John Parker is a psychiatrist at Lentegeur Hospital. This psychiatric facility in Mitchells Plain is at the frontline of treating methamphetamine-related psychosis. Parker, a barefoot poet and surfer, has developed programmes to address the “tik” crisis. But drug abuse is one facet of a multitude of social problems on the Cape Flats.
It is seven, still dark on Baden Powell Drive, a beachfront road that connects the suburb of Muizenberg to the Cape Flats. A white VW Citi Golf with only one headlight, its hazard lights flashing, negotiates the dawn traffic. The sole occupant of the car, psychiatrist John Parker (48), is on his way to meet Kurt Meavers, a mechanic in Strandfontein. The Citi Golf is in need of repair. John is clean-shaven, wears glasses and has a small silver earring in his left ear. He has been up since five. Each morning begins with a meditation routine, either inside his Noordhoek home or outside in his daughters’ Wendy house during the hot summer months. The early morning quiet is important to John, who devotes time to cultivating mindfulness, the ability to be in the moment and pay attention in a purposeful and non-judgmental way. The fruits of this practice are recognisable: the doctor holds the space around him when he speaks in his metered and thoughtful manner. John pulls up outside the mechanic’s house. Meavers, an affable man with neatly trimmed beard, comes out and greets John with a handshake and a hug. They met two years ago when Meavers saw John standing by the side of the road next to his car—it had broken down—and have become close friends. Meavers says he has learned a lot from John during their conversations whenever he has had to drive the psychiatrist to nearby Lentegeur Hospital, a specialist psychiatric facility in Mitchells Plain, where John has worked since late 2003. The hospital was established in 1987.
The entrance to Lentegeur Psychiatric Hospital at which John parker has worked for the last 10 years. In Parker's view, the institution's architecture does not lend itself to the idea of recovery. The entrance, which he compares to that of a prison, is an example for Parker of the disconnected thinking involved in constructing the hospital.
Others who know John reiterate this sentiment: John is mindful, easy to relate to. And his thoughtful demeanour, as well as the strong sense of self-belief he projects, helps the psychiatrist navigate the broad range of human emotion and experience he encounters in his work. It has also served him well in confrontational encounters with psychotic patients. Like the time he talked a burly patient out of hitting him with a chair, or when he got a knife-wielding patient to hand over his weapon—both events took place early in his career, when he was based at Fort England Psychiatric Hospital in Grahamstown in the Eastern Cape. I can engage with someone who’s completely psychotic.
John Parker is a straight-talker. He populates his conversations with anecdotes, tales of his travels to different parts of the world by land and sea, observations on the intricacies of human connection, and experiences as a doctor before becoming a psychiatrist. Between graduating from medical school at the University of the Witwatersrand in 1990 and starting work in psychiatry at Fort England in 1995, John did stints as an intern and later a medical officer at Cecilia Makiwane Hospital outside East London. He also worked in the trauma unit in Cape Town’s Victoria Hospital.
If you do things only for other people, self-sacrifice, it’s the surest road to bitterness and burnout
With psychiatry, John wanted to go beyond saving lives and work with people who have been othered in some way: he wanted to help them find meaning in their lives. Despite dealing with the darker aspects of human experience on a daily basis, John is clear that his role as a psychiatrist in a government hospital serving poor communities on Cape Town’s periphery is not altruism. “If you do things only for other people, self-sacrifice, it’s the surest road to bitterness and burnout,” he says. “You need to do it for yourself, but it’s a conception of the self that is well beyond Western individualism. It’s closer to sort of ubuntu stuff: I do it for myself in the knowledge that what I give to other people is the most rewarding thing I can do.” Despite Parker's 50-hour week on average, he finds meaning working with people that have been othered in some way. He sees purpose in the people that he works with. "I'm doing something with them, and that thing gives me joy."
John has a casual, approachable air about him and typically wears open-neck shirts paired with a dark jacket when he is at work. Work is a collection of face-brick units with red roofs behind an electrified fence, which John says is there to keep thieves out, not patients in. Three times a week, behind a closed door in the outpatients department, John consults patients with severe mental illnesses, including borderline personality disorder, schizophrenia and bipolar disorder. Patients tell of hearing voices in their head; some of them slash and burn themselves. He has had patients kill themselves. A few feet away from his office door, a woman in a white coat dispenses medication from the counter of the hospital’s pharmacy. Patients push brown envelopes, containing their details and scripts, into a slot labelled “folders”, wait, and then leave with up to a month’s worth of medication. This is one of the daily cycles at Lentegeur, one of three state-run psychiatric hospitals in the Western Cape. Built by the apartheid government, the hospital serves the urban populations living in some of Cape Town’s poorest areas, including Mitchells Plain, Khayelitsha, Philippi, Strandfontein and Crossroads. Collectively known as the Cape Flats, this sprawling mishmash of low-income neighbourhoods and slums on the city’s outskirts is where the apartheid government sent non-white residents who were forcibly removed from the city under the notorious Group Areas Act of 1950. Unemployment here is high; basic services are rudimentary and mental health issues not uncommon. Lentegeur houses a small population of persons with intellectual disabilities and forensic patients, the latter criminal offenders either unfit to stand trial or serving court-ordered sentences based on their diminished capacity to distinguish right and wrong. But mostly Lentegeur’s patients arrive experiencing psychotic episodes: some hallucinate, others are delusional; often they are dangerous to themselves, sometimes to others too. Many of Parker's patients have backgrounds marked by the harsh living conditions of the Cape Flats. Drug and alcohol abuse and violence-related trauma contribute to the prevalence of mental health issues in the area.
When visiting Lentegeur it is easy to forget that it is a psychiatric hospital because the patients are behind closed doors in their wards. Reminders of its function soon materialise. Occasionally, patients are seen outside, walking around in pale blue gowns. A few times when meeting with John I encountered a man, a long-term resident at the hospital, in the passageway unable to form words. He would talk at me, loudly, making garbled sounds, looking me in the eye, seemingly frustrated at our lack of understanding. Mental illness remains poorly understood. What is known is its pervasiveness: about 30% of adult South Africans will experience at least one mental disorder in their lifetimes, in part due to the high incidence of alcohol and drug abuse and dependency—also classified as mental disorders in the South African Stress and Health (SASH) study, a nationally-representative study of common mental disorders undertaken between 2002 and 2004.
In the Western Cape, the province with the highest prevalence of common mental disorders according to SASH, and particularly the poorer areas on the city’s periphery, drug use underpins a rise in the prevalence of mental illness. There is however no data that localises the incidence of mental health disorders on the Cape Flats, where the popular street drug tik—a methamphetamine sold in crystal form and usually smoked using a straw and light bulb or glass pipe—is strongly associated with mental illness, especially bouts of psychosis. Many tik users who experience psychotic episodes end up at Lentegeur.
DENSITY & RECREATION
The highest residential densities are observable in informal settlements and townships that characterise the South-East of the city. However, the vast majority of recreational infrastructure is found at the opposite end of the city.
