All psychiatry in Cape Town was under-resourced, under-staffed and under-funded, but this seemed to be most evident, or perhaps just most upsetting, in Child and Adolescent psychiatry. An excellent service is provided by the multi-disciplinary team of the Red Cross Children’s Hospital, but more than anywhere else I saw, they could only address the very tip of a very large iceberg.

The complexity of child and adolescent psychiatric need was vast. This was unsurprising, in conditions of extreme poverty, uprooting of family structures by premature death (often HIV, TB or trauma-related) and economic migration – most patients did not know their fathers and many were raised by extended family or friends. Some of the need related to other issues I had already encountered such as tik abuse, foetal alcohol syndrome and deprivation – leading to dropping out of school and involvement with gangs. Other problems were more broadly and complexly associated with the violent history of South Africa and its current struggle to leave its past behind.

In 2000, South Africa had the world’s highest per capita rape rate, with one in three surveyed women reporting rape in the past year. With a 40% lifetime risk, a South African woman has a higher chance of being raped than completing secondary school. Rates of sexual violence against babies and children are also extremely high, with 67,000 reported incidents per year representing a fraction of unreported abuse. It has been argued that one factor is a widespread myth that sex with a virgin can cure a man of AIDS, though its extent has not been quantified. The legacy of sexual violence was evident among patients I met, and nowhere so extensively as in child and adolescent psychiatry.

One thirteen year-old girl fortunate to receive extensive multi-disciplinary treatment as an inpatient had psychotic symptoms, low self esteem, obsessional traits, self harm, mood disorder and dissociative symptoms, with a long history of sexual abuse and inconsistent parenting. While her home environment was unsafe, she spent her weekends there and often returned with much of her progress undone after two days in the township. Poems she wrote about the abuse she had suffered provided a small insight into some of the trauma experienced at such a young age. The team worked tirelessly with her challenging behaviour, to support her as she went through puberty and tried to cope with her childhood past – though still a child.  Ultimately though, she was to be discharged back into a violent, risky home environment – since there were so many boys and girls just like her, in grave need of one of the few inpatient beds available. The team did amazing work with her, but it really was the tip of the iceberg. The ability of the CAMHS team to work non-judgementally with parents with as many social and psychiatric problems as their children was truly powerful to watch.

	I  will never forget my four weeks in Cape Town and hope, as I progress in Medicine, that I can make some small difference to the enormity of the problem that exists below the surface of what can currently be addressed. Organisations that extend some of the benefits of healthcare in the West to assist sustainable development will, I hope, work towards a world in which the scope of care offered is not so unequal on the other side of the world.   My elective experience was one of contrasting frustration, sadness and regret, with inspiration and even hope. I could leave each day thinking how much more could be done with just a little more – another psychiatrist, another clinic, a little more funding for a few more psychiatric medications or psychological therapies. Or I could leave thinking how much was achieved with so little, how life-changing the treatment in the face of such unimaginable deprivation, suffering and trauma.
Even on a more optimistic day, there was no denying the sheer magnitude of inequality and plain unfairness of life in Cape Town – and the Western Cape is the country’s most prosperous province. How, as a doctor, do you get up each day and go to work in this context? The 19th century French quotation adopted as Valkenberg Hospital’s motto stays with me, as I approach the start of my medical career, in the magnificently privileged NHS environment. Sometimes to cure, often to relieve, always to comfort.

Organic psychiatry was what attracted me to an elective in Cape Town and I was not disappointed. Differential diagnoses for psychotic presentations included HIV or opportunistic cerebral infections, temporal lobe epilepsy and tik (methamphetamine) psychosis – the single largest mental healthcare burden on the psychiatric wards.

Tik is described as an ‘epidemic’ by psychiatrists here because its use has exploded among the urban poor of the townships. Methamphetamine can be easily manufactured using basic items including ephedrine and ammonium fertiliser, making it widely available (and commonly produced in rural farming areas). Cheap, tik is described as ‘the poor man’s cocaine’, since its effects last much longer. It is highly addictive and associated with aggression, hypersexuality and violence – resulting in high crime rates in communities already plagued by gangs, gun and knife crime.

Most of the patients I met with tik psychosis were admitted for their own or others’ safety, until they had recovered in about a week. In others, however, methamphetamine formed the trigger for a much more enduring psychotic illness, in some the starting point for lifelong Schizophrenia. In Cape Town, tik played a role much like that of cannabis in the UK: patients who became abstinent from the substance recovered better, while those who returned to tik abuse, widespread among their peers, tended to relapse.

