Essay: A case study of mental health practices in South Africa reproducing colonial health structures

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History plays a vital role in helping us understand the intended and the, at times, unintended outcomes of the current global mental-health institutions and practices (Greene et al., 2013). Foucault, through biopolitics, was highlighting almost fifty years ago what the present day is well quite obvious: “life” and “living being” are at the heart of new political battles and new economic strategies”(Foucault 1984 cited by Lazzarato, 2006).This means that health and the discourse surrounding it is political and that certain power-related inferences can be drawn from health. Alongside this, Foucault “also demonstrated that the “introduction of life into history” corresponds with the rise of capitalism” (Foucault 1984 cited by Lazzarato, 2006). This shows that health has been used to serve the economic agenda as well and it is, therefore, necessary to explore the health discourse and practices that were dominant during imperialist rule, this will allow for a thorough analysis and evaluation as to how some of the very same narratives are still prevalent in the present-day capitalist driven world and global mental-health field.

The South African apartheid-era lasted for almost half a century, during which one of the many functions of colonial medicine was to support the military, before expanding to include European-born administration and civilians, with services offered primarily in important ports and urban centres (Greene et al., 2013).This meant that health care was predominantly for the Europeans and was meant to facilitate them in pursuit of their imperialist agenda by ensuring they were healthy. The current global mental health (GMH) etic approach based on mental health universality in South Africa is inappropriate for the given predominantly Black African population, who do not subscribe to it (Summerfield, 2008). In essence, the universal GMH approach serves only the minority of South Africans who are of European descent and who identify with the Cartesian dualist and biomedical narrative surrounding mental health. The etic approach is based on the assumption that mental illness is similar across contexts and that mental-health taxonomies, their measuring instruments and health care designed in the West are globally applicable (Summerfield, 2008).This approach completely disregards differences in the perception of the body across cultures.

Cherry picking and ranking health challenges in terms of western-based priority, what historians of science call ‘problem choice’, illustrates that the present-day focus of global health has been patterned by forces with deep social roots in the colonial past (Greene et al., 2013).With poverty on the rise and more than half of the South African population living in poverty (Africa, 2017) and the top causes of death being tuberculosis, cerebrovascular disease and HIV (, 2017). Can GMH approaches developed in relatively well-resourced societies distinguish the mental disorder from normal responses to an ill-managed society? The medicalisation of social and everyday issues draws away the necessary attention from the distal cause of distress, which are often poverty related.

This essay will initially give a brief description of the Xhosa tribe’s perception of mental illness, then use the body politic as a primary framework(Scheper-Hughes and Lock ,1987) and incorporate the framework by Hacking (1998 cited by Mills ,2014) to discuss evaluate the GMH links to colonial discourses in this particular tribe.

Xhosa perception of health

There are two main concepts that underpin life for AmaXhosa, the first is “Ubuntu” which is defined as “I am what I am because of what we all are” (Matalon, 2013), this frame of thought places emphasis on mutual respect in the community and working together. The second is ancestral reverence which means that “something of the dead person does not wholly disappear ” (Berg, 2003).One’s relationship with the ancestors is the most important factor for good health (Berg, 2003) and this good rapport is maintained through rituals and sacrifices of animals such as cows and goats (Peires, 1987). After death, though the physical body may disintegrate, the spirit is said to live on and maintains the health of its living descendants (Patel, 1995). The AmaXhosa value their working together in harmony and the collective good of society. They attribute ill mental health to sorcery which is often a result of disharmonious social interaction and the spiritual unrest of the ancestors, who may be unpleased by certain acts. There is a general consensus that mental disorders stem from various external factors.

With colonial medicine came the introduction of Christianity to South Africa, the conversion of ‘heathen faiths’ to Christianity (Bhabha, 1994 cited by Mills 2014).Missionary medicine, was a ‘benevolent conquest’ which emerged to convert the African beliefs through clinical medicine (Butchart 1999 cited by Mills 2014). Christianity is used as a tool of bio-power to control and regulate of the body through clinical medicine a specific kind of knowledge, this was a means of legitimizing colonization in the name of health-related progress.

Currently, mental health nurses in South Africa are faced with a dilemma, whether to refer their patients to a traditional healer or to treat them according to the Western concepts that they have been educated with. In 1974 traditional healers who were not registered with the South African Medical and Dental Council which was still a council that was run by the then Apartheid government were banned from performing practising. However, traditional healing has persisted: and almost 80% of the population continue to consult traditional healers. Research shows that most nurses try to adopt a position of neutrality, and use both (Kahn and Kelly, 2001).The effectiveness of this treatment is questionable because except for a minority of ideas and concepts, whose origins are debatable, the Xhosa traditional beliefs and the Western mental health discourse are contradictory to each other.

Like many other health-related issues, the question that now remains is whether the AmaXhosa identified mental health as an issue before colonization?

Did Mental Health always exist in South Africa?

The more precise and relevant question would be, did mental health as it is currently framed and identified by the WHO exist in precolonial South Africa? The use of an allegory by an author uses an ecological niche to represent the fact that at certain times and places, experiences may be interpreted as ‘symptoms’ of specific ‘illness’. This means that they are in a constant state of change, not for the individual but within the evolving society (Hacking 1998 cited by Mills, 2014). Hacking was highlighting the importance of the political and social context of a time and place and the shift cultural norms and beliefs that colonial medicine contributed to by determining what illness is.

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