“The thing about tik is there’s no other drug with such a strong association with mental illness,” says John. He points to the findings of an Australian study of just over 300 regular methamphetamine users: 13% of them screened positive for psychosis, 11 times higher than the figure for the general population. There’s nothing to suggest South Africa would have a lower incidence of methamphetamine-related psychosis. One of Parker's patients tending to the garden that's part of the Spring Project, designed to enable patients to integrate themselves into their community. Those that involve themselves grow and sell these vegetables.
Tik’s popularity as a recreational drug in Cape Town rose sharply in the 2000s, according to numbers from the Medical Research Council (MRC). In the first half of 2003, just 5% of patients admitted to city rehabs reported using tik as a drug of choice. Four years later that proportion had jumped to 49%. Tik remains the drug of choice in the province. In 2013, two-fifths of those in city rehabs reported using tik as a primary or secondary drug of abuse. Tik also has a pronounced racial demographic. Nearly 80% of people using tik as their primary substance of abuse are coloured persons. More coloured people are primary abusers of tik than alcohol, according to the MRC. Tik is also popular among younger users. Since the beginning of 2004, the number of primary users younger than 20 in city rehabs has yo-yoed between 16% and 60%. I do it for myself in the knowledge that what I give to other people is the most rewarding thing I can do
The relationship between drug use and mental illness among children and adolescents in the Cape Flats is so volatile that a few years ago Lentegeur had to close an inpatient child and adolescent therapeutic unit—it was dedicated to treating youth with nominally more prosaic psychiatric illnesses like depression, suicidal behaviour, severe anxiety, post-traumatic stress disorder and the like—and convert it to a psychosis recovery unit so as to open up more beds for psychotic children and adolescents.
In the Western Cape, like other parts of South Africa, a small cache of middle-to-high income earners use high-quality private hospitals, paying handsomely to do so through contributions to medical aids. The majority of residents rely on public sector hospitals. Based on predictions of the prevalence of mental illness, there are roughly four to five times the number of severely mentally ill people who need hospitalisation in the Western Cape than are actually admitted, estimates John. The combination of an under-resourced public health sector and high prevalence of substance abuse and social toxicity in areas like the Cape Flats has produced a lethal concoction. “In the last ten years in the Western Cape we’ve been absolutely battered by the amphetamine epidemic, in particular, but HIV is also playing a big role in increasing the figures, the number of people in need,” says John. The Spring Project has seen the introduction of vegetable gardening for long-term patients and the greening of some parts of the hospital. Parker hopes for patients to reconnect with themselves and their community through their involvement.
Fragmented and unstable home environments and a hostile social fabric also contribute to mental health issues in Lentegeur’s catchment area. René Nassen, a medical doctor specialising in child psychiatry who trained with John at the University of Cape Town’s psychiatry department, gives a window into the types of backgrounds that shape the outcomes for young patients at the hospital. Nassen, who is also head of Lentegeur’s child and adolescent psychiatry service, conveys a genuine sense of empathy when she speaks. Her dark wavy hair frames a warm smile that I imagine sometimes finds itself subdued, momentarily extinguished by the sombre realities of the young people she consults. A set of Russian dolls, perched quietly on top of the bookshelf in her office, listen with wooden ears as she talks about the intertwining roles of poverty, abuse, drugs and violence.
Typically, teenage boys who land up at Lentegeur get their start in the world with a learning difficulty that may be coupled with ADHD (attention deficit hyperactivity disorder). They struggle to cope academically at school and begin exhibiting behavioural problems. Often, they end up dropping out of school, or being suspended, usually around Grade 8. At this point they generally start using drugs, usually cannabis and tik. Three or four years after starting on these drugs they experience a psychotic episode.
about 30% of adult South Africans will experience at least one mental disorder in their lifetimes, in part due to the high incidence of alcohol and drug abuse and dependency
“The reason why we see these learning disordered children has got everything to do with the social adversity these children suffer,” says Nassen. “Right from in the womb they are disadvantaged.” These adverse conditions include mothers who may be using drugs and alcohol, poor nutrition, and exposure to violence in their homes and communities. “It’s pretty much what one would expect in low-income areas,” she says. “The problem in our situation is that it’s not just poverty and low income, it’s the violence and crime which compounds the picture.” Girls face similar adversity, but have the added trauma of sexual abuse in their backgrounds. About 90% of the teenage girls admitted for treatment of adolescent psychosis have been sexually abused from a young age, says Nassen. “Many times, I feel like I preside over a human tragedy out of all proportion.”
Mental illness is one facet of a multitude of social problems on the Cape Flats. The area is home to a deeply embedded gang culture. Gang violence has become so chronic in some parts that in 2013 government closed schools in one badly affected area, Manenberg, for two days over fears about the safety of pupils caught in the crossfire of warring gangs. Western Cape Premier Helen Zille has at times over the past few years called for the national army to be deployed to help combat the powerful gangs. Amid high levels of unemployment and poverty, children are readily co-opted into gangs and used to peddle drugs at schools and elsewhere. For kids in the area gunshots are nothing anymore, says Joe van der Berg, director of Cornerstone Therapeutic Community, a drug rehab in Mitchells Plain. His office is in a lemon-coloured building next to a boarded-up church; it is not far from the hospital where John works. Across the street from the rehab, children play in a park. Their voices drift intermittently into the office. “They look up to the gunshots. The [drug] merchant is becoming their role model,” says Van der Berg. “Coming from a poor family, you want to have money, you want to have that power—with money comes power.”
Patients working with the gardens give their produce to visiting family members and sell them on site. In this way Parker hopes that patients find a renewed sense of purpose through their work.
Treating psychotic patients in this challenging environment is tough: relapse rates are high. With pressure on the available beds, psychotic patients at hospitals like Lentegeur need to be discharged as soon as possible. Doctors see many of the same faces, patients returning after relapsing, sometimes only months later. In 2013, 61% of patients admitted to Lentegeur were readmissions. John likens this frustrating cycle to the fate of Sisyphus, the deceitful king of Ephyra who in Greek mythology was condemned by the gods to unsuccessfully roll a huge boulder up a mountain, for eternity.
“We’ve come into this profession trying to help people and for the first week or two they’re fighting with us, in every way possible,” says John. “You’ve no sooner got them to the point where they’re actually grateful for what you’re doing and out they go. Then two months later they’re back screaming at you again. It just completely wears you down. And even more so when you’re trying to fight for resources to actually do this better and you’re getting flak from the rest of the health system for not taking all the ‘mad’ people out of their hospitals quick enough.”
In the first half of 2003, just 5% of patients admitted to city rehabs reported using tik as a drug of choice. Four years later that proportion had jumped to 49%
John, who nowadays clocks 50 hours a week at work on average, reached a point of burnout after watching the boulder roll downhill one too many times while running the hospital’s female admission unit. In 2009, he wrote a resignation letter. His CEO asked him to reconsider, so he took extended leave, packing his family—wife, Belinda, and two children, Hana and Grace—into his Land Rover. The Parkers headed off on an extended camping trip through Mozambique, Malawi, Zambia, Zimbabwe and parts of South Africa. Ten months later John returned to Lentegeur.
Parker wishes to change the way in which society sees mental illness as something hopeless and shameful. Challenging stigmas can enable psychiatric patients to feel accepted within their societies.
