Psychiatric Bulletin (1992), 16, 343-345 Psychiatry in the 'New South Africa' SEANKALISKI,Consultant Psychiatrist, Valkenberg Hospital, Private Bag XI, Observatory 7935, South Africa Academic medicine in South Africa was created Psychiatry and the 'Old South Africa ' largely by talented graduates who, having travelled overseas (especially to Britain) for postgraduate Psychiatry in this country has always been a training, returned to teach in the newly established Cinderella specialty. Most psychiatric institutions medical schools and teaching hospitals. However, not associated with a medical school employ mostly over the past three decades fewer have decided to medical officers, not psychiatrists. return. Consequently academic medicine generally Valkenberg Mental Hospital in Cape Town, which is in decline. Hospital specialists are demoralised, last year celebrated its centenary, has only been part and about 80% of those recently surveyed indicated of the University of Cape Town over the last two that they intended leaving the public health service decades. Those with academic ambitions and talent if the present imbalance between service commit were often so frustrated at the poor infrastructure for ments, research opportunities, and poor pay persists psychiatric research, that political considerations (Curtin, 1991). About 40% of graduating medical aside, it was logical to migrate overseas. The other students emigrate, usually to avoid conscription. The medical specialties in South Africa have succeeded in continuing violence and political uncertainty within garnering international recognition for themselves the country probably ensure that few willever return. because they managed to attract funding for better There are only some 200 registered psychiatrists in facilities, and were able to divorce themselves South Africa, of whom about half work lucratively in more easily from the psychosocial realities of their private practice. That leaves about 100public service patients. Ironically, the World Medical Association psychiatrists tending to a population of almost 35 has always maintained warm relations with the million. Apartheid has ensured that almost all are medical fraternity here, despite having authored white, and either speak English or Afrikaans. Not sur the Declaration of Tokyo. The recent report from prisingly service commitments virtually overwhelm the American Association for the Advancement of research opportunities and teaching duties. Science on health care in South Africa (1990) noted The main buildings of Valkenberg Hospital in which the original hospital was housed. These were commissioned in ¡891,andlast year (the Hospital's centenary) weredeclared a national monument. At present they serve as an administrative block. 343 344 Kaliski that all sectors of medicine practised apartheid, and which "would mean eschewing official contact with that psychiatry enjoyed a particularly low status. Yet any organisations or individuals in South Africa that psychiatry bore the brunt of the international aca continue to support apartheid, while maintaining demic boycott. Some battled against the system, but active professional relationships with those who many psychiatrists, themselves products of apartheid advocate ending apartheid and the development of institutions, were just as adamant in their defence of an integrated, unitary health service, and who can be the status quo. The Society of Psychiatrists of SA seen to be working towards those ends" (1990, p 34). (SPSA) seemed always to be in a state of suspended This strategy, which would have been most powerful intentions. if applied at the height of the international campaign The threat and use of intimidation by the auth against apartheid, is to be welcomed. Overseas orities always inhibited concerted protest. In 1987, support for anti-apartheid organisations within the 100 junior and senior doctors at Baragwanath country always distressed the government and its hospital signed a letter condemning the conditions supporters. Now in the throes of socio-political at that hospital. All were ordered by the Transvaal transition, it has become fashionable for all official Provincial Administration to submit apologies, even bodies to proclaim an abhorrence of apartheid and though the Director of Hospital Services officially racism. Their efforts in abolishing racist practices admitted in a letter to a medical journal that there was and structures have not necessarily followed apace of substance to their concerns (van Wyk, 1987). Those these utterances. How, then, will such a policy of who refused had their contracts cancelled and were "selective support" be monitored? Either a mission barred from working in any hospital in the province representing the College will have to be established thereafter. Many left for indefinite 'holidays' abroad. within the country, or regular visits by delegations The appalling failure of the Medical Association will be necessary. A new, internationally acceptable of South Africa (MASA) to censure the doctors political dispensation may be realised in South involved in the Biko case underlined the split within Africa before the Society of Psychiatrists of SA the medical profession, and together with the fact (SPSA) manages to satisfy the above requirements. that the institutions of medicine and health care have Under such circumstances would the College be always been under the control of the state (directly obliged to continue the campaign of isolation, even and indirectly), and policed accordingly, has meant though general sanctions surely will disappear? This that the abolition of apartheid in medicine would is not a theoretical question as the inequalities in this only follow general socio-political change. country, which have been painstakingly maintained over the last 300 years, will surely persist for decades still. Sanctions: Academic boycotts and selective support After apartheid There has not been a change in heart among the ruling elite, but rather a sober realisation that the South African psychiatry faces three challenges: to status quo cannot be sustained. The academic provide equitable non-racial care to all within the boycott provoked much internal debate, as this did country, to develop within the general African context, and to explore the 'new' transcultural contribute to the decline of academic standards, which will be difficult to reverse. psychiatry. The corollary of the academic boycott is that A future health system will have to be national, South African doctors should have been denied comprehensive, available to all without financial or employment in other countries. Sanctions were geographic barriers, subject to constant evaluation, intended to seal the country hermetically from the and have the support of local communities (Susser, rest of the world to force social change, and pro 1990). Although it is generally accepted that many fessionals should have been encouraged to remain to existing institutions will survive, the immediate goal facilitate this. There is an anecdote that during job is to unify all psychiatric services into a more efficient interviews for psychiatry posts in the UK, South and non-racial department, instead of the present tri Africans are sometimes asked to list ex-countrymen partite system (in which it is possible for psychiatrist, now prominent in British psychiatry. Apparently the nursing staff and patient each to be administered by list is still growing. different departments simultaneously). The report of the delegation to the president of Devising an egalitarian psychiatric service will not the College on its preliminary visit to South Africa in itself assure a favourable outcome on the mental is generally accurate (although the statement that health of the populace. Redress of social, political practitioners without specialist training are allowed and economic injustices is essential, together with a to practise as psychiatrists is not true), and recom realignment of priorities and allocation of resources mends that a policy of'Selective Support' be applied. toward serving the needs of the mentally ill. Psychiatry ¡nthe'New South Africa ' 345 The College of Medicine of South Africa has intro Even though each psychiatrist may be ethical in his duced a Diploma in Mental Health for GPs to inte daily contact with patients, there now appears to be grate psychiatry into the primary health care service. the added obligation that he be actively involved in Community nurses, and perhaps even lay people, changing the socio-political structure of his society. could also be trained to deal with common psychi This should be distinguished from those instances atric problems, and to recognise those that require where psychiatry is abused as an instrument of referral to psychiatrists, who for some time will con oppression, such as the involuntary hospitalisation tinue to practise predominantly in those urban areas of political dissidents. But psychiatrists could also be served by teaching hospitals. In addition to training guilty collectively for acts of omission, that is, failure and evaluating the above, psychiatrists must be to oppose injustice, especially when it impacts on involved in dismantling, and researching the effects mental health. There is, however, the danger that this of racism. may lead to a politicisation of psychiatry in which In Africa the manifold problems of poverty, dis ideology displaces ethics. ease and war are overwhelming, and it is not surpris Accountability is a difficult