On the neuropsychiatry ward (five beds in a city with 17.8% HIV prevalence),I observed two unusual cases of psychosis and Multi Drug-Resistant tuberculosis in young women who were HIV negative. This presentation was unfamiliar to the team. After extensive research, they considered the most likely cause to be a rare neurotoxic response to Quinolone antibiotics prescribed for MDR TB. Another woman on the ward had a more predictable picture of HIV encephalopathy associated with an extremely low CD4 count.

What intrigued me about these cases was the clear need to treat mental illness with physical therapy. In Britain, the law clearly distinguishes between treatment of the mind and the body. The Mental Health Act allows for treatment against a patient’s wishes for a disorder of the mind, but not for one of the body. This was upheld in a case where a patient with paranoid schizophrenia (Re: C) was able to refuse amputation of his gangrenous leg, despite it being life-threatening, because he had capacity to make that decision about his physical health, however unwise. This leads to difficulties with physical treatment (such as refeeding) for psychiatric disorders (such as anorexia nervosa).

In Cape Town, there were so many possible organic aetiologies for psychiatric presentations that doctors had to prescribe physical treatment for psychiatric disorders, in their patients’ best interests. For example, in the many patients with depression, psychosis or dementia directly attributable to their HIV infection, the treatment simply was Anti-Retroviral Medication – and this is what was prescribed. However, infectious disease specialists were loath to commence ARVs in patients who lacked the insight to commit to a life-long course, since the risks of non-compliance are high.

Observing the practice of neuropsychiatry in Cape Town brought home to me theinconsistencies in the mind/body dualism upon which mental health legislation is founded. It may have its roots in religious separation of the ‘soul’ from the body, or in Cartesian traditions that reject the materialist view that mind and body are one.  But artificially separating the mind from the body prevents us from seeing the whole person and encourages you to ignore physical complaints when treating the mind or forget psychiatric concerns when treating the body. I saw how this is potentially very dangerous, clinically, not to mention, detrimental to the relationship with a patient.  It was exciting in Cape Town to observe the genuine enactment of the oft-quoted buzzword, holistic healthcare, as doctors considered every aspect of the individual in their diagnosis, treatment and management.                        

Cape Town is a beguiling city of immense beauty and horrendous contrasts. More than any place I have ever been, there is a sinister level on which you can live here, unaware of the suffering going on around the corner. Drink a mojito with royalty on Camp’s Bay, get your Maserati serviced, eat lobster with the rich and famous – just don’t take a wrong turn down the N2 and end up in Khayelitsha. Or Gugulethu, or other evocatively named townships like Brixton, Barcelona or Malibu Village. This is the legacy of apartheid, in which Black and ‘Coloured’ families were uprooted from their homes in the city, like the vibrant and now infamous District 6, which was bulldozed to the ground. These families were removed from the sight of ‘White-only’ areas and relocated to hostels without basic amenities, or schools, or healthcare. This explains why so much of the city’s deprivation and destitution seems conveniently located out of sight of the Table Mountain Cable Car, the Mount Nelson Hotel and the penguins on Boulder’s Beach.

This is why the community clinics run by psychiatric registrars and consultants within the townships are such an important part of healthcare in post-apartheid South Africa. The majority of doctors are White and there is a deep symbolism to the act of them travelling into the townships (where they certainly do not live) to diagnose and treat their patients. Here, listening to Afrikaans questions translated into the magical clicks of Xhosa, was where I observed truly holistic psychiatric medicine – and gained a small sense of the deprivation in which the majority of Cape Town’s residents live.

It’s not easy to take a psychiatric history with one or two language barriers between you, the nurse interpreting and your patient. A lot of the meaning of what you want to ask seems lost in translation. And your cultural conception of their symptoms might be different to theirs. While in Cape Town, most patients embraced the medical model to a degree, and did not dispute the role medication played in their recovery, it was not the only treatment they sought. Many patients first looked to their sangoma (traditional healer) for support and advice. Often, after little success, the sangoma would refer them to mainstream services and doctors even spoke of successfully working alongside a sangoma, whose role was more one of social support than one of ‘healer’. But other, less reputable members of this unregulated specialty were known to prescribe hallucinogenic drugs which worsened psychotic symptoms, or even advocate painful and disfiguring procedures to ‘banish the demon’ to which they were attributed. Psychiatrists in community clinics had to work together with the patient’s cultural as well as religious belief system in order to engage patients with a rather alien biological model of their distress.

