People with Mental Illness in The City
…A wide-ranging perspective from National Psychiatric Hospital’s Dr Violet Mwanjali
“I am reporting a mentally challenged man who has placed rubbish in front of our shops. Please come and take him away before he harms people”. “I’m reporting a person with mental illness at President Center Shopping Complex parking lot. He brought his dirty stuff and is disturbing our customers. Please remove him”. The above quoted statements are some of the many customer service requests that the Municipal Council of Manzini has been receiving on its 24/7 Call Centre (800 2004/2505 7000) and its Facebook platform (Manzini News) in the recent past. It must be mentioned that these are some of the rare kinds of customer service requests to be received by the Municipality in any other month; an indication that something needs to be done as the situation clearly causes discomfort to other citizens. Manzini News approached an expert in the field in the name of Dr Violet David Mwanjali who serves at the National Psychiatric Referral Hospital as Medical Specialist in Mental Health and Psychiatry. The following questions were posed to the doctor and she responded to all of them;
Manzini News: Does the National Psychiatric Hospital have a service that collects people with mental illness from the streets into the hospital? If not; who does the hospital expect to perform this task and what’s the process involved?
Dr Mwanjali: The National Psychiatric Hospital provides clinical care to its patients. These include social welfare services, clinical psychology services, occupational therapy services, as well as medical surgical services. The hospital has also integrated clinical dietary services, HIV/AIDS clinical care services and Sexual Reproductive Health services. With regard to issues of mental illness and mental health our services are guided by the Mental Health Order of 1978. We receive patients that are brought to us. Patients can be brought to the hospital by the police, relatives, friends, co-workers, supervisors, etcetera. Ideally, those who have displayed undamaged behavior that may pose danger to themselves or others need to be brought in by the police as the police service is the Government department responsible for monitoring safety and order. The expectation is that those who are mentally unwell and not violent would be handled by the Municipality; ensuring that the patients are given the attention they need. I must clarify, however, that this expectation from the Municipality is not legislated but it is a global best practice. The legislation is old and is presently being reviewed.
Manzini News: We are seeing an influx of people with mental illness in the city centre lately. What could be the cause of that situation? Why can’t they all be admitted? Are they escaping from the National Psychiatric Hospital?
Dr Mwanjali: Please note that not everyone brought to the psychiatric hospital will be admitted. There is an admission criteria that we follow; and the criteria is largely medically oriented. Those that present with behaviors that may cause harm to themselves or others are surely admitted. Even those that may not cause direct harm to themselves or others, but display public indecent behaviour such as nudity. Ideally, (and that is the practice in other countries globally) those that do not meet admission criteria, and are not mentally stable or do not have good family support, need to be put somewhere; for example, in a halfway home like the elderly who are cared for in a nursing home. Otherwise, the best way is to manage them in their communities (deinstitutionalization) under the care of their families and close relatives. However, it becomes difficult for Eswatini because there are no half way homes. As a way of closing the gap, municipalities in other countries then take it upon themselves to assign social workers to monitor and ensure that the person with mental illness takes medication and receives psychological and social support that they need. Mental illness is a lifetime condition and consistent taking of medication is critical. Failure to take medication results in a relapse. Another gap that makes the situation difficult is that there is no clause in the legislation which compels parents and relatives to take care of their mentally ill relative. For example, we have patients that have been treated and discharged from the hospital but because parents or relatives are not forced to collect them, they remain in the hospital wards. We are not allowed to release persons with mental illness on their own accord, unfortunately, hence we keep them in the wards despite them being discharged. Sometimes we assign our social worker to take them home. You must remember that the psychiatric hospital is just a hospital like any other. It’s not like it has iron bars like a prison. Therefore, after staying in the hospital uncollected by their relatives despite having been discharged, the risk of absconding from the hospital without medication is high hence they eventually relapse in the streets.
Manzini News: Can persons with mental illness be a danger to citizens? Are there any signs/indicators of a potentially violent person with mental illness?
