Hyderabad: It is a terrible indictment on us as humans that we stigmatise and discriminate against individuals or groups because of their perceived difference or “otherness”. We welcome this new Lancet Commission and its aim to end stigma and discrimination in mental health, rather than merely reduce it.
The Commission comes at a time when mental health movements are gaining momentum globally, and the UN and its agencies are advocating greater recognition of mental health and transformed mental health services. The importance of mental health to economic and social development is now also conclusive. However, the WHO Mental Health Atlas shows that most countries lag behind in mental health policy, laws, and services and real change in mental health is distressingly slow.
Globally, budgets and resources for mental health services are hugely inadequate and unequally distributed. The extent to which neglect of mental health can be attributed directly to a perception by governments that mental health is not as important as physical health and to other stigma-related concerns is not straightforward but these factors are likely to be involved. The benefits that accrue to those who stigmatise other people can at times explain prejudicial attitudes and behaviours.
For example, racist conceptualisations of Indigenous people have been used to legitimise colonisation and economic exploitation. In mental health, the underlying reasons for stigma and discrimination are complex. Associations of mental illness with violence and personal weakness are among the driving factors, but, as with bullying behaviour, it is people's insecurity and uncertainty that seem to result in their need to derogate others. Among health workers, inadequate training and knowledge are often presented as reasons for not wanting to engage with mental health. This situation can be changed, but once irrational attitudes and behaviours are established among a dominant group, redressing them is hugely challenging.
The Lancet Commission on ending stigma and discrimination in mental health by Graham Thornicroft, Charlene Sunkel, and colleagues makes important recommendations for various stakeholders. Key among these is for governments to develop policies and legislation against discrimination, promote social inclusion of people with mental health conditions and uphold their rights, and run evidence-based programmes to combat stigma.
However, our experience in South Africa, where we each served as the National Director for Mental Health with responsibility for policy and legislation, highlights that although anti-discrimination policies and laws as well as affirmative-action policies are necessary, they are by no means sufficient. We believe countries can learn from the South African example that policies and law are inadequate without comprehensive support and implementation. Indeed, there is a risk of complacency once laws and policies that promote human rights are in place.
South Africa has a progressive constitution and numerous anti-discrimination and affirmative-action laws. Yet almost three decades after the end of Apartheid, stigma, hatred, and resistance to implementing this legislation are rife. We regularly encounter malicious racist, sexist, homophobic, and anti-disability language and actions that show that othering is still deep within society. In this context, mental health services are far from meeting people's needs. Despite comprehensive policy and legislation to end stigma and discrimination and achieve equity, mental health stigma has resulted in harm to individuals and many lives lost.
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The South African Mental Health Care Act (2002) states that “The person, human dignity and privacy of every mental health care user must be respected” and that “A mental health care user may not be unfairly discriminated against.” Yet in 2016–17, at least 144 people with mental health conditions died while being transferred from institutional care to so-called community care in Gauteng province. The treatment of these people and many others who survived the transfer lacked dignity and was discriminatory. The investigative inquiry into these deaths found that mental health service users were dehumanised, treated without compassion or understanding, and even tortured.
From the politicians and bureaucrats who conceptualised and planned the move to the individuals who received people in the community and dealt with the bodies of those who died, it was clear that these people with mental health conditions were perceived and treated as lesser human beings. Perhaps the law was violated because people did not know it, but more likely it was because of poor understanding or disregard of the meaning and importance of concepts such as dignity and protection from discrimination. This tragic example of stigmatisation and dehumanisation resulted in multiple deaths and received much public attention and outcry, but the inhumane ill-treatment of people with mental health conditions is widespread globally in institutions and communities.
The South African Mental Health Care Act also states that “Every mental health care user must receive care, treatment and rehabilitation services according to standards equivalent to those applicable to any other health care user.” This law implies parity in access to mental health care with physical health care. But there is no other area in health care in South Africa where the gap between need and provision of treatment and services is as high as the 90%, which it is in mental health.
Good-quality mental health care means access to care for the majority of people in the community, yet 86% of mental-health-care expenditure in South Africa is on inpatient care and 50% of this budget is spent on care in psychiatric hospitals. South Africa has legal targets for employment of people with disabilities, but disability targets are not being met and the number of those employed who have psychosocial disabilities is lower than those with physical and sensory disabilities. Laws to combat stigma and discrimination mean little unless they are enforced. Effective follow-up and advocacy of legislation must be done and, if necessary, prosecutions for non-compliance need to be pursued.
This Lancet Commission emphasises the importance of centring people with lived experience in movements to end stigma and discrimination in mental health. This principle has been well established in the disability sector and in the struggles for equity of racially minoritised populations, women, LGBTQI+ persons, and others. The Commission rightly underlines the importance of intersectionality, since ending stigma and discrimination is not a single-issue endeavour.
Crucially, efforts to end stigma and discrimination against people with lived experience of mental health conditions need to be embedded in general anti-discrimination programmes. Moreover, laws and policies must be fully implemented and supported once adopted. MF was Chief Director of the Division of Non-Communicable Diseases (which included mental health) at the National Department of Health at the time of the deaths in Gauteng province, but had no role in the decision to move patients or in their actual transfer.
