Mental Health Care Bill: hearings

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Health

21 October 2001
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Meeting Summary

A summary of this committee meeting is not yet available.

Meeting report

 

HEALTH PORTFOLIO COMMITTEE
22 October 2001
MENTAL HEALTH CARE BILL: HEARINGS

Chairperson: Dr Nkomo

Relevant documents:
Mental Health Care Bill [B69-2001]

 

SUMMARY
Submissions were made by the President of the South African Society of Psychiatrists, the chairperson of the social development committee in the National House of Traditional Leaders, the Lifecare Group, a psychiatrist serving the rural areas of the Western Cape, the Association for Revenue Research, a general practitioner and people who had personal experience of the limitations of the current mental health care system.

MINUTES
South African Society of Psychiatrists
The submission by Dr Zabow, President of the South African Society of Psychiatrists, served as an introduction to the Bill, as well as to point out some of the issues in its practical application, and some of the points of contention. He noted his credentials, as a member of various committees concerned with the issue of psychiatry and law and traced the history of legislation concerning the mentally ill.

He made the point that the Bill reflected the move to a continuum of care, with services being provided not just in institutions, but the community as well. The other major advance over the previous act was that the Bill was informed by the principles of human rights, and conformed to the World Health Organisation’s ten principles for mental health law. It also represented a shift towards the power for the care of the mentally ill being more of a matter for psychiatrists than the courts. This move was welcomed, as psychiatrists and other mental health practitioners were trained in these issues. He raised concerns over the involvement of the police in the transport of patients, saying that this could facilitate abuse. Other issues included the qualifications of mental health practitioners, the use of judicial rulings, the need for the restriction of psychiatrists liability in a court of law in circumstances where they had "acted in good faith". He also drew attention to some of the trends in mental illness worldwide, including the increase in substance abuse worldwide.

Questions
Dr Nkomo commented that the Committee could not have asked for a better start to the proceedings than to have Prof. Zabow with all his qualifications there to present.

Dr Jassat (ANC) asked if there were comparative figures relating to mental health in the developed world and Africa, as well as in South Africa. He also mentioned that America had vast numbers of psychiatric support, and asked what this indicated.

Ms Kalyan (DP) said that she welcomed the Bill, and asked in relation to the Review Panel, how the professor viewed the community member i.e. what qualifications he would recommend, and what role was envisaged for this person. She also said that she shared Prof Zabow’s concern over the SAPS, and asked what his view was on locking mental health service users in the same cells as ‘hardened criminals’. She asked for clarity on the measures envisaged for the control of patients by the SAPS, in terms of whether he felt handcuffs would be used, or medication, or straight-jackets etc.

Ms Malumise (ANC) asked what constituted maximum security in hospitals.

Ms Baloyi (ANC) asked the professor to clarify what he had meant by the judicial and clinical aspects, as she was unclear on the distinction. She asked what the course of action was to address the shortage of professionals which Prof Zabow had outlined, particularly with a view to ensuring the successful implementation of the Bill. She asked what measures could be embarked on to encourage young doctors to enter the field. In terms of the training of the police, she said that those in her province were not trained and there were no facilities to house patients in the police stations. She asked what needed to be done to address this. She ended by saying that there seemed to be a lack of physical infrastructure, a lack of financial infrastructure, and a lack of personnel. She expressed the hope that the Bill did not fail due to the inability to implement it efficiently.

Prof Zabow replied that today’s initiatives were a start to begin to address some of these problems. The USA had a lot of personnel, and they were not necessarily all dealing with those who had been diagnosed as mentally ill, but there were many who dealt with family therapy etc. In Great Britain, there was a shortage of six hundred psychiatrists, and if one travelled to the UK, you would find that many of the staff there had been trained in South Africa. He said there was a need to take steps to address this skills drain. He went on to say that Africa undoubtedly had the greatest need, and to address this, various African governments had formed an association and governments were funding the training of staff in South Africa, who could then return to their countries with skills. The World Health Organisation (WHO) had begun to investigate the situation in China, and it was clear that everywhere, there was a shortage of psychiatrists.

