72 hours to care: The precarious road to psychiatric help

Dinah Mbalati was still in bed when she heard it. Something heavy was being dragged across the house’s concrete floor. Then she could make out the sounds of the front door opening, of someone stepping out into the front yard.

She got up to see what was happening. As she got outside, she saw him: there, in the early morning sunlight, was her uncle David bent over his mattress.

He grabbed the mattress with both hands and then began to pull it apart, Mbalati remembers.

After that, he slept on the floor. The scene wasn’t entirely out of place at the Mbalati home in Soweto. In 2015, the Gauteng health department decided to terminate its contract with the Life Esidimeni hospital group, which had provided state-funded care for psychiatric patients for decades. Diagnosed with schizophrenia almost nine years ago, David was one of the almost 1 700 patients who had to leave Life Esidimeni.

Many patients went to unlicensed nongovernmental organisations and at least 144 eventually died. The Gauteng health department still can’t trace 20 of the patients it removed from the private facilities, Democratic Alliance spokesperson on health Jack Bloom said in a recent statement.


But David, who has schizophrenia, went home.

Schizophrenia is a severe, chronic mental illness characterised by a distortion in perception, emotions and behaviours. The condition often results in hallucinations, delusions, disordered thoughts and abnormal behaviour, the World Health Organisation explains.

At Life Esidimeni, medication helped to control David’s symptoms. But back home, he stopped taking his daily drugs. The man whose family described him as kind and loving with a quiet demeanour began to act out in destructive and sometimes violent ways.

Even if David couldn’t see it, his family could: he needed to be readmitted into hospital.

That’s when the problems began. The vast majority of people with mental health conditions will never become violent. In fact, mental health patients are more than twice as likely as the general population to be victims of violent crime than to commit it, a 2014 study published in The Lancet medical journal found.

But when people with mental illness do become gravely ill, so sick that they are a risk to themselves or — in rare cases, others — the law provides for people to intervene on their behalf.

Under the 2002 Mental Health Care Act, people like David can be admitted into designated hospitals and kept there for 72 hours in specially reserved wards. During this time, they’ll be observed by healthcare workers to determine whether they need treatment, more specialised psychiatric care or if it is safe for them to return home.

Getting volatile patients like David to these units can be a battle. 

  • Like what you’re reading? Sign up for our free weekly newsletter or donate to support great journalism.

Dinah’s mother Jeanny, David’s sister, estimates they phoned the police at least five times for help in getting him to one of these specialised wards. Each time, the police would arrive with sirens blaring, scaring David, who would “disappear”, Jeanny remembers.

“He runs fast, fast, fast. You will never catch him.” 

Eventually, Dinah says, frustrated police officers would utter a common refrain: “Hayi! It’s the ambulance that’s supposed to deal with these patients.”

But when emergency medical services arrived, they refused to take David because they weren’t equipped to restrain him — and couldn’t administer medication to calm him down during the ride to the nearest specialist facility, Dinah explains. “They’d say, ‘No, you need to call the police if the patient is violent.’”


David stayed with the family in this room, now used for storage, for more than a year before they could find him help after he was removed from Life Esidimeni facilities. (Oupa Nkosi)

When we get sick we go to the doctor, and the National Health Act protects people’s right to choose when they seek out and receive medical care. But, under the Mental Health Act, the South African Police Service (Saps) must intervene if someone is a threat to themselves or others because of mental illness, taking them to the nearest designated facility for a 72-hour assessment.

For desperate families, police are a lifeline and most often the only way patients who are acting out make it into 72-hour facilities, a 2010 study published in the journal Psychiatric Services argues. As part of the studyUniversity of Cape Town (UCT) researchers reviewed the records of 151 hospital admissions for schizophrenia and found that, in one out of two cases, police played a role in getting patients to hospital.

But as the Mbalati family learned, this doesn’t always happen.

This isn’t lost on Christine Nxumalo. Her sister, Virginia Machpelah, died during the Life Esidimeni move. Today, she continues to represent other Life Esidimeni patient families as part of a family committee.

She says several families who took ill loved ones home during the move have turned to the police for help to get violent family members readmitted.

“The police and the ambulances haven’t been trained in how to deal with these situations.”

Psychiatrist and senior UCT lecturer John Parker agrees. “In some cases, the police’s eyes just roll.”


What would you do if someone you loved became a danger to themselves? (Oupa Nkosi)

Numerous studies over the years have called for better and more training for Saps personnel on dealing with mental health patients. The country’s mental health strategy even recommends developing guidelines to assist police in managing patients who are on the way to hospital or waiting to be admitted.

The Gauteng health department trained 60 officers on how to handle mental health patients in July, acting director of mental health Kobie Marais says. But, nationally, it’s unclear whether this kind of training happens regularly or whether the guidance envisioned in the mental health policy for police has been developed.

The Saps did not respond to Bhekisisa’s requests for comment. Eventually, more than a year after they had first contacted the authorities for assistance, Jeanny’s oldest daughter, Flavia, called the police before sunrise one day and pled for help.

“I think I spoke to someone that understood and who could feel my frustration,” Flavia says.

The police van arrived silently and David got into the back without a struggle.

