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By Mark Moran
"I am ready to forgive, but I need to know whom to forgive and what to forgive."
South African-born and -trained psychiatrist Charles Ndlela, M.D., speaking to an audience of American and South African psychiatrists at APA's annual meeting in San Diego, recalled those words of a persecuted Chilean political dissident to describe the mood of a renascent South Africa, emerging now from a history of apartheid.
As that country faces the Herculean task of coming to grips with an oppressive past while trying to fashion a harmonious, multiracial future, South African psychiatrists are looking for the help and cooperation of their colleagues in North America and around the world, said Ndlela, who is with the department of psychiatry at the University of California, San Francisco.
Ndlela was one of several psychiatrists who joined past APA president Mary Jane England, M.D., on a visit to South Africa in fall 1996.
That delegation of 13 professionals visited four South African medical school departments of psychiatry and met with government officials, mental health professionals, and business leaders (Psychiatric News, October 4, 1996).
England and the other members of the delegation also met with members of South Africa's "Truth and Reconciliation Commission"--the new panel established in 1995 by the government of South African President Nelson Mandela to settle issues surrounding reparations for victims of apartheid and amnesty for apartheid-era crimes.
Ndlela and others who spoke at the annual meeting symposium--including England; Cliff Allwood, M.D., president of the Society of Psychiatrists of South Africa; and Tiffany Ho, M.D., a resident at the University of California, San Francisco--said the visit by a former APA president marks a crucial turning point in relations between North American psychiatrists and psychiatrists in South Africa, who for years shared in the international isolation imposed on that country by the apartheid regime.
One outcome of that visit was the establishment of an APA Task Force on Sub-Saharan Africa, recently appointed by new APA President Herbert Sacks, M.D., to address issues of importance to American psychiatry in all the sub-Saharan countries.
England also told Psychiatric News that Hlengiwe Mkhize, a clinical psychologist with the Truth and Reconciliation Commission, has requested guidance on issues related to post-traumatic stress disorder (PTSD) in individuals imprisoned or tortured during the apartheid era. She added that she will be working with the National Institute of Mental Health to develop a "white paper" outlining research on PTSD to assist the commission in making recommendations.
Also arising, in part, from last year's visit to South Africa is the development of the independent Caucus of South African Psychiatrists (see "South Africans Launch Caucus"), to include South African-born and -trained psychiatrists now working in North America.
(The journey to South Africa by England and her colleagues last year was coordinated by Ellen Mercer, director of APA's Office of International Affairs, who noted that the trip occurred at no cost to APA. All members of the delegation paid their own expenses, except for two psychiatry residents, whose expenses were paid by Zeneca Pharmaceuticals, Mercer said.)
As Ndlela, England, Allwood, and others made clear at the annual meeting, the challenges facing a new South Africa are enormous. A multicultural society blending first-world and third-world elements, South Africa is being watched by the world to see whether it can peacefully overcome what England described at the annual meeting as "the worst continuing holocaust since the second World War."
The renewed alliance between psychiatrists here and in South Africa may have much to contribute to this struggle.
"The work of the Truth and Reconciliation Commission remains a bridge between the past and the future," said Ndlela. "As psychiatrists we need to provide our advice, consultation, and expertise."
There are just a few more than 200 psychiatrists in South Africa serving a population of more than 43 million. That fact only begins to describe the uphill struggle of mental health professionals working in a country in which just 9 million people are covered by health insurance.
Perhaps the most pressing concern for psychiatrists working in South Africa is the lack of resources, said Dan Stein, M.D., a psychiatrist at the University of Stellenbosch School of Medicine, Cape Town, in an interview with Psychiatric News.
"It's very hard for an American psychiatrist to understand how we can possibly get by with so few resources," said Stein.
"Clearly, by the standards of a developed country our resources are very limited. On the other hand, our resources are significantly better than those of many other African countries. There are some amazing opportunities for U.S. psychiatrists to collaborate with us on--from such things as genetics research on our isolated and homogenous populations, to the fascinating psychopolitical phenomena being played out in the work of the Truth and Reconciliation Commission."
Yet Stein resists the perception of South African psychiatry as a "needy" distant relative and argues that the country must work toward self-sufficiency in all ways.
"Ultimately, we need to depend on ourselves to grow our resources," he said. "So rather than turn to a 'needs' model, I would use a collaborative model. For example, both U.S. and South African clinicians would benefit by clinical exchange programs or collaborative research.