With regard to what steps could be taken, he said that psychiatry had become a very popular specialisation, and there was currently a two-page waiting list of highly suitable candidates, but that the posts were lacking. He said that it was not highly trained specialists that were needed and that UCT had introduced diplomas in mental health for general practitioners, and nineteen had been awarded this past Thursday, who could then go out to the rural areas. South Africa had 400 psychiatrists, which was good for Africa but which still fell short of what was needed. He went on to say that mental health also involved advocacy work and support groups, and these people were doing wonderful work. Cape Town had the only Fountain House outside of the USA, which was a clubhouse for people with mental illnesses, where they could receive vocational training. There were a number of advocacy groups, and how to qualify these people remained to be seen, but they are part of the system of care.

In terms of the police, he said that there is the potential for abuse, particularly in the extremely dangerous situations, and there were reports of beatings, handcuffing people to beds and teargas all being used. He suggested that there was a need to train all roleplayers and embark on education programmes. Policemen had been trained in the past, but it should be compulsory, as it was with First Aid. Patients must not be placed with criminals, because they are patients first, and the law stated that they were not responsible for their actions therefore they could not be treated as criminals.

The maximum security facilities were something of a misnomer, as they were more along the lines of intensive care in hospitals, providing treatment for severe cases who represent a threat. He added that South Africa had two such facilities when Britain had none when he had gone there to advise them on their creation in 1978, perhaps reflecting the priorities of the times. These facilities required very skilled people, with a high staff-to-patient ratio, which meant a drain on resources.

In terms of the question regarding the division between clinical and judicial, he said that at the moment the patient was seen by a district surgeon who filled out a basic form which the magistrate ‘rubber-stamps’. He asked how it was fair that he had the power to write a report which could put anyone in hospital. The Bill separated a respect for judicial process, which was handled by a judge from the clinical aspects, which were decided by the Review Board. He added that this was a very important facet of what was an innovative Bill. He felt that it met all ten standards set by the WHO.

On the comparative figures of rates of mental illness, Prof Zabow said that there were not comparatively more people suffering from serious mental illness in this country although there had been a comparative increase in rates of depression. The WHO has reported a worldwide increase in all areas of mental illness. South Africa had seen an increase in the number of trauma-related cases, for example in the incidence of post-traumatic stress disorder. Communities were under more stresses. This did not need hospital-based intervention, but rather prevention in the communities. There had been an increase in drug-related illness, which followed a worldwide trend. It was also likely that AIDS would lead to an increase in the number of neuropsychiatric problems, and consequently, he reiterated the need for more trained people.

Dr Nkomo commented that the interaction with the professor would be ongoing, as it was a practice of this Committee to review all legislation after one year to monitor its implementation.

National House of Traditional Leaders
Nkosi Suping, chairperson of the social development committee in the National House of Traditional Leaders, noted the fact that the Bill ignored the part played by traditional healers in the treatment of mental illness, who worked closely with the traditional leaders. With regard to the issue of human rights, he said that traditional leaders could play a role in ensuring that traditional healers do not abuse patients under their care, and he gave examples of such abuse. It was also suggested that the traditional leader could play an advisory role as a member of the Review Board in certain areas. He emphasised the need for government and its departments to consult with traditional leaders on implementation as they had the experience of local conditions and could assist by adding their weight to legislation.

Questions
Dr Cwele asked what the experience had been of the leaders with regard to the work of the traditional healers. He asked whether the traditional leader played a role in preventing abuses.

Dr Jassat said that many people went to traditional healers, and did get relief. He asked for some input on the tokoloshe.

Ms Mnumzana (ANC) asked for clarity on the issue of the Review Board. She asked if the House was suggesting a representative on this Board given that there were only a limited number of people on such a board.

