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

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  • A case study of mental health practices in South Africa reproducing colonial health structures
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Introduction

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 (cdc.gov, 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.

Hacking also discussed how the body politic through certain factors places an emphasis on certain ‘disorders’ at specific times. These factors are: 1) “a medical taxonomy (system of categorization)” this was introduced to the South African Xhosa tribe through the bio medicalisation and colonisation of health, 2) “cultural polarity (currently co-existing competing social phenomena)” that is the current traditional healing based on Xhosa cultural body beliefs versus the western biomedical cultural approach to mental health, 3) “observability (a system of surveillance and detection that enables certain behaviours to be understood as ‘strange, disturbing, and noticed)” this can be linked objective nature of the biomedical culture a residual effect of colonial medicine that has infiltrated the South African society (Hacking, 1998:82 cited by Mills, 2014). This f
ramework emphasizes a shift in understanding from the brain chemistry as the cause of mental illness, to the socio-political conditions which facilitate experiences to be framed as ‘illnesses’.

Medical Taxonomy

The International Classification of Diseases (ICD) by the WHO and the Diagnostic and Statistical Manual of Mental Disorders (DSM) are the main global biomedical systems of calibration of mental illness, it is expected that these two systems of diagnosis be adhered to, universally. They are based on Western research and contexts, this links back to colonial medicine in that it was designed primarily to treat those of European descent. The diagnostic categories are merely “conceptual devices emerging from committee decisions” (Summerfield, 2008). Decisions that privilege a western ideology of the individual body and are propagated into health systems of various and often polar contexts through globalisation.

Cultural Polarity

Based on the second aspect of Hacking’s framework, there are currently two distinct cultural approaches in South Africa to mental health. Studies show how AmaXhosa believe that the soul is the seat of feelings and is found in the blood and the heart. They suggest that the mind is located in the brain and is “the initiator of action and required for health”. In comparison to Western concepts which place emphasis on the cognitive components of mental health, the AmaXhosa emphasize the behavioural aspect of mental health and focus much less the emotional (Patel, 1995). As discussed earlier in this essay the general ideas of health that the AmaXhosa have are quite distinctive to those of the biomedical perspective.

Observability

Biopedagogy is widely used in the South African global mental health field, a WHO report on mental health in South Africa makes reference to the department of health and its responsibility to raise mental health awareness through school programmes and media campaigns (World Health Organization, 2007).

GMH’s promotion of mental health literacy and categorization purposefully and unintentionally establishes a market for the pharmaceutical industry (Mills, 2014). The mental health literate global north market is already well established and hence an infiltration of the global south would create a new market. A parallel to colonial health can be drawn from this, the first is that as “drugs enter the body, they may well be one of the deepest forms of colonization” This further resonates with Steven Biko’s (1978:92) assertion that ‘the most potent weapon in the hands of the oppressor is the mind of the oppressed’, and perhaps increasingly the brains of the oppressed’ Biko was a key figure in the South African liberation struggle.

Mental health literacy serves to ensure that the public is well versed in GMH terminology and in so doing they will associate certain feelings and presentations with a particular mental health-related problem (Mills, 2014).A study done within the Xhosa tribe revealed that even though their beliefs of mental health are different from the biomedical cultural perspective there are some interesting similarities. The mental health symptomatic classifications such as “heat in the head and tension” which are similar some western symptoms associated with mental disorders. Descriptions of the 2 main Xhosa categories of disturbed behaviour reveal links with behavioural disturbances associated with “acute psychoses (e.g. agitation, disrobing, sleeping less, aggressive behaviour, unpredictable behaviour, suspiciousness), major depression (e.g. not eating, becoming very lazy, crying because the heart is sore, becoming thin)” (Patel, 1995). There is a strong element of bio-power in this instance as the GMH literacy may have shaped a desire in the Xhosa people to liken the symptoms they associate with mental illness with those they have often been exposed to through GMH literacy. There is no evidence that this is due to bio-pedagogy, or that it was even intentional, however, one must take into consideration the possible Xhosa cultural adaptations that may have occurred as a result of a 50-year colonial rule and the effect of GMH campaigns and literacy post-apartheid.

Conclusion

After analysing contemporary global health practices and institutions in South Africa using the body politic as a primary framework and further elaborating the body politic by the use of a secondary Hacking’s (1999) framework, one can deduce that there are strong links to colonial discourses and structures. This is evident in the current mental health treatment dichotomy that is, relying on either traditional medicine or the western biomedical one. Religion and its medical association, medical taxonomy and observability through the bio pedagogy of the Western GMH discourse are all part of a residual colonial health system based on imperialist motives, they are also a means of maintaining governance and control over individual body and the body social.

Contemporary global health institutions need to start embracing their own epistemological positions and incorporating them into health systems. This will ensure that health care serves its main purpose. In the case of the AmaXhosa, the “damage” of colonisation has been done however, it is necessary to preserve the little of what is left of their culture, this could be done by institutionalising traditional medicine.

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