The tip of the iceberg

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.

 

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