The second enlightening aspect of community psychiatry in Cape Town was the realisation that when statutory mental health services are under-resourced, the burden of care lies truly with the patient’s family. The epitome of this overwhelming responsibility was encapsulated by the predicament of Mrs F. She financially supported and cared for her niece (since her sister had died), who had managed to stay out of hospital despite many previous admissions for bipolar disorder,  and her  daughter, who had learning disabilities. She also supported her own children, one of whom caused her anxiety through his involvement with knife crime in a local gang. She had nursed her own mother until her death and then her husband until his death from cancer. She worked nights cleaning offices and spent most of her day taking care of the small, meticulously well-kept flat she shared with her family in the township of Athlone. My first thought was “when does she sleep?” She doesn’t sleep much. You wondered how she coped with so much. But as you looked around the lovingly polished photographs of all these different children, siblings, nieces and cousins – you could see exactly why she did it. She knew that if she didn’t keep things together, many inter-connected lives, held together so tenuously, would fall apart. The extent of sacrifice and care Mrs F represented was incredible to witness. But the enormous burden she bore, for which she had previously been admitted to a psychiatric ward, took its toll. Mrs F’s suffering was the result of deinstitutionalisation, without the creation of community services to support the needs of discharged patients. Her sacrifice was wonderful, but grossly unfair. It was symptomatic of the historic abandonment of the people of the townships – left to bear the social ills created by the very regime that then refused to help. This was why it meant so much that White doctors got in their cars and came to the clinics and visited the houses of their patients – rather than staying within the mansion walls of Groote Schuur.

Cape Town is a beautiful place. Surrounded on three sides by dramatic coastline and stunning beaches, you can surf, scuba and whale-watch (or cage dive) to your heart’s content. But when you visit the Two Oceans Aquarium on the waterfront, look out for the sign that tells you everything you need to know: “80% of Cape Town’s children have never seen the sea.”

The imposing Cape Dutch revival facade of Groote Schuur Hospital, Cape Town, made a for a striking contrast to Mulago Hospital, Kampala, where I spent four weeks studying Obstetrics and Gynaecology. Inside, Groote Schuur had much in common with a London hospital, but as I was soon to find out, it was the aetiology of psychiatric presentations to the Emergency and Assessment wards that would be so different to anything I would see at home.

I chose Cape Town for my psychiatry elective based on strong recommendations from KCL students in the years above me. Most patients speak English, making in-depth history taking and mental state evaluation possible. High rates of HIV (17.8%) mean HIV encephalopathy, dementia and psychosis are common presentations as well as common mental health problems on a background of HIV. Tik (methamphetamine) is widely abused in the community, resulting in acute psychotic episodes, and hallucinogens are often prescribed by traditional healers (sangomas) for relief. This breadth of organic psychiatry, in the context of the great socio-political challenges facing a post-apartheid nation made for an irresistible opportunity to learn psychiatry in a brand new context.

My first day on the psych wards did not disappoint me. I met a range of warm, friendly and fascinating patients, all with unique stories to tell. One middle-aged gentleman had a twenty-year history of schizophrenia but had recently been diagnosed with Dandy-Walker malformation, with enlargement of the cerebral ventricles and shrinking of the cerebellum. He presented with cognitive deficits and worsening psychosis. The challenge was to discern whether this was an incidental CT finding or an indication of underlying neuropathology explaining his chronic illness.

Next, the psychiatrist covering A&E was called to assess a suicidal twenty-year-old girl with learning disability secondary to foetal alcohol syndrome. Typical of the tragic childhood stories of young people from deprived backgrounds in South Africa, she had lost her mother to TB (likely HIV-related) and her father to a road traffic accident and was living in a township with a kindly woman (she was not in contact with her siblings). This lady had attended mainstream school late (because, after their parents died, her sister forgot to enrol her), but her learning disability was never commented on by teachers or assessed. She became suicidal, she said, after one of her friends stabbed the other and when she reported this to one of their mothers, she was not believed. Attending A&E for this suicide attempt was her first opportunity to access the learning disability and mental health services available, which she had never been aware of before.

Finally, I met a lady in her sixties with worsening persecutory delusions and self-neglect who was thought to have had well-controlled chronic paranoid schizophrenia but was now developing vascular dementia, confirmed by MRI. All three cases were fascinating examples of the interface of psychiatry with neurology and general medicine - and, on day one, affirmed to me the importance of the psychiatrist as the doctor, who foremost, must exclude organic pathology before proceeding to treat psychiatrically. After such a rich first day, I can't wait to see what the rest of my elective holds in store!