"We can draw upon one another's expertise in the ongoing battle to reform the health care system and in dealing with societal trauma and multiculturalism," he said.
Contrasts to America are stark in many ways, yet there are similarities as well.
"I was immediately impressed by the beauty of the country and by the contrasts apparent as soon as we landed in Cape Town," said Sandra Walker, M.D., a resident at the University of Washington.
"A whole row of 747's parked beside a small airport reminded me of airports in small Southern cities 30 years ago or more," said Walker, an African American who grew up in Alabama in the late 1950's.
Walker was struck by the tripartite distinctions of race in a nation divided by skin color: black, white, and colored.
She recalled these images: "A squatters village of corrugated metal huts that seemed to be rapidly growing beside the road from the airport to town. . . . The immediacy of the distinctions of class and color as the black squatters village without plumbing or electricity gave way to a colored community of modest homes, which in turn gave way to the white city of Cape Town. . . . All this within my first hour in the country."
The mood of people with whom she talked varied. "Whites whom I met informally seemed very disturbed by violent crimes," she said. "Many of the homes of whites which we saw in Cape Town and Johannesburg had walls around them with security systems advertising an armed response to intruders. . . . People seemed to recognize that Mandela, who is widely loved, will not be president forever and that the government will need to be able to adapt to new leadership."
Spreading criminal violence was also cited by Ndlela as troubling, though Stein noted that many parts of the country are quite safe and that tourists should not be deterred from visiting the country.
"I do think this is very much a socioeconomic problem that will get better if there is more business and economic growth here," Stein said.
"Speaking as a psychiatric researcher, this is a good opportunity for those interested in the study of violence to come here and collaborate on researching solutions."
When asked what American psychiatry could contribute to combating violence in his country, Stein responded pointedly: "What can APA do to stem violence in the states?"
The contrasts in living conditions among the races in South Africa, noted by Walker, extend unavoidably to health care.
In 1978 an official delegation of American psychiatrists visited South Africa to investigate charges that blacks were systematically detained in mental hospitals for political reasons.
The Committee to Visit South Africa, which included past APA president Alan Stone, M.D., and former deputy medical director Jeanne Spurlock, M.D., did not find those charges to be true. They did confirm, however, grave discrepancies in the care received by blacks and whites in a fairly blistering report that appeared in the American Journal of Psychiatry (November 1979).
Walker said that mental hospitals today have been integrated for several years. Yet she noted that disparities still exist, citing "stark circumstances at Baragwanath Hospital in Soweto versus the nicer environment at Tara Hospital in Johannesburg."
She added that few black South Africans are being trained in psychiatry, and that the country is experiencing a "brain drain" as new trainees continue to leave.
The extent to which health care providers were complicit--willingly or unwillingly--in the worst aspects of the apartheid regime is unclear.
Ndlela told Psychiatric News that he believes health care professionals were harassed for challenging human rights violations, and that some received death threats.
The stifling atmosphere of apartheid may have contributed to what some American psychiatrists have termed a sense of "learned helplessness."
Said England, "Now that apartheid is over, it is really hard for [professionals in South Africa] to take a proactive, aggressive stance to work for the continued changes that need to occur. Because of this kind of feeling, many of their residents come to the United States."
Stein applauded England for her initiative in leading the trip to South Africa. However, he cautioned against the use of labels like "learned helplessness" in assessing a complex psychosocial situation. Ideally, American psychiatrists will view their colleagues in South Africa as collaborative partners, he said.
He was joined by others, including England, in expressing an optimism about the future and a sense that the Truth and Reconciliation Commission can withstand politics and the desire of people for denial or revenge.
At the San Diego annual meeting, Ndlela noted that the commission's work is grounded in the African notion of ubuntu--or interconnectedness--a term denoting the desire for restoration rather than retribution.
Ndlela quoted the Reverend Desmond Tutu, chair of the Truth and Reconciliation Commission and a winner of the Nobel Peace Prize, whose words encapsulate the brightest hopes of all who pray for South Africa.
Said Tutu: "There are different kinds of justice. Retributive justice is largely Western. The African understanding is far more restorative--not so much to punish as to redress or restore a balance that has been knocked askew. The justice we hope for is restorative of the dignity of the people."
(Psychiatric News, July 4, 1997)