffed, as the majority of resources were directed to “white” hospitals. In 1981, there was one doctor for every 330 white people, compared to only one doctor for every 91,000 non-white people.12 A legacy of horrific racism, South Africans often have a justified distrust for a health system that never represents them: People turn to their communities in times of mental distress and postpone seeking medical care until it is absolutely necessary.
As a result of this disconnect, campaigning for improvements to the mental health care system becomes even more complicated. Suppose mental health is not seen as a high priority issue by government officials, policy makers, policy advocates and the general public. If no one is asking for it, the government will not feel the need to put it high on its agenda. Lack of awareness of mental health also hampers civil society campaigning for policy change. While there are mental health service organisations in South Africa, they generally support specific individuals with mental health issues rather than calling for policy change or development. Advocacy organisations play a key role in shaping national policy. Without advocacy organisations, the issue would not be seen as a big problem to solve compared to other more general lobbying issues.
It is not surprising that the basic principles of modern thinking on mental health have yet to penetrate the South African national consciousness. It cannot be assumed that mental health principles are culturally neutral or easily transferable. The introduction of Western health models into African patterns of behaviour is at best ineffective and at worst harmful.
But the alternative is much harder and takes much longer. A model must be established based on a country’s specific values, beliefs, and philosophies surrounding health. Awareness of mental health will increase dramatically because the theory will match the beliefs the public already holds. It will be easier to advocate for mental health when we are all fundamentally on the same page. A major shift in mindset is needed for mental health to truly be a priority in developing countries and for people to receive the best possible treatment.
References
1 Christine Lochner, “Mental Health in an Unequal World,” Mental Health Information Center, 2021.
2 Joanna Moncrieff, The Myth of Chemical Cure: A Critique of Psychiatric Drug Treatment, London: Palgrave Macmillan, 2008, p. 217.
3 Alison Turtle, “Psychologizing Asia or Asianizing Psychology: A New Prescription for Dr. Watson?” Psychology and Developing Societies, 1989, p. 69.
Four Rubén Ardila, “Psychology in Latin America Today,” Annual Review of Psychology, 1982, p. 106.
Five Faith Martin, Psychology, Religion, and Development: A Literature Review, 2009, p. 9.
6 Bame Nsamenane. Psychology in Sub-Saharan Africa. Psychology and Developing Societies. 1992, 173 pages.
7 Fernando, Susan. Mental Health, Race, and Culture. 3rd ed. London: Red Grove Press. 2010, 37 pages.
8 Anthony Chioracci. African Spirituality. Harvard Gazette. 2015.
9 Maye Omar et al., “Mental Health Policy Process: A Comparative Study of Ghana, South Africa, Uganda and Zambia,” International Journal of Mental Health Systems, 2010, p.3.
Ten Sandisiwe Shoba. What HHP taught me about mental health in the Black community. 2018.
11 Crick Lund et al., “Mental Health Policy Development and Implementation in South Africa: A Situation Analysis,” Country Report, 2008.
12 Rajendra Kale. “The New South African Health Impression: The Recovery Phase.” BMJ (Clinical Research ed.), 1995, p. 1119.