“It was like coming home,” he recalls. “I got back here and people would see me from across the hospital and come running and give me a hug. It was very special.” He knew he wanted to stay, as well as find a mechanism to cope with the stress. “I had to find a way to survive, basically.”
That path to survival involved introducing the ideas that would culminate in John’s ongoing venture, the Spring Project, which has seen the introduction of vegetable gardening for long-term patients and the greening of some parts of the hospital. Outside the forensic ward there are neat rows of cauliflower, lettuce and spring onion. Behind the same ward, a patch of sweet potatoes has taken root. Patients sell these. At another garden outside the occupational therapy centre—it is known as the “Beehive”—local organisation Food and Trees for Africa provides permaculture training to forensic patients. At another section of the hospital there is a hoophouse (a polytunnel hothouse) in the making. A semi-circular frame draped with white mesh, it houses various greens. Strewn nearby is plastic piping and troughs; they will eventually be turned into vertical gardens, with the pipes sucking fish droppings out of the water to nourish the plants.
John Parker stands with Belinda and their two children, Grace and Hana. Parker and both his daughters share a preference for being barefoot. The gardens are not just an aesthetic accompaniment to beautify the hospital. There is a deep theoretical concept attached to John’s ideas, informed by the recovery movement: a body of thought that places the need to find meaning in one’s life and a sense of hope at the core of the healing process. “The whole way our society sees mental illness is that it’s profoundly hopeless and is something that’s shameful,” says John. This is something he wants to change. He is fond of dispelling the notion that people cannot recover from serious mental illness such as schizophrenia by making references to those with psychiatric disorders who have gone on to work as professionals, including as psychiatrists—one, an American psychiatrist who was diagnosed with schizophrenia in the 1960s, went on to study psychiatry at Harvard and acquired a second doctorate.
John’s hope is that patients will find their work in Lentegeur’s gardens purposeful, and will begin to experience a sense of hope for life outside the institution. The aim is also to help them reconnect with broader society, overriding the historical legacy of mental institutions as spaces that remove the mentally ill from society. John wants to see Lentegeur’s patients reconnect with their communities, and have the hospital reconnect with the community too. Patients give vegetables to visiting family members; they also sell them on site. In this way people become something more than just patients by shifting into the role of providers. John also sees the project as a way to heal the hospital itself, making it more welcoming. Lentegeur does not lend itself visually to the idea of recovery, thinks John. He points to the imposing and dour entrance. A horizontal column of text set in a version of Times New Roman lettering reads “Welcome to Lentegeur Hospital and Western Cape Rehabilitation Centre”. It sits above a brick security box, where guards sign visitors in and check their car boots on the way out (to make sure there aren’t patients hiding in them). The only other places that have gateways like that are the prisons, he says, and possibly Tygerberg Hospital. “It’s just such a perfect example of disconnected thinking,” John says. “No one who built that gate was thinking, ‘I want people who come through this entrance to feel like they’re about to get help.’ It was completely the opposite.”
It would be a disservice to John’s Spring Project to see it as just vegetable gardening. This is the opinion of Peter Smith, a medical doctor and psychiatrist at Lentegeur who has known John since the late 1990s when they were both training to be psychiatrists at the University of Cape Town. The project ties into a broader framework that brings together elements related to human rights and ethics, explains Smith. “Digging holes and planting trees is a pretty ordinary, humble activity. But it is actually directed at a very complex process, which is about connection,” he explains. “It is about a kind of reconciliation of human beings who have been taken on a detour away from themselves.”
Institutions can be slow to change. New ideas take time to get support. John’s project has not been without its critics. “I imagine that for John there must have been immense frustration and obstacles,” says Smith. “I think very few people could have taken on a project like the one he has. What I think has helped him is his natural determination and perspicacity, his belief, I suppose.”
An avid surfer, Parker places importance in practising mindfulness in the knowledge that psychiatrists need to be able to let go of the profession's sombre moments. he surfs daily.
John spent his early years growing up in Rio de Janeiro, Brazil, where his father, a manager with British American Tobacco, had been posted. At age nine his parents sent him to St John’s College, a private boarding school for boys in Johannesburg. The formal school culture was a big change from the American school he attended in Rio, where children went without uniforms and called their teachers by their first names. While studying medicine at the University of the Witwatersrand during the 1980s, a period marked by increased political upheaval and protest against the apartheid system, John got involved with the leftist student movement. Part of his activism involved working with an emergency services group, training underground activists in the townships to administer first aid during clashes with police. He recalls working in the basement of a general store in the Zeerust area, during clashes between troops from Bophuthatswana and local citizens. “I can still remember some of the people we saw. Women, shot, beaten up. An amputee sjambokked [whipped] on his amputated leg so badly that it had split open.”
LEADING CAUSES OF PREMATURE MORTALITY IN THE CITY
After years of battling HIV, the city and its health support services have awoken to the burden of various lifestyle risk factors like obesity and high sugar and salt intake, which have begun to wreak havoc on the population resulting in an increase in diseases like heart disease and diabetes. The difficulty in accessing good nutrition and easy availability of unhealthy mass-produced food products for most of the population is a significant public health challenge in Cape Town. Additionally, the burden of TB in the city ranks amongst the highest in the world. With new drug resistant strains of the disease emerging, it remains to be seen how or when this disease can be eradicated. The ubiquity of informal settlements across the city — characterised by environments which simultaneously enable the spread of diseases like TB, and act as barriers to physical activity and healthy eating— present an imperative for the city to solve its housing crisis, taking into consideration the configuration of communities and issues of violence and safety.
Source: MRC, Western Cape Mortality Profile, 2010
Having witnessed the apartheid system’s brutality, John was not hopeful about change. “In 1988 I remember seeing a poster from the UDF [United Democratic Front] Youth League that said, ‘Freedom in our lifetime’. I remember getting tears in my eyes thinking, ‘Geez, these poor guys are so naively optimistic.’” But things did change. John now works for the government.
Every workday John returns home to the small Atlantic seaboard community of Noordhoek on the southern outskirts of Cape Town. His house backs onto Table Mountain National Park and overlooks a long, white beach, where he enjoys surfing. It is warm inside the living room on a cold Sunday afternoon, Father’s Day, when I visit. We sit near the fireplace. A westerly wind blows salty air landward from the grey Atlantic Ocean. John is on the couch. He wears a loose sweater and grey shorts with a hole in them. A few hours earlier his wife trimmed his hair. The neighbour’s dog, a laconic creature prone to seizures due to epilepsy, is curled up next to him. A wetsuit hangs from a rafter. There is a photo of famed Cape Town big wave surf spot Dungeons, which produces gigantic waves in front of the Sentinel, a mountain peak not far from John’s home. Another photo shows John on a yacht in Fiji. He is younger, his hair wilder. The water in the photo’s background is cobalt, the vegetation lush. Two drums and a marimba stand against the wall next to the fireplace.
