Picture: 123RF/Levente Gyori
Picture: 123RF/Levente Gyori

The UN predicts that 68% of the world’s population will live in cities by 2050. Mental illness, substance abuse and violence are interrelated upshots of rapid urbanisation.

SA is 66% urbanised and the urban growth rate is about 2% per annum. About 70% of migrants in SA cities are citizens from other provinces; only 30% come from other countries. Yet there is limited data available on the extent of mental health challenges in SA, or even what proportion of SA’s medical budget is spent on mental health care.

Depression, suicide and substance abuse are increasingly recognised as global epidemics and they should be considered “in the context of growing urbanisation and declining social capital”, Dr John Parker from the SA Society of Psychiatrists said.

“We have the problem of a continuous inflow of people into our cities piling shack upon shack, as well as more density within our townships creating slum areas, and an established population in our cities adding to our natural population growth — and absolutely no planning,”  Dr Lesley Robertson from Wits University’s department of psychiatry said.

Nicole Breen, a project leader at the SA Federation for Mental Health, said there is “a collision between mental illness, substance abuse, violence and poverty. There is no concurrent development of services to accommodate people flocking to the cities,” she said. “Urban areas are increasingly violent, and substances are easier to access. This is disastrous for those with a proclivity towards substance abuse or poor mental health.”

Robertson said there is little understanding of the burden of mental illness. The two major household surveys are the National Income Dynamics Study, which measures levels of depression, and the SA National Health and Nutrition Examination Survey, which measures levels of psychological distress in households.

“Are informal settlements sufficiently represented, given their high density? How do the surveys address population migration? And what are they identifying in urban areas amongst youth? We don’t know what we are dealing with,” Robertson said.

“Records of how many people, under what conditions and in which areas, receive disability grants should theoretically be available; details of how many people access mental health-care services should also be available; the numbers of people accessing community-based care and hospital care should  theoretically be accessible, and it should be possible to demonstrate the status of mental health in multiple settings in the country. Some of this information is contained in the World Health Organisation Mental Health Atlas, but this is nonspecific and sparse,” Breen said.

There are no large-scale social interventions and there has been no increase in treatment capacity for susceptible individuals, Robertson said. “We have awareness campaigns running all the time but who is going to treat people if you don’t capacitate the treatment services? And what is [the department of] social development doing to improve the circumstances that predispose to mental illness?”

People who suffer from mental illness and their families, who come to the cities in search of treatment and a higher standard of care, are “met with an overloaded system that cannot accommodate them”, Breen said. In addition, poverty, inequality and unemployment trigger or worsen mental health issues.

“After the elections, we need to see an integrated, intersectoral planning approach to the rapid urbanisation we are experiencing,” Robertson said. Government departments “are not producing concrete, detailed plans of how and what they are actually going to do”, she said. A unified plan of action by the departments of social development, health, education, safety and security, correctional services and justice is imperative.

Parker suggested that although mental health care is considered to be part of integrated service delivery at the primary level, in reality, it does not get the attention of physical illnesses such as TB and HIV that staff have been trained to manage.

“It is no good us trying to work intersectorally in the district when the messages come down from the top in silos,” Robertson said. “It just creates conflict between departments at grassroots level — and the person with a mental illness or intellectual disability is pushed from pillar to post.”

According to Robertson, the evidence for health system organisation should be examined in the same way that medicines are examined and selected. She is part of a team from the Centre for Health Policy at Wits that is developing an evidence map, using global experience, for strengthening primary care and community support for people with mental illness.  

On the question of costs, Robertson commented: “We can’t afford not to provide care. But how to provide it must be looked at strategically, so that the money is put into systems which are effective.”

Parker said there has been a failure at national level to see mental illness as the national crisis that it is. As a result, “we cannot, as a country even figure out what percentage of our health budget is spent on mental health care”.