About the author:
Kate Sherry holds a PhD from UCT School of Public Health, an MSc in International Primary Health Care from University College London and a BSc in Occupational Therapy from UCT. She volunteers for one of Thumela’s partners, Rural Rehabilitation South Africa and has a passion for primary healthcare, community-based rehab and mental health.
About a year ago, I found myself in an argument with an entire roomful of senior academics about mental health. It was a meeting about an undergraduate textbook on primary healthcare (PHC), and I had suggested, unsuspectingly, that perhaps a chapter on mental health should be included.
I know far too little about textbook publishing and academia in general to understand what happened then. I thought the growing evidence of the mental illness pandemic would be enough to justify the suggestion (1 in 3 adults during their lifetimes??), alongside the well-established links between mental health and other (more respectable) public health issues like HIV and maternal and child health. Mental health brings together the biomedical, psychological and social components of wellbeing, has a strong relationship with poverty and injustice, and demands an intersectoral and multidisciplinary approach. It could be the poster child for the PHC philosophy, and to date most healthcare workers have far too little understanding of it. I even offered to write the chapter.
But my public health colleagues disagreed almost unanimously, some with a vehemence that took me utterly by surprise. Their arguments came down to the assertion mental illness is simply a diagnosis like any other, and since this was not a textbook focused on clinical diagnosis and treatment, it was unnecessary to include. There were not to be specific chapters on hearing loss or tuberculosis, so why mental health? I was taken aback.
I eventually got the go-ahead to write the chapter anyway, but after months of drafts and corrections, the editors decided not to include it after all – for the same reasons initially given. These are highly respected academics, with many years more experience in teaching, research and practice than I have. Several I know by reputation to be dedicated advocates for the health of marginalised populations. I had to question my own conviction – and come to the same conclusion.
Framing mental health as just another clinical topic reduces it to a technicality of healthcare, not an issue of human rights which requires social and health system change. It assumes that purely clinical interventions are adequate to address it – or, more frighteningly, that the role of healthcare workers is simply to carry out those interventions, not to think beyond them. It dismisses the longstanding effects of stigma, ignorance and fear on the availability of services for people living with mental illness – graphically illustrated so recently in the Life Esidimeni tragedy. It pigeon-holes mental health as a “speciality”, instead of understanding its interweaving in the health of every person, family and community. To communicate all this to first-year students is a powerful statement. And given that they will be providing our nation’s healthcare for the next forty years or more, I find it deeply worrying.
The whole experience perhaps typifies the ongoing struggle to have mental health taken seriously in the health sector. It must compete with the (justifiably) well-established interests of issues like child survival and tuberculosis. It must overcome the still-pervasive dualistic biomedical frame of reference. And finally, it must overcome our own deep-seated, perhaps only half-conscious, unease with the questions of mental health and illness themselves.
Perhaps every cause taken up by health rights activists faces the same initial argument: “This is not a problem”. Or alternatively, “Change is impossible”. But our very recent history says otherwise. As a medical colleague pointed out during a mental health advocacy workshop: not many years ago, HIV/AIDS was in a very similar position. Downplayed as a minority problem, heavily stigmatised, treatment dismissed as an unaffordable luxury only feasible through specialists. And yet through the combined efforts of activists, healthcare workers, academics and ordinary citizens, it was brought centre-stage. Today ARV’s are available free of charge at PHC level for all. No healthcare worker or educator in South Africa would consider HIV/AIDS a merely clinical topic (in fact, the final chapter breakdown of the PHC textbook itself includes one specifically on HIV/AIDS).
I don’t regret my one-woman campaign for that chapter, however unsuccessful it proved. As my colleague concluded: “If we did it for HIV, we can do the same for mental health.”
I choose to believe that.
The Thumela team thanks Kate for her article! If you wish to submit an article or response please email firstname.lastname@example.org
*The views and opinions expressed in this article are that of the author and not necessarily of Thumela as a whole*