Mental illness is one facet of a multitude of social problems on the Cape Flats. The area is home to a deeply embedded gang culture. Gang violence has become so chronic in some parts that in 2013 government closed schools in one badly affected area, Manenberg, for two days over fears about the safety of pupils caught in the crossfire of warring gangs. At the nearby dining table, Belinda (45) and Hana (9) are crafting animal sculptures from clay. A set of miniature horses stand complete, drying. Belinda has just put the finishing touches on a red cat. These sculptures, and others yet to be made, will take their place on a model of an ark that Hana has made for a school project. John and his daughters are barefoot despite the winter chill. John doesn’t like shoes and neither do the girls. When he gave a TEDx talk in Cape Town in 2012 he went barefoot on stage. I ask him why.
“He doesn’t like wearing shoes,” interjects Hana. “I hate wearing shoes too.”
“They’re horrid,” Grace (10) chimes in. John recites from memory a poem, ‘Footloose’, penned during a perennially barefoot period in 1995:
small wonder the putrid odour that emanates from the shoe,
straightjacket to the foot. silent strangler that leaves the toes to rot in humid darkness,
stolen from the soil.
they say that leather moves and breathes as living skin.
how pleasant, dead animals to cushion and comfort like a padded cell.
I yearn only to tear them loose and stand free,
my feet alive, spread out and feeling how the earth sings beneath me. Inside John’s home, nestled against the mountainside, where poetry is spoken, it is warm and secure. John’s daughters, each wearing a weave in their hair, seem unencumbered. John has found a place where he is connected to his family and the surrounding nature.
I am reminded of John’s deep familial and geographical connections early one morning a week or so later. We are walking down the beach on the shortest day of the year, winter solstice, with a freshly birthed sun on the rise. John, in a wetsuit, his surfboard under his arm, has just crossed the beach’s brackish lagoon. As he reaches the other side, a flamboyance of flamingos lifts off into the sky, pointing their snake-like necks in the direction we’re heading. The sand is cold underfoot and I sink into it as I struggle to keep up with his brisk pace. He tells documentary filmmaker Simon Taylor, who is accompanying us, a story I’ve heard before. Years ago, when John wanted to move from his apartment in the city centre to the south peninsula, he was counselling a mother and her children using narrative therapy. They had been through a tough divorce situation and communication in the family was poor. John had been asking the girls to share their stories with him. They would always ask him, “What’s your story?” John, who struggles with the classic psychoanalytic notion of a therapist as a blank slate, wondered what to share with these girls. Folklore and fairy tales were strong contenders.
One Saturday morning, after recently seeing the girls, he was driving to Noordhoek to go surfing and got to thinking about what he could tell them about whales and surfing. He remembered reading about a surfer being “picked up” by a whale and thought that would be a nice story to tell. He tried to imagine it happening to him. Sitting on his board in the water that day, John noticed something dark below him, which he initially took for rocks or kelp. Looking closer, he realised it was a tail shape. Moments later he felt a surge of water boiling up below him. Something came out of the water and knocked him off his surfboard. He rolled onto his back, landing on a whale’s fluke, put out his hand and touched the whale’s leathery skin, feeling a distinct mammalian response as it pulled away from him. “I felt it feel me,” he recalls.
John went to view the home, where he now lives, shortly after the incident. He could see the spot where the encounter in the water happened from the deck; he felt it was the right place to call home. He bought it soon after. John is not religious, but when making decisions he trusts that the right way forward will be revealed to him. “Serendipity,” he says, “the ability to see and surf synchronicity. I think synchronicity events do happen, and there’s maybe, I don’t know—it’s almost a skill you can develop. Either that, or I’m just freaking lucky.”
There is value here...that’s why I’m here.
Patients in the Spring Project garden
On the walk back along the beach after our surf John adopts a more sombre tone when he talks about losing a patient to suicide. He says psychiatrists need to be able to let that type of thing go so they can move on with their work. It’s part of the job, not everyone recovers, despite a doctor’s efforts. Others, though, make real progress.
It is just after lunch on a Wednesday afternoon. I am with one of John’s patients, 19-year-old Jason*. He lives a short walk from the hospital. Jason has bipolar disorder. He says he was also previously diagnosed with schizophrenia—“just for four months, not so bad”. His father, a mechanic, died in 2009; the event had a profound effect on Jason, the youngest of four siblings. “To me, he said he’s only 14 years old, why should he grow up without a dad? He had a dream of getting old with his dad,” says Jason’s mother. She is sitting on a worn black armchair placed in the corner of the lounge at their home. The home’s walls are painted an orangey-pink. There are no pictures displayed. Along with other family members, Jason’s older sister is at home. She has had her front teeth and incisors removed, a procedure resulting in what is colloquially known as a “passion gap” or “Cape Flats smile”. She removes the plate she wears with false teeth to fill the gap. The incisors are gold. It is something she had wanted ever since she was a little girl.
Not long after his father’s death, Jason’s aunt and uncle died too. He became withdrawn and spent hours sitting in front of the TV not saying anything. One day his mother came home to find him having a breakdown: screaming and crying. She took him to a nearby hospital, where she says he was given tablets for epilepsy meant for adults. Shortly afterwards he had a seizure, and wound up at Groote Schuur Hospital, the large teaching hospital near Devil’s Peak. He spent two months there, and a further two months at Tygerberg Hospital, a tertiary hospital located in Parow, before being transferred to Lentegeur.
During his psychotic episodes, Jason says the TV spoke to him. He heard the voice of Riaan Cruywagen, a well-known South African news anchor, telling him he would take him on a tour with former president Nelson Mandela. He also heard his dead father telling him he would come to kill him. He saw creatures that weren’t there: they looked like meerkats, a type of mongoose.
After treatment at Lentegeur, Jason is now an outpatient and sticks to a regime of psychiatric medication. He works as a volunteer at the Spring Project, going into the hospital daily for a few hours. At work he wears a denim overall with a set of black gumboots. He is well known at the hospital, popular with the staff, and has become like a “pop idol” there, his mother says. Working at the hospital has helped Jason, who dropped out of school when he got ill. It is a chance to get out of the house. Being at the hospital makes him feel at ease, his mother says. “It helped me a lot to stay away from drugs,” says Jason. “That’s the most important thing.” He recently made the pages of a local community newspaper, appearing in an article about the Spring Project. He keeps a pile of copies of that edition at home, and is keen to show them off. “I was actually crying when I saw him in the newspaper,” says his mother. “I didn’t know that one of the children would be like him.”
Positive stories like Jason’s give John hope. Part of the reason he got into psychiatry was to work with people who have been othered in some fashion and help them find meaning in their lives—much in the way he has found meaning, largely through his work at Lentegeur. John doesn’t gloss over the tougher aspects of his job. The social ills that sculpt the lives of the people that come to the hospital are real. But he finds beauty on the Cape Flats among the people he works with, both amongst his colleagues and patients. He praises their “depth of humanity” despite trying circumstances. “There is value here,” he says. “That’s why I’m here.” He is quick to point out that he is not a martyr compelled to labour on the Cape Flats out of a misplaced sense of charity. “I’m not here to save people,” he says. “I’m doing something with them, and that thing that I do gives me joy.”