Dr Mwanjali: The mentally ill individuals are patients who need to be taken care of like any other physically ill patients. The secret lies in timing. The moment the relatives/citizens notice that someone is mentally unwell, provide advice or support by taking that individual to the health facility immediately. Do not wait for the illness to progress and worsen. There are many indicators of a potentially violent person with mental illness. Non-verbal ones include showing a fist, facial expression as well as presence of wounds or blood stains on their clothes. Verbal aggression is another indicator.
Manzini News: How should citizens behave in the midst of people with mental illness? What are the behavioral Dos and Don’ts?
Dr Mwanjali: The best we can all do is to support them by providing basic needs. Also support them by making sure they take medication and they go to the health facilities for follow up care. I am happy that we do have medications in the form of an injection that can be given monthly especially to patients with history of poor medication adherence. It is crucial to give them love and respect as human beings. Don’t discriminate against them and call them names such as lihlanya. Name calling agitates them. Also; it honestly would be very nice to have all eligible people with mental illness benefit under the social disability grants because they need money for food, shelter and other basic needs. I am very thankful to the Government of Eswatini for providing social disability grants (to some persons with mental illness) and free mental health services to all individuals with mental illness. My message to citizens of Manzini is to provide support to people with mental illness rather than being uncomfortable all the time around them. When you spot signs of abnormal behavior, don’t be a hero and try to manage them rather inform relevant authorities to provide the needed assistance and guidance. Even if the person is your relative, don’t attempt to manage them or wait for too long once they start being violent. Just call the police or take him/her to the health facility near you.
Manzini News: Some people are of the view that members of the public should desist from offering money, food, etcetera, to people with mental illness as that may be what attracts them to town. What would be your comment on that?
Dr Mwanjali: That question is very tricky. It depends on the individual citizen, really. However, we need to know that some of the money may be used to buy illegal substances that may worsen their mental lines or it may be used to buy basic needs like food or pay for accommodation etcetera. That’s why I’m saying this is a tricky question. You should, as an individual, follow your intuition.
…HOW MUNICIPALITY DEALS WITH MENTALLY ILL PERSONS
The Municipal Council of Manzini has as one of its strategic objectives in the 2019/2024 Integrated Development Plan (IDP) the provision of responsive integrated health and social welfare services by 2024. Moreover, it has committed itself to inclusion as one of its corporate values. In light of the above, there are a number of interventions that the Municipality carries out as a mitigation to the issue of people with mental illness in the City of Manzini. The Municipality identifies the sites that they usually occupy for constant monitoring purposes. As a result, there is a database in place which points to the presence of approximately 30 people with mental illness in the city. The site identification enables the Municipality to monitor whether or not the people take medication and whether or not they exhibit violence.
The Municipality also monitors their medical health and facilitates for those that are sick (e.g. headache, stomach ache, etc) to get treatment. Even with the advent of the Covid-19 virus, the Municipality facilitated for donations of face masks towards people with mental illness and it is grateful to the organisations that lent a helping hand. The Municipality is presently making arrangements for them to get vaccinated against Covid-19. Monitoring also helps minimize incidents of property vandalism or emptying of litter bins. In cases where they are violent or present themselves indecently (such as nudity) the Municipality facilitates for their removal by the police to the National Psychiatric Hospital. The greatest challenge is that some do not have their medical cards; making it difficult to monitor and ensure they take their medication. The card contains all the information about the medication they need to take and frequency thereof. Another challenge experienced is that there is not much information available for purposes of tracing their relatives.
The Municipality makes an effort to engage them and find out why they do not go back home; and the common response given is that there is a lot of stigma, discrimination and name calling from family and community members hence they prefer being on the streets than home. Some do not remember where their homes are. Members of the public are urged to report violent or public indecent behavior by people with mental illness to the police, any nearest security officer from Global Protection Services or, alternatively, they may notify the Municipality through its 24/7 Call Centre (800 2004/2505 7000).