Ms Kalyan acknowledged that she had found a multi-disciplinary approach was useful in her work as a psychotherapist. She said that mental illness in the traditional sense had a stigma which led to victimising. She asked what the leaders’ role would be in challenging this stigma. She also asked, in relation to the Review Board, whether the role of the traditional leader might not be as the community member on that board.

Nkosi Suping started by saying that there had been many successes in treating mental illness from a traditional healing point of view. However, there were those who claimed knowledge without actually possessing such knowledge. In such instances, as guardians of the people, the traditional leaders intervene. At the moment, the government is in the process of defining the role of traditional leaders, to provide a framework within which traditional leader can intervene.

Nkosi Suping’s colleague added that there were differences according to the provinces. For example, some provinces required traditional healers to register, and people who are under the care of a traditional healer are made note of when they enter care and when they are discharged. This allows communication between the leader, the healer and the community. He suggested that the government consider providing facilities for traditional healers, to facilitate this monitoring.

In response to the question of the tokoloshe, Nkosi Suping said that unfortunately he was not that knowledgeable. It was related to witchcraft, but differed depending on the context. He added that fear led to a search for a cause, and in African society, there was no disease without a cause, which has to be identified.

In response to the issue of the review board, Nkosi Suping said that he was making an appeal for traditional leaders to be part of furthering the objectives of the Bill, and that he did see the traditional leader as part of a multi-disciplinary approach.

Dr Baloyi (IFP) voiced concern over the suggestion that the government provide facilities to traditional healers, who were part of the private sector.

Ms Luthuli (ANC) said she was concerned about the issue of abuse, adding that it was not infrequent, and her particular concern was for the women and girls and sexual abuse. She said she was not satisfied that there was a clear monitoring system, and she had the impression that traditional healers were left to do what they wanted. She asked for clarification, adding that there were instances where the patient was left in the care of the healer for long periods of time.

Ms Baloyi (ANC) said that her concern was similar to Ms Luthuli’s. She asked if the person who reported to the traditional leaders had representation on hospital and clinical boards.

Nkosi Suping said that there was a need for control and monitoring, not only by the government but also by the traditional leaders. With regard to abuse, he agreed that some of these things did happen, and were hidden. He said that the wish was for traditional leaders to be involved, to enable greater awareness of the Act among members of the community, which would serve as a protective measure.

With reference to the clinic board, he said that he was not sure, as traditional leaders were not always kept informed, and he appealed for the Health Portfolio Committee to forge a link with the House of Traditional Leaders, and for links between the House and all government departments.

His colleague added that, for example, the health department and its officials were involved in the monitoring of circumcision schools, and he said there were other areas where the House might be able to inform and advise government.

Dr Nkomo thanked the representatives of the House, adding that their concerns had been noted by Prof Freeman (Chief Director of the National Directorate for Mental Health and Substance Abuse).

Lifecare Group
Dr Frankish, accompanied by his colleague, Ms Sekukune, explained that Lifecare was a subsidiary of Afrox Healthcare, operating over 6000 beds for people diagnosed with chronic mental illnesses and intellectual disability on a contract basis in six of the nine provinces. The processes related to admission, care, treatment and rehabilitation, and some aspects of clinical care were the parts of the Bill that Lifecare’s submission dealt.

He said that, in general, the Bill and its objectives were welcomed. They raised questions on:
- whether establishments could be classified as only psychiatric hospitals or "care and rehabilitation centres, or both since patients could be diagnosed with both intellectual disabilities and chronic mental illness;
- who was qualified to conduct the periodic reviews;
- the issue of practitioner liability in the case of involuntary care;
- the financial impact of frequent periodic reviews with the suggestion that in cases where there is evidence of stability less frequent reviews might suffice as this would also place an additional burden on existing staff numbers.

The point was also raised that the Review Boards would need to be established very soon after the promulgation of the Act, to avoid ‘bottle-necks’. The issue of the need for regulations was also addressed, with the suggestion that, for example, the issue of emergency surgical/medical interventions for involuntary users would need to be dealt with.

