Doctors will need to pay attention not only to a patient’s physical health but also the person’s emotional, social and psychospiritual aspects.
South Africa’s healthcare system is in crisis — and has been for several years. The South African Medical Research Council (SAMRC) last year noted that although disadvantaged individuals do have access to free healthcare, the quality of healthcare they receive is not always adequate.
“Of 696 facilities evaluated in the Office of Health Standards Compliance’s latest report, only five met 80% of the required performance standards, which include drug availability and proper infection control,” SAMRC writes.
Additionally, the healthcare system is facing an exodus of workers. Since July 2023, 10 000 healthcare workers have sought residency in Canada alone. The perceived threat to livelihood and professional autonomy that the NHI brings also risks deepening this facet of the crisis.
Then there is the fact that in cases where South Africa can provide care in a strained system, it is not providing the right kinds of care. Non-communicable diseases (NCDs) — obesity, cardiovascular diseases, cancers and diabetes, for example — remain a major cause of death in the country: in 2010, they caused a similar number of deaths to HIV/AIDS and tuberculosis combined. From 1997 to 2018 the rate of death caused by major NCDs increased by almost 60 percent. And yet, they remain perennially mistreated.
How we manage NCDs should be a focus of the NHI — but it requires a full recalibration of how we understand health.
Ancient Egyptians and Greeks treated illnesses from the angle that body and mind were joined. One affected the other, and vice versa; a sick part affected an entire person. This was how medicine operated for hundreds of years.
But in the early 20th century, biomedicine came to the fore, and medical progress began to occur in research and disease management: cancer treatment, vaccines, antibiotics, organ transplants.
Medicine became a science, and the point of science is to eliminate subjectivity. This meant the mind and body were separated, and a person’s emotions were seen to have nothing to do with a disease. But, in certain cases such as cases of NCDs and mental health issues, treating diseases as purely physical or purely mental has significant drawbacks.
NCDs are lifestyle diseases. By their very nature they are diseases that arise from the ways in which a person lives — physically, socially, psychologically and emotionally.
But at medical school, doctors are trained to find physical symptoms. When a patient comes in suffering from a chronic ailment — which may have arisen equally from whatever facet of their life, but is now representing itself physically — a doctor looks for and treats the physical issue.
The other aspects — the emotional, social and psychospiritual nature of humans — are not given as much attention. The physical problem — the shortness of breath, chest pain, lack of appetite, weakness, trouble sleeping — may be cured. But the sickness goes on. The patient does not become truly healthy.
South Africa is full of patients suffering in this way. On top of the huge burden of NCDs, the country has an estimated 16 million people suffering from depression — more than a quarter of the population.
In the public health system, these people have nowhere to go. Private mental healthcare is financially out of reach for most. It is something of a catch-22: the NHI might provide access to psychologists and psychiatrists, but there is a risk of overwhelming mental health professionals and contributing toward the exodus of medical workers.
Furthermore, having one professional treat only a person’s mental health continues the problem of treating mind and body as separated from one another.
A patient’s psychologist and physician might rarely be in contact with one another, if at all. They may treat a patient’s symptoms using approaches that are in conflict with one another. This is what is meant when it is said that South Africa’s healthcare system — even its private healthcare system — does not always provide the right kinds of care.
As South Africa’s public healthcare system is overhauled, it is necessary that from the outset it is clear how patients suffering from NCDs and mental health issues will be treated. Medical schools may need to focus on training a new kind of doctor — one who can care for patients holistically: emotionally, physically, socially and beyond that, psychospiritually. Family physicians should be trained in this capacity. While they do learn to perform a three-stage assessment — physical, personal and contextual — they need to go even further and incorporate a person’s psychology and spiritual state to treat patients with the utmost effectiveness.
No patient suffers in their mind or body alone; these elements are irrevocably connected, and must be treated in tandem with one another. If we treat just one, we treat only half of a human.
It is an overhaul that begins with a restructuring of our understanding of health itself. As the World Health Organisation defines it, “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” It is to this principle that we must return.
Professor Shadrick Mazaza is a specialist family medicine physician and past national chairperson of the South African Academy of Family Physicians.