NOTE: Where images of mental health care users may have been used, this has, in all cases been done with the full informed consent of the individual involved
Well-being: Hazel's battle with TB (Atlantis)
Infographics:Blain van Rooyen
John Parker is a psychiatrist at Lentegeur Hospital. This psychiatric facility in Mitchells Plain is at the frontline of treating methamphetamine-related psychosis. Parker, a barefoot poet and surfer, has developed programmes to address the “tik” crisis. But drug abuse is one facet of a multitude of social problems on the Cape Flats.
It is seven, still dark on Baden Powell Drive, a beachfront road that connects the suburb of Muizenberg to the Cape Flats. A white VW Citi Golf with only one headlight, its hazard lights flashing, negotiates the dawn traffic. The sole occupant of the car, psychiatrist John Parker (48), is on his way to meet Kurt Meavers, a mechanic in Strandfontein. The Citi Golf is in need of repair. John is clean-shaven, wears glasses and has a small silver earring in his left ear. He has been up since five. Each morning begins with a meditation routine, either inside his Noordhoek home or outside in his daughters’ Wendy house during the hot summer months. The early morning quiet is important to John, who devotes time to cultivating mindfulness, the ability to be in the moment and pay attention in a purposeful and non-judgmental way. The fruits of this practice are recognisable: the doctor holds the space around him when he speaks in his metered and thoughtful manner. John pulls up outside the mechanic’s house. Meavers, an affable man with neatly trimmed beard, comes out and greets John with a handshake and a hug. They met two years ago when Meavers saw John standing by the side of the road next to his car—it had broken down—and have become close friends. Meavers says he has learned a lot from John during their conversations whenever he has had to drive the psychiatrist to nearby Lentegeur Hospital, a specialist psychiatric facility in Mitchells Plain, where John has worked since late 2003. The hospital was established in 1987.
The entrance to Lentegeur Psychiatric Hospital at which John parker has worked for the last 10 years. In Parker's view, the institution's architecture does not lend itself to the idea of recovery. The entrance, which he compares to that of a prison, is an example for Parker of the disconnected thinking involved in constructing the hospital.
Others who know John reiterate this sentiment: John is mindful, easy to relate to. And his thoughtful demeanour, as well as the strong sense of self-belief he projects, helps the psychiatrist navigate the broad range of human emotion and experience he encounters in his work. It has also served him well in confrontational encounters with psychotic patients. Like the time he talked a burly patient out of hitting him with a chair, or when he got a knife-wielding patient to hand over his weapon—both events took place early in his career, when he was based at Fort England Psychiatric Hospital in Grahamstown in the Eastern Cape. I can engage with someone who’s completely psychotic.
John Parker is a straight-talker. He populates his conversations with anecdotes, tales of his travels to different parts of the world by land and sea, observations on the intricacies of human connection, and experiences as a doctor before becoming a psychiatrist. Between graduating from medical school at the University of the Witwatersrand in 1990 and starting work in psychiatry at Fort England in 1995, John did stints as an intern and later a medical officer at Cecilia Makiwane Hospital outside East London. He also worked in the trauma unit in Cape Town’s Victoria Hospital.
If you do things only for other people, self-sacrifice, it’s the surest road to bitterness and burnout
With psychiatry, John wanted to go beyond saving lives and work with people who have been othered in some way: he wanted to help them find meaning in their lives. Despite dealing with the darker aspects of human experience on a daily basis, John is clear that his role as a psychiatrist in a government hospital serving poor communities on Cape Town’s periphery is not altruism. “If you do things only for other people, self-sacrifice, it’s the surest road to bitterness and burnout,” he says. “You need to do it for yourself, but it’s a conception of the self that is well beyond Western individualism. It’s closer to sort of ubuntu stuff: I do it for myself in the knowledge that what I give to other people is the most rewarding thing I can do.” Despite Parker's 50-hour week on average, he finds meaning working with people that have been othered in some way. He sees purpose in the people that he works with. "I'm doing something with them, and that thing gives me joy."
John has a casual, approachable air about him and typically wears open-neck shirts paired with a dark jacket when he is at work. Work is a collection of face-brick units with red roofs behind an electrified fence, which John says is there to keep thieves out, not patients in. Three times a week, behind a closed door in the outpatients department, John consults patients with severe mental illnesses, including borderline personality disorder, schizophrenia and bipolar disorder. Patients tell of hearing voices in their head; some of them slash and burn themselves. He has had patients kill themselves. A few feet away from his office door, a woman in a white coat dispenses medication from the counter of the hospital’s pharmacy. Patients push brown envelopes, containing their details and scripts, into a slot labelled “folders”, wait, and then leave with up to a month’s worth of medication. This is one of the daily cycles at Lentegeur, one of three state-run psychiatric hospitals in the Western Cape. Built by the apartheid government, the hospital serves the urban populations living in some of Cape Town’s poorest areas, including Mitchells Plain, Khayelitsha, Philippi, Strandfontein and Crossroads. Collectively known as the Cape Flats, this sprawling mishmash of low-income neighbourhoods and slums on the city’s outskirts is where the apartheid government sent non-white residents who were forcibly removed from the city under the notorious Group Areas Act of 1950. Unemployment here is high; basic services are rudimentary and mental health issues not uncommon. Lentegeur houses a small population of persons with intellectual disabilities and forensic patients, the latter criminal offenders either unfit to stand trial or serving court-ordered sentences based on their diminished capacity to distinguish right and wrong. But mostly Lentegeur’s patients arrive experiencing psychotic episodes: some hallucinate, others are delusional; often they are dangerous to themselves, sometimes to others too. Many of Parker's patients have backgrounds marked by the harsh living conditions of the Cape Flats. Drug and alcohol abuse and violence-related trauma contribute to the prevalence of mental health issues in the area.
When visiting Lentegeur it is easy to forget that it is a psychiatric hospital because the patients are behind closed doors in their wards. Reminders of its function soon materialise. Occasionally, patients are seen outside, walking around in pale blue gowns. A few times when meeting with John I encountered a man, a long-term resident at the hospital, in the passageway unable to form words. He would talk at me, loudly, making garbled sounds, looking me in the eye, seemingly frustrated at our lack of understanding. Mental illness remains poorly understood. What is known is its pervasiveness: about 30% of adult South Africans will experience at least one mental disorder in their lifetimes, in part due to the high incidence of alcohol and drug abuse and dependency—also classified as mental disorders in the South African Stress and Health (SASH) study, a nationally-representative study of common mental disorders undertaken between 2002 and 2004.
In the Western Cape, the province with the highest prevalence of common mental disorders according to SASH, and particularly the poorer areas on the city’s periphery, drug use underpins a rise in the prevalence of mental illness. There is however no data that localises the incidence of mental health disorders on the Cape Flats, where the popular street drug tik—a methamphetamine sold in crystal form and usually smoked using a straw and light bulb or glass pipe—is strongly associated with mental illness, especially bouts of psychosis. Many tik users who experience psychotic episodes end up at Lentegeur.
DENSITY & RECREATION
The highest residential densities are observable in informal settlements and townships that characterise the South-East of the city. However, the vast majority of recreational infrastructure is found at the opposite end of the city.
