The mental health effects of the coronavirus pandemic may seem tangential to the overall health risk. However, 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.
As countries travel further along the road of social distancing, the psychological toll of the global coronavirus pandemic is becoming more apparent. Yet, globally and in South Africa, the mental health impact of the pandemic has been sorely neglected.
“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 impacts, the mental health burden is likely to fall unevenly across socio-economic divides. While the lockdown makes the isolation of those living in walled-off homes in affluent areas more prominent, in low income areas, the same tips on how to manage the effects of isolation cannot be applied. Instead, the stressors that contribute to an already high risk for mental illness are highlighted and exacerbated: health worries, crowded living, a lack of access to basic services, financial stress, food insecurity 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.”
Past and present trauma
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 that’s 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 higher risk of PTSD.
In a 2015 study included in the review, respondents from Liberia placed under Ebola quarantine experienced serious socioeconomic distress.
In South Africa, mental illness, PTSD, is already common: the 2012 South African National Health and Nutrition Survey found that 1 in 5 South Africans had experienced at least one traumatic event, and 4% had PTSD symptoms. Those currently struggling with mental illness are at particular risk.
Says Mkone, “From a psychological and an emotional perspective, for a lot of people what this time is bringing up is perhaps even past traumas – childhood and early life traumas that people have experienced around lack of agency [and] around restriction of movement.”
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 from the University of Cape Town and his colleagues found that education, food insecurity, housing, social class, socio-economic status and financial stress exhibit “a relatively consistent and strong association with common mental disorders”. In South Africa, already experiencing pandemic levels of gender based violence, domestic violence support centres have recorded a spike in calls.
At 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 1 in 10 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 psychological 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 healthcare 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 healthcare 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 must include upstream protection measures, Lund says. “It’s not just about treating the mental health problem – it’s about addressing all the risk factors.”
In a recent Conversation piece, Murray Leibbrandt of the University of Cape Town and others argued for a temporary top-up of the child support grant, an intervention also suggested by the shack dwellers’ movement Abahlali baseMjondolo. During his announcement of the lockdown extension, President Ramaphosa promised increased social support and urged South Africans to contribute to the Solidarity Fund.
Evictions, trust and mental health
Over the Easter weekend, people were evicted from the Empolweni settlement in Khayelitsha, after the City of Cape Town ordered the demolition of uninhabited structures that it said people were claiming only after having been evicted elsewhere.
The evictions came after Abahlali baseMjondolo issued statements in response to the demolishment of homes in settlements in eThekwini, with the latest evictions in the Azania settlement in Cato Manor including the arrest of 29 women. The movement warned that 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 review finds that community involvement, clear communication and voluntary quarantine protect against the worst psychological impacts and are 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.
Relocating of people in townships
Meanwhile, according to water and sanitation minister Lindiwe Sisulu, plans are underway to relocate thousands of people from densely populated townships, beginning with Du Noon in the Western Cape, Duncan Village in the Eastern Cape, Kennedy Road in Durban, Stjwetla in Alex, and Mooiplaas in Tshwane. 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. “So,…if you start to, in that phrase “decant people”, forcibly remove them, you really are setting yourself up for an absolute social disaster.”