Questions
Dr Jassat asked what subsidy the company received from the state per person, per day. He also asked where referrals with regard to children came from, for example were autistic children referred from social services or the health department.

Dr Baloyi asked if the presenters agreed with Prof Zabow’s view regarding the need to regulate the length of stay and other concerns related to moderately mentally impaired individuals, and what happened to these individuals subsequent to discharge.

Ms Kalyan asked if the presenters were advocating forcing people to return for treatment, given their objections in relation to voluntary returns. She also asked if defining the people who were eligible to sit on the Review Boards might not preclude other categories of people from sitting on such boards i.e. other categories of mental health practitioners. With regard to the comments made in relation to Clauses 32 and 34, she asked if the request for consent was meant to apply to ECT, or if other situations were envisaged, and she asked for an example in this regard. She also asked if the limitations on intimate adult relations should not be amended to relate to all intimate relations, thinking particularly of mentally impaired girls.

Dr Cwele asked for clarity on how the group worked. His understanding was that it was on a contract basis. Did they deal with private patients or are all the patients interacting with State institutions? He also asked how many mental health professionals were employed by the company.

Ms Dudley asked whether they housed State patients, and whether they were treated among other patients. She said that the Bill made it possible for patients to go out on leave and the community had no input on this matter.

A member of the ANC asked for clarity regarding the recommendations on readmission.

Dr Frankish replied that, with regard to the subsidy, all patients were admitted from State hospitals at a rate negotiated with the provinces and the national government. The tariff system was not ideal for either side, and there were currently moves being made to address this. They did not admit any private patients, and some of the contracts derived from contracts going back twenty years, which could be revised. In terms of care for children under 18, although he was not sure with regard to autism, generally they dealt with those who were mentally retarded as a result of birth defects, and those who suffered from psychiatric illness. In terms of moderate retardation, discussions had been started with the provinces and investigations into other types of accommodation had begun, as it was recognised that institutions were not ideal. They tried to categorise and deal with people according to their ability. Length of stay was regulated by the periodic review. He added that there were considerable challenges and that ways of involving the community were needed. In terms of cancelling discharge, he said that Clause 40 of the Bill made provision for this. He concluded by saying that as Lifecare did not admit State patients, he could not comment on this issue further.

Ms Sekukune said that, with regard to the periodic review, for psychiatrists to be the only ones responsible for these, it would place significant pressure on them. She added that it was preferable to have the person designated so that the relevant people could be prepared and trained. The reference to emergency surgery had been seen more in terms of physical complaints, such as appendicitis. She also agreed that restriction on intimate relationships not be limited to adults.

Ms Kalyan asked a follow-up question saying that surely the Review Board would be responsible. She asked if they were saying that it would be the concern of the mental health professional on that board to write the report.

Ms Sekukune replied that the board did not write the report, it read and evaluated the report. There was consequently a need to clarify who would be responsible for the actual writing of such a report, as it required investigation etc. On the issue of surgery, currently the person under whose care the patient was, was responsible for giving consent for the surgery. They were recommending that the responsibility for giving consent shift to the hospital.

Dr Cwele said that it seemed that they were advocating the hospital should give consent, but then it would be responsible. He asked for more clarity on this issue.

Dr Frankish said there were certain circumstances in which a person was in custodial care and therefore the head of the health establishment gave consent on their behalf., for example when there is an emergency.

Mr De Klerk
Mr de Klerk said that he was there not as a patient, but as an individual, as he rejected the label of patient. He said that he had experienced how people were mis-diagnosed and labelled in archaic fashion. He asked how someone could be admitted to the hospital on the basis of family reports, when they were untrained to make such judgements. Although his presentation was somewhat disjointed, the two concerns which emerged were the danger of creating legislation which was not effectively implemented. As examples, he cited the Domestic Violence Act and the anti-discrimination and equality promotion legislation. He said that the implementation of these acts had not been adequate. He said that he had been ‘abducted’ by the police from his home and placed in an institution against his wishes. His experience of the mental health system was one which disempowered people by making decisions for them. He challenged the psychiatrist’s role, saying they were inadequately trained, and the role of the family in causing someone to be institutionalised.