“The thing about tik is there’s no other drug with such a strong association with mental illness,” says John. He points to the findings of an Australian study of just over 300 regular methamphetamine users: 13% of them screened positive for psychosis, 11 times higher than the figure for the general population. There’s nothing to suggest South Africa would have a lower incidence of methamphetamine-related psychosis. One of Parker's patients tending to the garden that's part of the Spring Project, designed to enable patients to integrate themselves into their community. Those that involve themselves grow and sell these vegetables.
Tik’s popularity as a recreational drug in Cape Town rose sharply in the 2000s, according to numbers from the Medical Research Council (MRC). In the first half of 2003, just 5% of patients admitted to city rehabs reported using tik as a drug of choice. Four years later that proportion had jumped to 49%. Tik remains the drug of choice in the province. In 2013, two-fifths of those in city rehabs reported using tik as a primary or secondary drug of abuse. Tik also has a pronounced racial demographic. Nearly 80% of people using tik as their primary substance of abuse are coloured persons. More coloured people are primary abusers of tik than alcohol, according to the MRC. Tik is also popular among younger users. Since the beginning of 2004, the number of primary users younger than 20 in city rehabs has yo-yoed between 16% and 60%. I do it for myself in the knowledge that what I give to other people is the most rewarding thing I can do
The relationship between drug use and mental illness among children and adolescents in the Cape Flats is so volatile that a few years ago Lentegeur had to close an inpatient child and adolescent therapeutic unit—it was dedicated to treating youth with nominally more prosaic psychiatric illnesses like depression, suicidal behaviour, severe anxiety, post-traumatic stress disorder and the like—and convert it to a psychosis recovery unit so as to open up more beds for psychotic children and adolescents.
In the Western Cape, like other parts of South Africa, a small cache of middle-to-high income earners use high-quality private hospitals, paying handsomely to do so through contributions to medical aids. The majority of residents rely on public sector hospitals. Based on predictions of the prevalence of mental illness, there are roughly four to five times the number of severely mentally ill people who need hospitalisation in the Western Cape than are actually admitted, estimates John. The combination of an under-resourced public health sector and high prevalence of substance abuse and social toxicity in areas like the Cape Flats has produced a lethal concoction. “In the last ten years in the Western Cape we’ve been absolutely battered by the amphetamine epidemic, in particular, but HIV is also playing a big role in increasing the figures, the number of people in need,” says John. The Spring Project has seen the introduction of vegetable gardening for long-term patients and the greening of some parts of the hospital. Parker hopes for patients to reconnect with themselves and their community through their involvement.
Fragmented and unstable home environments and a hostile social fabric also contribute to mental health issues in Lentegeur’s catchment area. René Nassen, a medical doctor specialising in child psychiatry who trained with John at the University of Cape Town’s psychiatry department, gives a window into the types of backgrounds that shape the outcomes for young patients at the hospital. Nassen, who is also head of Lentegeur’s child and adolescent psychiatry service, conveys a genuine sense of empathy when she speaks. Her dark wavy hair frames a warm smile that I imagine sometimes finds itself subdued, momentarily extinguished by the sombre realities of the young people she consults. A set of Russian dolls, perched quietly on top of the bookshelf in her office, listen with wooden ears as she talks about the intertwining roles of poverty, abuse, drugs and violence.
Typically, teenage boys who land up at Lentegeur get their start in the world with a learning difficulty that may be coupled with ADHD (attention deficit hyperactivity disorder). They struggle to cope academically at school and begin exhibiting behavioural problems. Often, they end up dropping out of school, or being suspended, usually around Grade 8. At this point they generally start using drugs, usually cannabis and tik. Three or four years after starting on these drugs they experience a psychotic episode.
about 30% of adult South Africans will experience at least one mental disorder in their lifetimes, in part due to the high incidence of alcohol and drug abuse and dependency
“The reason why we see these learning disordered children has got everything to do with the social adversity these children suffer,” says Nassen. “Right from in the womb they are disadvantaged.” These adverse conditions include mothers who may be using drugs and alcohol, poor nutrition, and exposure to violence in their homes and communities. “It’s pretty much what one would expect in low-income areas,” she says. “The problem in our situation is that it’s not just poverty and low income, it’s the violence and crime which compounds the picture.” Girls face similar adversity, but have the added trauma of sexual abuse in their backgrounds. About 90% of the teenage girls admitted for treatment of adolescent psychosis have been sexually abused from a young age, says Nassen. “Many times, I feel like I preside over a human tragedy out of all proportion.”
Mental illness is one facet of a multitude of social problems on the Cape Flats. The area is home to a deeply embedded gang culture. Gang violence has become so chronic in some parts that in 2013 government closed schools in one badly affected area, Manenberg, for two days over fears about the safety of pupils caught in the crossfire of warring gangs. Western Cape Premier Helen Zille has at times over the past few years called for the national army to be deployed to help combat the powerful gangs. Amid high levels of unemployment and poverty, children are readily co-opted into gangs and used to peddle drugs at schools and elsewhere. For kids in the area gunshots are nothing anymore, says Joe van der Berg, director of Cornerstone Therapeutic Community, a drug rehab in Mitchells Plain. His office is in a lemon-coloured building next to a boarded-up church; it is not far from the hospital where John works. Across the street from the rehab, children play in a park. Their voices drift intermittently into the office. “They look up to the gunshots. The [drug] merchant is becoming their role model,” says Van der Berg. “Coming from a poor family, you want to have money, you want to have that power—with money comes power.”
Patients working with the gardens give their produce to visiting family members and sell them on site. In this way Parker hopes that patients find a renewed sense of purpose through their work.
Treating psychotic patients in this challenging environment is tough: relapse rates are high. With pressure on the available beds, psychotic patients at hospitals like Lentegeur need to be discharged as soon as possible. Doctors see many of the same faces, patients returning after relapsing, sometimes only months later. In 2013, 61% of patients admitted to Lentegeur were readmissions. John likens this frustrating cycle to the fate of Sisyphus, the deceitful king of Ephyra who in Greek mythology was condemned by the gods to unsuccessfully roll a huge boulder up a mountain, for eternity.
“We’ve come into this profession trying to help people and for the first week or two they’re fighting with us, in every way possible,” says John. “You’ve no sooner got them to the point where they’re actually grateful for what you’re doing and out they go. Then two months later they’re back screaming at you again. It just completely wears you down. And even more so when you’re trying to fight for resources to actually do this better and you’re getting flak from the rest of the health system for not taking all the ‘mad’ people out of their hospitals quick enough.”
In the first half of 2003, just 5% of patients admitted to city rehabs reported using tik as a drug of choice. Four years later that proportion had jumped to 49%
John, who nowadays clocks 50 hours a week at work on average, reached a point of burnout after watching the boulder roll downhill one too many times while running the hospital’s female admission unit. In 2009, he wrote a resignation letter. His CEO asked him to reconsider, so he took extended leave, packing his family—wife, Belinda, and two children, Hana and Grace—into his Land Rover. The Parkers headed off on an extended camping trip through Mozambique, Malawi, Zambia, Zimbabwe and parts of South Africa. Ten months later John returned to Lentegeur.
Parker wishes to change the way in which society sees mental illness as something hopeless and shameful. Challenging stigmas can enable psychiatric p
atients to feel accepted within their societies.
