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