Living through global trauma: Why South Africa needs a public mental-health response to COVID-19

The mental-health effects of the COVID-19 pandemic form a significant part of the overall health risk. Failure to put in place measures to mitigate the psychological impacts of quarantine is likely to undermine its effectiveness and slow economic recovery. In South Africa, the stage is already set for major mental-health implications. By Andrea Teagle

Rasta Paul sits alone in Greenmarket Square a day before lockdown. Without means of making an income, Paul, who sells art and drums to passers-by, is one of many despairing of being able to pay rent. Photo: Andrea Teagle

The mental-health effects of the COVID-19 pandemic form a significant part of the overall health risk. Failure to put in place measures to mitigate the psychological impacts of quarantine is likely to undermine its effectiveness and slow economic recovery. In South Africa, the stage is already set for major mental-health implications. By Andrea Teagle

As countries travel further along the road of social distancing, the psychological toll of the global COVID-19 pandemic is becoming more apparent. Yet, in South Africa, the mental-health impact of the pandemic received inadequate attention in the first month of lockdown.

“It is a global trauma that everyone is going through,” says Dr Charity Mkone, a clinical psychologist and associate lecturer at Wits University. She warns that while measures might successfully flatten the curve, a failure to consider the psychological toll of the pandemic and incorporate a mental-health response will come with dire costs to wellbeing.

Like the physiological-health impact, the mental-health burden is likely to fall unevenly across socio-economic divides. While lockdown underscores the comparative isolation of those living in affluent areas, in low-income areas, the stressors that contribute to an already high risk for mental illness are highlighted and exacerbated. These include food insecurity, health worries, crowded living, a lack of access to basic services, financial stress, and the risk of violence.

“What the lockdown has been able to do is really shine the light quite brightly on the disparities in our country, and expose what has always been there...,” Mkone says. “People [in higher income brackets] are realising for the first time just how difficult conditions in informal settlements must be.”

The psychological toll of quarantine
A rapid review published in The Lancet in February 2020, including 27 studies of the psychological impact of quarantine in response to epidemics in different parts of the world, found significant and, in some cases, long-lasting negative effects. These included post-traumatic stress disorder (PTSD), low mood, irritability, insomnia, anxiety, anger, and depression.
“There’s so much uncertainty lurking and certainty is the one thing that we as human beings thrive on: knowing what’s going to happen in our day, knowing what the week ahead of us holds — and the sense of control it gives us… no matter how false that sense of control is,” Mkone says.

According to the Lancet review, quarantine stressors included infection fears, frustration, inadequate supplies, inadequate information, financial loss, and stigma. Longer quarantine periods - greater than 10 days, in one study — were associated with worse mental-health outcomes, including a higher risk of PTSD. In a 2015 study included in the review, respondents from Liberia placed under Ebola quarantine experienced serious socioeconomic distress.

Poverty and mental health
In low-income areas, which are likely to bear the brunt of the impact of the pandemic, people already face a high risk for mental illness. Poverty and mental illness are widely understood to work in a vicious cycle — with the stress associated with poverty predisposing individuals to mental illness, while mental illness in turn increases the risk of falling into, or remaining, in poverty.

In a 2010 systematic review, Professor Crick Lund and colleagues from the University of Cape Town found that education, food insecurity, housing, social class, socio-economic status and financial stresses have “a relatively consistent and strong association with common mental disorders”.

In South Africa, which is already experiencing exceptionally high levels of gender-based violence, domestic violence support centres have recorded a spike in calls since lockdown began. Researchers have also warned of the possibility of xenophobia in the coming weeks and months.

In a public lecture last year, HSRC CEO Crain Soudien pointed to the psychosocial aspects of inequality as little recognised factors behind the persistence of poverty in South Africa. Yet, mental health in South Africa receives a fraction of total health expenditure: according to a 2019 analysis of the 2016/2017 financial year, 5% of the total health budget. Fewer than one in ten South Africans receive the treatment they need.

To date, despite swift and commendable leadership from South African President Cyril Ramaphosa, there has been little mention of a public-health response that incorporates a mental-health component, despite the interplay between psychological and physiological health. Lund, who is also the director of the Alan J Flisher Centre for Public Mental Health, says that there is a need for a public mental-health response that targets vulnerable populations.

A 2004 study included in the Lancet review found that, among health-care workers in Taiwan who might have come into contact with severe acute respiratory syndrome (SARS), those who had been quarantined were more likely to experience acute stress disorder. Another study found that having been quarantined increased hospital employees’ risk for PTSD symptoms three years later. This suggests that adequate psychological support of health-care workers will be critical to the continued functioning of South Africa’s health-care system during and after the COVID-19 pandemic.

A comprehensive public mental-health response to the pandemic mustaddress risk factors such as food insecurity, Lund says. President Ramaphosa’s announcement of a R500 billion social and economic relief package on 21 April - that includes the called-for increase in the child-support grant - was widely welcomed in the face of the country’s fifth week of lockdown and a looming humanitarian crisis.

Evictions, trust and mental health
During the lockdown, authorities have evicted hundreds of households from settlements in eThekwini, Cape Town and Johannesburg. At least 1000 people have been left homeless after the Red Ants demolished shacks in Lakeview, south of Johannesburg in mid-April, claiming that the structures were uninhabited.

The shack dwellers’ movement Abahlali baseMjondolo has issued warnings that ongoing evictions fly in the face of efforts to curb the pandemic and contravene a moratorium on all evictions during the lockdown.

These instances, together with instances of police brutality in informal settlements, place additional stress on already vulnerable populations. They also serve to undermine trust in public institutions, which is critical to efforts to slow the spread of COVID-19.

Based on the trajectories of past epidemics, the Lancet rapid review found that community involvement, clear communication and voluntary quarantine protect against the worst psychological impacts and would be more likely to be successful in reducing transmission.

Where relations between informal settlements and municipal wards are already fraught, careful community engagement is even more critical. Meanwhile, according to water and sanitation minister Lindiwe Sisulu, plans are underway to relocate thousands of people from densely populated townships. While Sisulu has stated that this would be undertaken sensitively, Lund warns that forced removal at a time of high anxiety and uncertainty is likely to have a major mental-health impact, and risks community backlash.

Where there is resistance, Mkone says, it does not mean that people don’t care about their health. Rather, “it is because people are feeling very triggered. If you take note of the people who live in townships currently, it’s either people who have themselves lived under the heavy-handed apartheid regime or their descendants… who have transmission of trauma from their parents and grandparents”.

“The best thing you can do is to protect people, provide… security, food security, income security, and try and maximise ways of people getting social support from each other while minimising physical contact,” Lund said. “If you start to, in that phrase ‘decant people’, forcibly remove them, you really are setting yourself up for an absolute social disaster.”

Author: Andrea Teagle, science writer at the HSRC