“It was like coming home,” he recalls. “I got back here and people would see me from across the hospital and come running and give me a hug. It was very special.” He knew he wanted to stay, as well as find a mechanism to cope with the stress. “I had to find a way to survive, basically.”
That path to survival involved introducing the ideas that would culminate in John’s ongoing venture, the Spring Project, which has seen the introduction of vegetable gardening for long-term patients and the greening of some parts of the hospital. Outside the forensic ward there are neat rows of cauliflower, lettuce and spring onion. Behind the same ward, a patch of sweet potatoes has taken root. Patients sell these. At another garden outside the occupational therapy centre—it is known as the “Beehive”—local organisation Food and Trees for Africa provides permaculture training to forensic patients. At another section of the hospital there is a hoophouse (a polytunnel hothouse) in the making. A semi-circular frame draped with white mesh, it houses various greens. Strewn nearby is plastic piping and troughs; they will eventually be turned into vertical gardens, with the pipes sucking fish droppings out of the water to nourish the plants.
John Parker stands with Belinda and their two children, Grace and Hana. Parker and both his daughters share a preference for being barefoot. The gardens are not just an aesthetic accompaniment to beautify the hospital. There is a deep theoretical concept attached to John’s ideas, informed by the recovery movement: a body of thought that places the need to find meaning in one’s life and a sense of hope at the core of the healing process. “The whole way our society sees mental illness is that it’s profoundly hopeless and is something that’s shameful,” says John. This is something he wants to change. He is fond of dispelling the notion that people cannot recover from serious mental illness such as schizophrenia by making references to those with psychiatric disorders who have gone on to work as professionals, including as psychiatrists—one, an American psychiatrist who was diagnosed with schizophrenia in the 1960s, went on to study psychiatry at Harvard and acquired a second doctorate.
John’s hope is that patients will find their work in Lentegeur’s gardens purposeful, and will begin to experience a sense of hope for life outside the institution. The aim is also to help them reconnect with broader society, overriding the historical legacy of mental institutions as spaces that remove the mentally ill from society. John wants to see Lentegeur’s patients reconnect with their communities, and have the hospital reconnect with the community too. Patients give vegetables to visiting family members; they also sell them on site. In this way people become something more than just patients by shifting into the role of providers. John also sees the project as a way to heal the hospital itself, making it more welcoming. Lentegeur does not lend itself visually to the idea of recovery, thinks John. He points to the imposing and dour entrance. A horizontal column of text set in a version of Times New Roman lettering reads “Welcome to Lentegeur Hospital and Western Cape Rehabilitation Centre”. It sits above a brick security box, where guards sign visitors in and check their car boots on the way out (to make sure there aren’t patients hiding in them). The only other places that have gateways like that are the prisons, he says, and possibly Tygerberg Hospital. “It’s just such a perfect example of disconnected thinking,” John says. “No one who built that gate was thinking, ‘I want people who come through this entrance to feel like they’re about to get help.’ It was completely the opposite.”
It would be a disservice to John’s Spring Project to see it as just vegetable gardening. This is the opinion of Peter Smith, a medical doctor and psychiatrist at Lentegeur who has known John since the late 1990s when they were both training to be psychiatrists at the University of Cape Town. The project ties into a broader framework that brings together elements related to human rights and ethics, explains Smith. “Digging holes and planting trees is a pretty ordinary, humble activity. But it is actually directed at a very complex process, which is about connection,” he explains. “It is about a kind of reconciliation of human beings who have been taken on a detour away from themselves.”
Institutions can be slow to change. New ideas take time to get support. John’s project has not been without its critics. “I imagine that for John there must have been immense frustration and obstacles,” says Smith. “I think very few people could have taken on a project like the one he has. What I think has helped him is his natural determination and perspicacity, his belief, I suppose.”
An avid surfer, Parker places importance in practising mindfulness in the knowledge that psychiatrists need to be able to let go of the profession's sombre moments. he surfs daily.
John spent his early years growing up in Rio de Janeiro, Brazil, where his father, a manager with British American Tobacco, had been posted. At age nine his parents sent him to St John’s College, a private boarding school for boys in Johannesburg. The formal school culture was a big change from the American school he attended in Rio, where children went without uniforms and called their teachers by their first names. While studying medicine at the University of the Witwatersrand during the 1980s, a period marked by increased political upheaval and protest against the apartheid system, John got involved with the leftist student movement. Part of his activism involved working with an emergency services group, training underground activists in the townships to administer first aid during clashes with police. He recalls working in the basement of a general store in the Zeerust area, during clashes between troops from Bophuthatswana and local citizens. “I can still remember some of the people we saw. Women, shot, beaten up. An amputee sjambokked [whipped] on his amputated leg so badly that it had split open.”
LEADING CAUSES OF PREMATURE MORTALITY IN THE CITY
After years of battling HIV, the city and its health support services have awoken to the burden of various lifestyle risk factors like obesity and high sugar and salt intake, which have begun to wreak havoc on the population resulting in an increase in diseases like heart disease and diabetes. The difficulty in accessing good nutrition and easy availability of unhealthy mass-produced food products for most of the population is a significant public health challenge in Cape Town. Additionally, the burden of TB in the city ranks amongst the highest in the world. With new drug resistant strains of the disease emerging, it remains to be seen how or when this disease can be eradicated. The ubiquity of informal settlements across the city — characterised by environments which simultaneously enable the spread of diseases like TB, and act as barriers to physical activity and healthy eating— present an imperative for the city to solve its housing crisis, taking into consideration the configuration of communities and issues of violence and safety.
Source: MRC, Western Cape Mortality Profile, 2010
Having witnessed the apartheid system’s brutality, John was not hopeful about change. “In 1988 I remember seeing a poster from the UDF [United Democratic Front] Youth League that said, ‘Freedom in our lifetime’. I remember getting tears in my eyes thinking, ‘Geez, these poor guys are so naively optimistic.’” But things did change. John now works for the government.
Every workday John returns home to the small Atlantic seaboard community of Noordhoek on the southern outskirts of Cape Town. His house backs onto Table Mountain National Park and overlooks a long, white beach, where he enjoys surfing. It is warm inside the living room on a cold Sunday afternoon, Father’s Day, when I visit. We sit near the fireplace. A westerly wind blows salty air landward from the grey Atlantic Ocean. John is on the couch. He wears a loose sweater and grey shorts with a hole in them. A few hours earlier his wife trimmed his hair. The neighbour’s dog, a laconic creature prone to seizures due to epilepsy, is curled up next to him. A wetsuit hangs from a rafter. There is a photo of famed Cape Town big wave surf spot Dungeons, which produces gigantic waves in front of the Sentinel, a mountain peak not far from John’s home. Another photo shows John on a yacht in Fiji. He is younger, his hair wilder. The water in the photo’s background is cobalt, the vegetation lush. Two drums and a marimba stand against the wall next to the fireplace.
