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The Royal College of Psychiatrists Improving the lives of people with mental illness

Cape Town

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October 2011 Posts

13/10/2011 11:23:23

Sangoma to mainstream services

Township house

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.

Township houses

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.

Traditional herbalist

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’.

Traditional herbalist
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.
Community health centre

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.

African Gospel Church
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.”

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About this blog

Roxanne Keynejad


Roxanne Keynejad is a final year graduate entry Medicine student at King's College London, having studied a first degree in Psychology with Philiosophy at the University of Oxford.


She is spending four weeks of her elective studying psychiatry at Groote Schuur and Valkenberg Hospitals, Cape Town, for which she received bursaries from the Royal College of Psychiatrists elective bursary fund and the Institute of Medical Ethics.