They took him to Soweto’s Bheki Mlangeni District Hospital, which is one of 17 district hospitals in Gauteng designated to provide 72-hour observation services, according to a list provided to Bhekisisa by the Gauteng health department. The 2014 document — the latest available — shows that fewer than half the hospitals had dedicated wards for patients. Although this is allowed under national guidelines, even health department regulations caution that this puts psychiatric patients at risk because wards may be poorly secured and staff may not be properly trained to care for them

In fact, Gauteng has the smallest number of designated 72-hour facilities among four provinces when compared to a list provided by the South African Federation for Mental Health of facilities in Mpumalanga (26), KwaZulu-Natal (29), the Western Cape (52) and Limpopo (66).

In Limpopo, some wards only have as few as seven beds and cannot always cater for all genders of patients.

A lack of beds means some facilities are forced to bend the rules, South African Federation for Mental Health deputy director Leon de Beer explains.

“Patients often actually have to be admitted and placed in other wards, which is a risk.”

Guidelines for 72-hour facilities recognise that gravely ill patients may pose a risk to themselves or others so they require wards meet strict safety standards, including panic buttons for staff, bolted-down furniture and closed-circuit television monitoring

Typical wards don’t meet all these criteria.

Even when designated wards are available, they aren’t always properly staffed, as postdoctoral researcher Abigail Ornellas describes after working at a 334-bed public hospital in the Western Cape.

“The social care staff — consisting of three full-time social workers, one part-time psychologist and a handful of medical students and practitioners — was hopelessly insufficient to meet the patients’ needs”, Ornellas writes in a 2018 study published in Stellenbosch University’s Social Work journal.

“The team was already struggling to render basic services to the general hospital population, and hence the needs of mental health patients in the 72-hour observation ward were often left to the care of nurses and student doctors”, she explains. “It was then that I became aware of the barrenness that was mental health service delivery and, moreover, that this was not an isolated issue.”

Gauteng is trying to increase the number of patients it can accommodate in 72-hour wards, Marais says, but doing so is about more than just finding the physical space for beds.

“In order to add an extra bed, resources around the bed also need to be in place,” he explains. “Resources to activate a bed include human resources: doctors, nurses, social workers, occupational therapists, psychologists … as well as nonclinical services like security staff, cleaners and administrative staff.”

Today, David is one of the lucky ones who are able to access long-term psychiatric care. He recently celebrated his birthday in a hospital in the south of Johannesburg.

But until South Africa takes a more holistic approach towards mental health, Parker warns, many more patients may go without care.

Subscribe to the M&G

These are unprecedented times, and the role of media to tell and record the story of South Africa as it develops is more important than ever.

The Mail & Guardian is a proud news publisher with roots stretching back 35 years, and we’ve survived right from day one thanks to the support of readers who value fiercely independent journalism that is beholden to no-one. To help us continue for another 35 future years with the same proud values, please consider taking out a subscription.

Thalia Holmes
Thalia Holmes

Thalia is a freelance business reporter for the Mail & Guardian. She grew up in Swaziland and lived in the US before returning to South Africa.

She got a cum laude degree in marketing and followed it with another in English literature and psychology before further confusing things by becoming a black economic empowerment (B-BBEE) consultant.

After spending five years hearing the surprised exclamation, "But you're white!", she decided to pursue her latent passion for journalism, and joined the M&G in 2012. 

The next year, she won the Brandhouse Journalist of the Year Award, the Brandhouse Best Online Award and was chosen as one of five finalists from Africa for the German Media Development Award. In 2014, she and a colleague won the Standard Bank Sivukile Multimedia Award. 

She now writes and edits for various publications, but her heart still belongs to the M&G.     

Related stories

Convoluted minds must also be heard

Mental illness carries a stigma, but with the publication of her book, Dr Ngcobo sheds light on living with bipolar disorder in an attempt to end judgment and educate people

Happiness is too important to leave to chance

Newfound clarity on the important things in life has been hailed as a silver lining of this crisis. Planning a future around ‘purpose, passion and pay’ may be the key to having it all

The unbearable sadness of lockdown

Loneliness can seem like a hopeless hole that increases anxiety, depression, fears or thoughts of suicide

We can’t expect learners and teachers to function optimally right now

It may well be that we have warm bodies in schools, but to think their minds are highly productive is a reach

Black youth can’t wait until tomorrow

The Covid-19 crisis has exposed the raw realities of South Africa’s under-resourced public schools

Academics’ health suffers under Covid-19

More than ever, higher education institutions need to look after employees’ mental wellbeing
Advertising

Subscribers only

Covid-19 surges in the Eastern Cape

With people queuing for services, no water, lax enforcement of mask rules and plenty of partying, the virus is flourishing once again, and a quarter of the growth is in the Eastern Cape

Ace prepares ANC branches for battle

ANC secretary general Ace Magashule is ignoring party policy on corruption-charged officials and taking his battle to branch level, where his ‘slate capture’ strategy is expected to leave Ramaphosa on the ropes

More top stories

Sudan’s government gambles over fuel-subsidy cuts — and people pay...

Economists question the manner in which the transitional government partially cut fuel subsidies

Traditional healers need new spaces

Proper facilities supported by well-researched cultural principles will go a long way to improving the image and perception of the practice of traditional medicine

Did Botswana execute ‘poachers’ ?

The Botswana Defence Force’s anti-poaching unit has long been accused of a ‘shoot to kill’ policy. Over 20 years the unit has killed 30 Namibians and 22 Zimbabweans

Limpopo big-game farmer accused of constant harassment

A family’s struggle against alleged intimidation and failure to act by the authorities mirrors the daily challenges farm dwellers face
Advertising

press releases

Loading latest Press Releases…