Questions
Dr Jassat thanked Mr de Klerk for taking the time to make a presentation of his experiences.

Ms Baloyi said that he seemed much aggrieved and recommended the Human Right Commission as the appropriate forum for these grievances. She did however point out that Prof Freeman (Head of Directorate for Mental Health & Substance Abuse) was present and could take note of these issues.

Mr de Klerk said that the HRC needed to be transformed to promote equal opportunities.

Ms Kalyan said that it was clear that Mr De Klerk had been traumatised by his experiences and it was this situation that the Committee was attempting to address. She did however point out that you could not label all therapists as bad, as there were many who did good work

Mr de Klerk agreed, saying he had found some. He said that he was aggrieved, and had found some comfort in some of the Zulu traditions. He added that he will not be a victim, and that he did not want pity. It became clear that he wanted several authorities and bodies to take note of his concerns.

Association for Revenue Research
Mr Dunkley’s presentation concerned a different look at mental health, drawing attention to the link between mental health and social conditions, particularly poverty. His presentation dealt with a new method of taxation, taking property as its focus, and doing away with all other forms of taxation. He traced the effects of taxation on production, and it was argued that current methods of taxation made many tracts of land unviable as sources of income. He argued that his method would make more land available, as low cost land would not be taxed, since the land tax envisaged would operate on a sliding scale.

Questions
Ms Baloyi thanked Mr Dunkley for his presentation which fore-grounded the socio-economic dimensions of mental health. She did however point out that no government in the world ran without taxation.

Mr Cwele said that while it was true that some taxes may be unnecessary, there were some which were unavoidable. He asked whether Mr Dunkley was raising a concern over the slow pace of land reform, and if so asked if Mr Dunkley was proposing a radical change to this policy. He asked what were the economic dangers of this new plan.

Ms Kalyan thanked Mr Dunkley, adding that at times it was possible to take a blinkered view. She added that there was therapeutic value in working the land, as a general comment.

Mr Dunkley agreed that taxes needed to be paid, but by taking only 80% of what he called the land rent, you could take in more tax revenue than is being taken currently, because it was impossible to hide land. He said that it would need to be phased in, but as the tax base grows, more money would become available for everything, including mental health. He said that his plan dealt with all land and its uses, including mineral wealth, which would be factored into the value of the land. He said that the land with the greatest value such as in cities would be the most heavily taxed. This meant that marginal land would be available, for use by the poorest sectors of society, and they would pay no taxes.

Dr G Winkler
Dr Winkler said that he was making a submission in his personal capacity, although he worked for the province, as a psychiatrist serving the rural areas of the Western Cape. He added that he had worked in Mpumulanga and KwaZulu Natal, and had trained in Gauteng. He had two general concerns, that of the feasibility of the Review Boards in terms of financing and personnel, and the powers of the police. He added that two of the concerns he had raised in his written submission had been dealt with because he had based them on an earlier draft of the bill.

One of his concerns was that a single person who experienced a violent episode in a small town could do significant damage to the years of work done to challenge the stigma of mental illness in the community. He suggested that ensuring that patients of this kind were not treated in the smaller hospitals, which might not be able to provide adequate care as well, would help to prevent this situation. He highlighted the need for sufficient well-trained staff who had the time to deal with patients. The fact that little was required in terms of equipment meant that mental health care could be provided in basic settings, provided the staff had sufficient time and were trained appropriately. Most of the examinations could be done as outpatients, and there was seldom a need for hospitalisation.

He did however caution that the Bill did not specify the appropriate levels of care for different levels of violent behaviour. Other concerns were that the definition of psychiatric hospitals was unclear, and the ‘full beds’ scenario which existed might place some of the principles underlying the Bill under pressure when it came to implementation. He cautioned against involuntary community care, saying it required a level of sophistication which did not exist in the services available at present. Overall, his view was that the Bill was a good piece of legislation, as it furthered the aims of community care, while still allowing for other modes of care.

