Rural mental health failings under the spotlight after family bloodbath

Mary Smith was asleep in her bed on Sunday‚ February 11‚ when her son Siphamandla landed his first blow with a panga.

Silenced as the blade struck her head – the blows continued – casting fine droplets of blood in a mist around the tiny room.

When the frenzied slashing stopped‚ his mother lay clinging to life in a bloodied blanket and the bodies of his niece and nephew lay cleaved and dead on the floor.

What caused the 20-year-old to snap will likely never be known‚ for as he fled his family home‚ he was killed by a truck as he ran across the road moments after the bloodbath. His mother remains in a critical condition in a Durban hospital.

Unable to cope with his psychosis‚ Siphamandla had dropped out of school and withdrew to his home‚ where he lived with his mother and siblings on a hilltop in Bhobhoyi‚ 150 kilometres south of Durban.

On the whole‚ Siphamandla was fine‚ said his cousin Siphiwe Nxumalo. "He would take his pills. His mother was very strict about that and she used to follow him to make sure he did it. Even when he had the pills‚ he would have his breakdowns‚" he said.

Standing in the room where the toddlers were slain‚ Nxumalo said that his family had been ripped apart.

"Whenever his episodes would start‚ he'd complain and say he's hearing voices and that people were after him. Then he'd go into his room and hug his church clothes. He loved church‚" Nxumalo said.

"He was a very calm and cool guy who loved playing with the kids but out of nowhere he'd sometimes get angry and argue with the family. One day he had gone to the shops during the day and when he came back in the evening‚ while everyone was eating dinner‚ something triggered him and he took all the food and threw it out and pulled a knife on everyone in the house."

A study conducted by the Rural Health Advocacy Project‚ completed in 2015‚ included the testimonies of mental healthcare users from rural areas.

The report revealed that rural mental healthcare services are still largely inadequate‚ due to budgetary constraints‚ psychiatric medication shortages‚ insufficient human resource capacity and a lack of integrated care‚ as well as stigma and discrimination.

Clinical psychologist Jasmin Kooverjee said that mental healthcare in the public sector was grossly under-resourced. "This is the reality. We are just so under-resourced and we can't get to everyone who needs it‚" she said. "This is a significant issue in terms of access to mental healthcare in poorer communities."

Kooverjee said that limited access to adequately trained healthcare practitioners because of vast distances that patients have to cover to reach them was a factor to consider.

"Moreover‚ limited resources impact on the quality and frequency of care. Also‚ we often use the medication that is available in the community setting rather than the best known medication. Some medications are not available‚" she said.

Psychiatrist Dr Lesley Robertson agrees.

"A district hospital is run by family medicine practitioners and not by specialists in psychiatry‚ so accessing specialist care for mental illness is very difficult‚" she said.

"Most specialists in the public sector are located in academic hospitals and we rely on family care practitioners to deliver care to very ill patients with complex disorders and this is a big problem."

Robertson said it was clear that the budget for mental health is inadequate for the burden of disease by World Health Organisation standards.

"These are chronic relapsing conditions – although you may have an episode and get admitted‚ patients very much need specialist follow-up to optimise treatment after discharge [and there is seldom access to this]‚" she said.

Robertson has her view of why the Smith tragedy occurred.

"The [Smith] family obviously recognised this illness and tried to get help but the level of treatment was clearly not commensurate with the illness‚" Robertson said.

For their part‚ Nxumalo and his grieving relatives are still trying to decode Siphamandla's final moments.

"This situation came as a shock to everyone. The mood in the house is very sour because of what happened‚" Nxumalo said.

"I often ask myself why he didn't just do this to himself‚ why did he have to do this to innocent children and his own mother‚ the person who looked after him?"