The crisis over mental health care in South Africa continues

On Feb. 1, a report by South Africa’s health ombudsman, Professor Malegapuru Makgoba, revealed that at least 94 state mental health patients died as a result of the Gauteng Province health department’s decision to remove them from facilities run by Life Esidimeni, a private company contracted by the state.

Many of the patients transferred to centers run by community-based nongovernmental organizations died of dehydration, hunger, cold and general lack of care, some of them within days of their new placement. To compound matters, in many cases the relatives of those who died were not promptly informed of patients’ deaths. It has been alleged that some deaths were covered up, giving rise to allegations last Friday by Mark Heywood, the head of Section 27, a human rights N.G.O., that 94 may be a conservative estimate of the casualties.

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Behind this crisis lies an escalation of tragic—and many would say avoidable—events centered on the question of what to do about state-funded mental health care, particularly care outsourced to private health care provider Life Esidimeni. The Gauteng minister for health to decided to end the province’s contract with the company, in part, because he believed that mental health treatment outcomes could be better achieved in a community as opposed to institutional setting. But cutting costs was also a consideration.

Many of the patients transferred to centers run by community-based nongovernmental organizations died of dehydration, hunger, cold and general lack of care, some of them within days of their new placement.

Patients, their families and other interested parties resisted the transfer, and the South African Society of Psychiatrists warned in June 2015 that the move was “premature.” Critics felt that the community-based N.G.O.s lacked the necessary skills to care for the patients. Indeed, many of the N.G.O.s lacked the proper licenses required under law to be their caregivers. The reported causes of the deaths suggest that many of the community N.G.O.s lacked adequate facilities and capacity.

S.A.S.O.P. and other professional organizations had taken the province to court in 2015 to try to stop the transfers. They feared that the move would include persons with serious mental health problems, those least able to care for themselves, and it did. They warned that the new caretakers lacked the skills to care from them, and they did. They were concerned that a sudden transfer to a new environment would further harm the patients, and it did.

Above all, they argued that the decision would violate the human rights of mental health patients. These included the right to dignity and health care under sections 10 and 27 of the Constitution, the Mental Health Act and the National Health Act. Furthermore, they feared that it could threaten the right to life as entrenched in section 11 of the Constitution.

The litigation, however, got nowhere. Following assurances by the health department that patients’ rights and care would not be compromised, and that those to be transferred no longer required comprehensive professional care, the court allowed the move in March 2016.

The reported causes of the deaths suggest that many of the community N.G.O.s lacked adequate facilities and capacity.

The painful history of public mental health care in South Africa should have served informed the health department’s actions. A recent Ph.D. completed through the Steve Biko Center for Bioethics at University of the Witwatersrand presented a grim history of psychiatry in the country over the last 150 years. State institutions have been overcrowded and under-resourced and provided inadequate care for patients. During the apartheid era, psychiatry was sometimes used as a political tool to “recondition” blacks arrested repeatedly for refusing to carry identity documents at all times (then a law) and to “treat” white men who refused to be conscripted into the army.

The state-private cooperation, the research revealed, had long been part of the mental health care environment, given the shortage of state institutions. A former social worker in the Eastern Cape Province who worked in hospitals run by Life Esidimeni’s predecessor in the field during the 1970s, told me that conditions even in these private-sector outsourced facilities were poor then; another person familiar with the facilities told me that even under the protection of post-apartheid legislation, they were not great.

But at least they were not lethal.

The crisis over public mental health care in South Africa continues. Even though Gauteng’s health minister, Qedani Mahlangu, has resigned, this is probably only the beginning. The pressure is on to investigate further, particularly to see whether this was a genuine tragic mistake or the result of a cynical exercise in cost-cutting by the province; whether the health department, Life Esidimeni and the community N.G.O.s knew the risks they were taking with human lives; and whether this is a regional aberration or a national problem.

Justice for the victims and compensation for their families is only the start. This affair highlights the gap in contemporary South Africa between legislation—often among the most progressive in the world—and realities of mismanagement, incompetence and corruption that makes our enviable Constitution look so often like nothing more than a piece of paper.

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