Questions
Ms Baloyi asked if Dr Winkler was proposing establishing dedicated beds for these patients. She asked if, in his experience the hospitals had the capacity to take care of these patients.

A member of the ANC asked what interaction the doctor had with traditional and spiritual healers, assuming some common ground between their areas of concern.

Dr Baloyi asked if the difficulties at the interface level could be relieved by additional staff.

Ms Malumise asked, in relation to point 4 of Dr Winkler’s submission, if psychiatric nursing staff were currently engaging in assessments.

Dr Winkler said that his region had eight district hospitals and one regional hospital. He recommended the development of capacity at regional level, for example by including a sessional psychiatrist, and dedicated nursing staff. Increasing capacity at district level depended on what was most cost effective, and this depended on the size of the region concerned. There were attempts to foster openness to mental illness among staff, which was insufficient. It would be possible to cope at present staffing levels if staff were motivated and had enough time. The smaller hospitals had beds, but could tolerate a smaller amount of disruption.

With regard to the 72 hour assessment, he said that at the moment, nursing staff had other requirements. Staff at smaller facilities were asking for seclusion facilities and training on sedation. He agreed with the need for seclusion, given the reasons about stigmatisation and disruption.

He went on to say that he had had meetings with traditional healers, and their systems were running in parallel. Traditional healers were more appropriate than he could ever be for some service users, and he had had training with some of them. He had not had any interaction with spiritual healers.

The Western Cape has numerous resources which were concentrated in the metropolitan areas, but was still advantaged when compared to the rest of the country in terms of staff etc. He conceded that this might make it difficult to justify more staff, to respond to Dr Baloyi’s question. In response to Ms Dumise, he said that this point had been addressed by the newer draft, and nursing staff were now allowed to be involved in the assessment.

Afternoon session
Ms M Hansen
Monica Hansen presented several stories, of herself and her friends. Many concerned domestic violence. She had been subjected to domestic violence, during a two and a half year relationship with a man in a small mining village. She highlighted the role tradition and the upbringing of women played in perpetuating gender-based violence. The other issue she touched on in her presentation was post-traumatic stress disorder. The underlying concern in the presentation was for the need to develop mental health services such as counselling etc in the communities. She said that there were insufficient services available, and those that were available were only affordable to a select few. The sense was that violence, particularly domestic violence, needed to be responded to through psychological interventions at the community level. She also gave a very personal insight into the way people who experienced such violence justified it to themselves.

Ms Mnumzana thanked Ms Hansen for her courage. She asked if, after all these experiences, there was any way she was getting help now.

Ms Ngobe asked what had eventually happened, to make her leave the man. She also asked if Ms Hansen had read the Bill, and if so, where was it helpful. She mentioned that there were a number of organisations which deal with women abuse and asked if Ms Hansen was interacting with these.

Ms Baloyi said that she felt Ms Hansen had spoken for many women and men who could not be present to make submissions. She asked if Ms Hansen had received any training as a counsellor, given that she seemed to counsel others so much. She asked if Ms Hansen had given thought to forming a support group, possibly with outside assistance.

Ms Kalyan said she was glad that Ms Hansen had stated that she was not a victim. She noted that Ms Hansen had said the system failed her because her partner would not submit for treatment. She pointed out that the Bill made provision for this, where others could request that someone receive treatment.

Dr Luthuli (ANC) said that what came across was the idea that there were numerous people in similar situations and that, without medical aid, there was little help offered in those situations. She said that it was important to recognise that everything was open to her now, and the Bill made all services accessible, even though they may not be felt to be adequate.