Mental illness is one facet of a multitude of social problems on the Cape Flats. The area is home to a deeply embedded gang culture. Gang violence has become so chronic in some parts that in 2013 government closed schools in one badly affected area, Manenberg, for two days over fears about the safety of pupils caught in the crossfire of warring gangs. At the nearby dining table, Belinda (45) and Hana (9) are crafting animal sculptures from clay. A set of miniature horses stand complete, drying. Belinda has just put the finishing touches on a red cat. These sculptures, and others yet to be made, will take their place on a model of an ark that Hana has made for a school project. John and his daughters are barefoot despite the winter chill. John doesn’t like shoes and neither do the girls. When he gave a TEDx talk in Cape Town in 2012 he went barefoot on stage. I ask him why.
“He doesn’t like wearing shoes,” interjects Hana. “I hate wearing shoes too.”
“They’re horrid,” Grace (10) chimes in. John recites from memory a poem, ‘Footloose’, penned during a perennially barefoot period in 1995:
small wonder the putrid odour that emanates from the shoe,
straightjacket to the foot. silent strangler that leaves the toes to rot in humid darkness,
stolen from the soil.
they say that leather moves and breathes as living skin.
how pleasant, dead animals to cushion and comfort like a padded cell.
I yearn only to tear them loose and stand free,
my feet alive, spread out and feeling how the earth sings beneath me. Inside John’s home, nestled against the mountainside, where poetry is spoken, it is warm and secure. John’s daughters, each wearing a weave in their hair, seem unencumbered. John has found a place where he is connected to his family and the surrounding nature.
I am reminded of John’s deep familial and geographical connections early one morning a week or so later. We are walking down the beach on the shortest day of the year, winter solstice, with a freshly birthed sun on the rise. John, in a wetsuit, his surfboard under his arm, has just crossed the beach’s brackish lagoon. As he reaches the other side, a flamboyance of flamingos lifts off into the sky, pointing their snake-like necks in the direction we’re heading. The sand is cold underfoot and I sink into it as I struggle to keep up with his brisk pace. He tells documentary filmmaker Simon Taylor, who is accompanying us, a story I’ve heard before. Years ago, when John wanted to move from his apartment in the city centre to the south peninsula, he was counselling a mother and her children using narrative therapy. They had been through a tough divorce situation and communication in the family was poor. John had been asking the girls to share their stories with him. They would always ask him, “What’s your story?” John, who struggles with the classic psychoanalytic notion of a therapist as a blank slate, wondered what to share with these girls. Folklore and fairy tales were strong contenders.
One Saturday morning, after recently seeing the girls, he was driving to Noordhoek to go surfing and got to thinking about what he could tell them about whales and surfing. He remembered reading about a surfer being “picked up” by a whale and thought that would be a nice story to tell. He tried to imagine it happening to him. Sitting on his board in the water that day, John noticed something dark below him, which he initially took for rocks or kelp. Looking closer, he realised it was a tail shape. Moments later he felt a surge of water boiling up below him. Something came out of the water and knocked him off his surfboard. He rolled onto his back, landing on a whale’s fluke, put out his hand and touched the whale’s leathery skin, feeling a distinct mammalian response as it pulled away from him. “I felt it feel me,” he recalls.
John went to view the home, where he now lives, shortly after the incident. He could see the spot where the encounter in the water happened from the deck; he felt it was the right place to call home. He bought it soon after. John is not religious, but when making decisions he trusts that the right way forward will be revealed to him. “Serendipity,” he says, “the ability to see and surf synchronicity. I think synchronicity events do happen, and there’s maybe, I don’t know—it’s almost a skill you can develop. Either that, or I’m just freaking lucky.”
There is value here...that’s why I’m here.
Patients in the Spring Project garden
On the walk back along the beach after our surf John adopts a more sombre tone when he talks about losing a patient to suicide. He says psychiatrists need to be able to let that type of thing go so they can move on with their work. It’s part of the job, not everyone recovers, despite a doctor’s efforts. Others, though, make real progress.
It is just after lunch on a Wednesday afternoon. I am with one of John’s patients, 19-year-old Jason*. He lives a short walk from the hospital. Jason has bipolar disorder. He says he was also previously diagnosed with schizophrenia—“just for four months, not so bad”. His father, a mechanic, died in 2009; the event had a profound effect on Jason, the youngest of four siblings. “To me, he said he’s only 14 years old, why should he grow up without a dad? He had a dream of getting old with his dad,” says Jason’s mother. She is sitting on a worn black armchair placed in the corner of the lounge at their home. The home’s walls are painted an orangey-pink. There are no pictures displayed. Along with other family members, Jason’s older sister is at home. She has had her front teeth and incisors removed, a procedure resulting in what is colloquially known as a “passion gap” or “Cape Flats smile”. She removes the plate she wears with false teeth to fill the gap. The incisors are gold. It is something she had wanted ever since she was a little girl.
Not long after his father’s death, Jason’s aunt and uncle died too. He became withdrawn and spent hours sitting in front of the TV not saying anything. One day his mother came home to find him having a breakdown: screaming and crying. She took him to a nearby hospital, where she says he was given tablets for epilepsy meant for adults. Shortly afterwards he had a seizure, and wound up at Groote Schuur Hospital, the large teaching hospital near Devil’s Peak. He spent two months there, and a further two months at Tygerberg Hospital, a tertiary hospital located in Parow, before being transferred to Lentegeur.
During his psychotic episodes, Jason says the TV spoke to him. He heard the voice of Riaan Cruywagen, a well-known South African news anchor, telling him he would take him on a tour with former president Nelson Mandela. He also heard his dead father telling him he would come to kill him. He saw creatures that weren’t there: they looked like meerkats, a type of mongoose.
After treatment at Lentegeur, Jason is now an outpatient and sticks to a regime of psychiatric medication. He works as a volunteer at the Spring Project, going into the hospital daily for a few hours. At work he wears a denim overall with a set of black gumboots. He is well known at the hospital, popular with the staff, and has become like a “pop idol” there, his mother says. Working at the hospital has helped Jason, who dropped out of school when he got ill. It is a chance to get out of the house. Being at the hospital makes him feel at ease, his mother says. “It helped me a lot to stay away from drugs,” says Jason. “That’s the most important thing.” He recently made the pages of a local community newspaper, appearing in an article about the Spring Project. He keeps a pile of copies of that edition at home, and is keen to show them off. “I was actually crying when I saw him in the newspaper,” says his mother. “I didn’t know that one of the children would be like him.”
Positive stories like Jason’s give John hope. Part of the reason he got into psychiatry was to work with people who have been othered in some fashion and help them find meaning in their lives—much in the way he has found meaning, largely through his work at Lentegeur. John doesn’t gloss over the tougher aspects of his job. The social ills that sculpt the lives of the people that come to the hospital are real. But he finds beauty on the Cape Flats among the people he works with, both amongst his colleagues and patients. He praises their “depth of humanity” despite trying circumstances. “There is value here,” he says. “That’s why I’m here.” He is quick to point out that he is not a martyr compelled to labour on the Cape Flats out of a misplaced sense of charity. “I’m not here to save people,” he says. “I’m doing something with them, and that thing that I do gives me joy.”
NOTE: Where images of mental health care users may have been used, this has, in all cases been done with the full informed consent of the individual involved
Well-being: Hazel's battle with TB (Atlantis)
Infographics:Blain van Rooyen