The year is 2017. I’m a nursing student working in a community health clinic serving the people of Mafikeng, North West in South Africa. I take the local transport to arrive at the clinic, there are not many people aboard. I gaze out at the streets of Mafikeng. For the most part, it’s deserted. Just plain brown sandy landscapes with a few buildings. We drive past the only shopping complex aside from its local street market. The driver ushers me to get down as I have arrived at M-Stadt Clinic. I cling to my sweater. It is early morning. Cold, autumn-like weather, but by 11 a.m. I know the sun will come piercing through. I stand outside the clinic with the smell of morning fat cakes filling the air from the local street vendors. I can taste the deep-fried dough on my lips, oily and moist yet so sweet. The patients stand in the line outside that extends around the building, waiting for the clinic to open. Many travel half a day’s journey to arrive here.
I sit in the worn leather chair accompanied by its small desktop in an equally small humid room with papers of positive HIV diagnoses surrounding me. My mind wanders, reflecting on the people behind those diagnoses. My next patients walk in. My attention returns to the patient in front of me. It is now a hot afternoon, the rays piercing through the wired window. Yet, I was cold, gloomy. I look at my watch as I open the HIV health assessment documentation and medication records. It’s only 12 p.m. The woman and her child are my 14th appointment already. I look from mother to child—both HIV positive—but I can’t help but think that while the illness is visibly HIV, there’s also a silent illness unspoken of in this room. Yes, as I look from the people in front of me to the dry dust sand plains of Mafikeng and reflect on the history of the country’s trauma, I realize this illness can not always be calculated by laboratory values, nor can its symptoms be fully understood by the individuals themselves. This is an illness of the mind. With my curiosity piqued, I follow up with my preceptor to discuss how the mental health of the society is greatly impacted by the HIV epidemic and the history of the country.
How do you treat trauma when your environment is the trigger?
As an African in the diaspora and in my interactions with Africans living in Africa, there is still evidence of generational traumas from underdevelopment due to colonization that took place on the continent. Being in South Africa, I was able to identify the diagnosis (trauma) but quickly realized how difficult it would be to treat when many situations and environments within the country were constant clinical triggers. Standing in front of the biggest shanty townships in Cape Town, South Africa, I looked in the distance and saw some of the most beautiful mansions I had ever seen. This was set up during apartheid so Black workers could be segregated from their white employers but still be accessible for domestic labour. The shanty towns have no electricity, running water, basic sanitation, or infrastructure needed for a community to grow and thrive. Unfortunately, this was not only in Cape Town but all over South Africa. It is evident that the wounds that apartheid and systemic oppression had inflicted on the country were still very active and acute.
Working with Black South Africans, I questioned how people were to truly heal if they had not even fully grieved the losses associated with their trauma.
As I reflected on the demographics of people served in the clinic, I realize they were all Black, mostly poor, and primarily uneducated. These were the types of losses that Black South Africans suffered and the reason they have remained victims of a broken system.
In Canada, the clinical treatment for trauma would be trauma-informed care (which focuses on validating the traumatic experiences of the individual), cognitive behaviour therapy, psychodynamic therapy, and possibly pharmacological management. However, in a small community clinic in Mafikeng there was very little time or resources to explore those avenues due to the lack of resources and limited finances in the healthcare system. Although there was no onsite psychiatrist, I was able to assist individuals in navigating community-led support programs dedicated to education and psychosocial support.
Religious groups also provided spiritual counselling for individuals in the community. There was also a social worker available in the local community clinic to help manage complex cases of grief and trauma. I learnt that although the clinical treatment standard was not the same as the one I was accustomed to in Canada, I witnessed a different type of healing: communal healing. I witnessed how the community created their own mindful environment and empowered themselves through activities such as local festive celebrations involving music and dance, therapeutic communication with elders and worship gatherings. The community in itself is the people’s treatment plan and the resilience is the medicine.
Finding the Balance Between Orthodox and Traditional Treatment
Most of my clinical practice focused on working with adults and children living with HIV. I was in a country where the prevalence of HIV and HIV/AIDS-related deaths are some of the highest rates in the world. There seemed to be an endless daily line up of individuals seeking antiretroviral therapy (ART). The sequence was always as follows: HIV diagnosis, medication management then health teaching. I knew the routine but I was not completely comfortable.
The imagery of the daughter and mother sitting in the office with the expression of gloom on their faces runs in my head. My preceptor explained how the HIV epidemic had really impacted many South Africans, “Some individuals had been left orphaned, others became more sick due to poor access to treatment, and to make it worse, there was very little comprehension of prevention strategies.” She elaborated that she had been a nurse “for over two decades and had seen the worst of it.” She acknowledged the association between chronic medical illnesses such as HIV and mental health conditions such as depression. She explained how individuals often take a holistic approach to their care with the collaboration of various traditional methods and native practitioners of wellness. She acknowledged that the blend of traditional and orthodox methods have been difficult to navigate to achieve optimal health when treating HIV.
However, when it comes to the area of mental health, traditional healing often focuses on the psychological and the spiritual, which tend to provide the individual with a sense of control and relief. It is important to emphasize that these practices are rooted in societal and cultural views of mental illnesses. Some of the symptoms are explained by supernatural elements. Nevertheless, popular traditional methods of treatment include the use of indigenous herbs and plants. The chemical properties of these indigenous herbs and plants are not fully researched nor are their drug interactions to medications such as ART understood, yet individuals in the community believe in their properties to help cure their depression. Other traditional remedies include the use of cleansing objects such as stones or beads, specific prayers that promote healing, and preventive behaviours that include restraints or dietary changes.
In comparison, there is a psychiatric hospital in Mafikeng that provides orthodox methods of treatment to psychiatric care. The care plan of the psychiatric hospital includes the use of pharmaceutical, diagnostic testing, regulated practitioners and vigorous assessments. These methods are all incorporated into the individual’s care similar to how it is done in Canada. In addition, telepsychiatry is a recent development in orthodox practice that has been adopted by many African countries. It has improved accessibility, health outcomes, and patient satisfaction with orthodox standardized care involving qualified and regulated practitioners. Nevertheless, the intersectoral collaboration of these two different standards of care is essential in South Africa. It is evident that the community strongly relies on both methods to heal not only their physical but also their mental well-being. It is only right as practitioners and healthcare professionals following a patient-centered approach to collaborate and educate patients on safe ways to integrate both practices.
I received as much healing as I gave in Mafikeng. I saw first-hand the power of resilience and community. I watched as my fellow Africans healed themselves. The inspiration that South Africa had on me still lingers today. I now work as a community mental health nurse and run a health coaching and consulting business specializing in health and wellness and health promotion for racialized and vulnerable groups. Whether in Mafikeng or in Hamilton, recovery is never easy. For South Africans it means facing national trauma, acknowledging the hurt, and forgiving others, including themselves. In order to build up the next generation and stop the cycle of trauma, the journey to recovery is one we must all take.