Ms Hansen remarked that it was interesting that only the women had asked questions. She said that she felt she did not need help now, as she was coping and getting better. She added that talking and sharing helped. She did not feel that the statistics indicated how extensive the problem was. In terms of how she eventually got out of the situation after a particularly violent weekend. It had been difficult for her to communicate with people outside, even with her family, because he was always around. And while her family suspected, they could not bring the subject up with her. She highlighted the economic factors in the situation, where a woman fears leaving because she has no means of financial support. She said that she had phoned her family after the weekend, when he had left for work on Monday, and she had broken down on the phone. But she was 700 kilometres from home. Her father had said that he would phone the manager of the company that ran the mining company village where she was living at the time. But she felt that was something that she needed to do herself. So she had phoned, explaining the situation and voicing her concern regarding the three guns in the house. With the assistance of security services, the manager had arrived at the house and taken the guns away, and she had left. She said that she had formed an informal support group. She concluded by saying that she would have valued input from men, given that South Africa was a chauvinistic society, in which one’s upbringing made it difficult to get out of abusive situations. She suggested men need to interrogate their conceptions of gender. She said that, as a woman, when you were disciplined by your father, you accepted being disciplined by other men.

Dr Nkomo said that, while the men might have been silent, he was sure that they were listening. He thanked Ms Hansen.

Dr Rapiti
Dr Rapiti, a family physician from Mitchell’s Plain, thanked the committee for the opportunity to make a presentation, adding that he was informed at very short notice. His presentation did however touch on many aspects of healthcare, not just mental health, and for this reason, only the issues relevant to mental health care will be raised. He said that one of his main concerns was the "damning effect" of violence on healthcare provision. As an example, he said that at Livingstone Hospital, there were usually around ten chest drains every Friday night, where in England there might be one every two months. He stressed the need to address the underlying causes of violence, including the psychological causes. Another area of concern was the growth in the effect of drugs on communities, adding that the USA spent $19 billion on policing the drug trade, but only $ 1 billion on rehabilitation, which suggested skewed priorities. In Mitchell’s Plain, a shebeen can turnover R2 million on a weekend, and this statistic was relevant because it suggests some of the dimensions of the problem of alcohol abuse. Dr Rapiti also drew attention to the link between alcohol abuse and violence, saying that solutions to both the problems were linked.

With regard to mental health care, he said that he had been trying to obtain a secondary qualification for thirteen years, since at present you could only be a general practitioner or a psychiatrist, and people did not necessarily need R380/hour psychiatrists nor could they afford them. He said that for as little as R40 per month, it would be possible to treat an HIV positive person for depression, using anti-depressants and psychotherapy. He felt that this was a much-needed service, as while nothing could be done to cure the disease, it would be possible to enhance the person’s quality of life. He added that the debate on costly anti-retrovirals had obscured some of these issues. He suggested that South Africa seemed obsessed with hi-tech cures, giving the example that Gauteng had more CAT scans and MRIs than the whole of England in support of this claim. He concluded by saying that, after listening to the previous speaker, he could speak further on the issue of women and violence, as well as the topic of mental illness.

Questions
Ms Ngobe (ANC) said that Dr Rapiti’s presentation was more of an attack on the government than anything else, and did not feed into the Mental Health Bill at all. She added that women go to drunken men, not the government. She said that only the last page of his submission had relevance to the present discussion, and that the aim of these hearings was to get public submissions around a specific issue. She continued that the other issues were known to the government and had not been forgotten.

Dr Cwele said that he was a medical practitioner before he came to Parliament, and he hoped that the health department and the committee would take some of these issues on board. Dr Jassat suggested that the committee clerk should have informed Dr Rapiti of the meeting’s purpose. Dr Nkomo added that the committee took note of Dr Rapiti’s concerns and would keep in touch, particularly when the relevant bill comes up for more debate in 2002.

Dr Nkomo noted that the formal stage of the Bill would be completed on Wednesday, with the second reading in the House due for 30 October, and then the Bill would move to the NCOP. He added that Friday was the formal stage of the Medical Schemes Amendment Bill, which was due to go to plenary on the 30th. The meeting was then adjourned.

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