When life's brokenness can't be easily put back together again, parts of it sink and drift into a murky swirl that sometimes ends up colliding with Lesley Robertson's professional life - and that's a good thing, says the community psychiatrist.
"Everything ends up in the health system," says Robertson who is also an adjunct professor in the Department of Psychiatry at the University of Witwatersrand and head of the community psychiatry clinical unit at Sedibeng District Health Service in Gauteng.
"To give you an idea, if drunk driving isn't regulated, it can end up in our hospitals as trauma. Those traumas and head injury patients might end up coming to us in psychiatry as aggression, depression, or PTSD. Ultimately," she says, "we pick up the ends."
Still, she'd rather that people be in care than be abandoned in mental health "brokenness". Robertson says people can be written off too easily as being "emotionally volatile" and become cast out of their social circles instead of being directed for care, diagnosis, and initiated on intervention, support, or treatment.
And that downward spiral happens easier than one might realise.
Robertson casts her mind back to two decades ago when her two children were young and she slipped into a debilitating haze of depression without recognising it.
"There were days that I just couldn't get the car into gear to go and get groceries. I delayed my daughter's immunisation at five years old because I couldn't arrange to go to the pharmacy. I was a doctor, educated, and resourced and I didn't spot this as depression," she says.
Mental health a low priority
She adds that even now in the aftermath of the Life Esidemeni tragedy that cost the lives of 144 people as well as the clear impact of COVID-19 on grief, loss, anxiety, and isolation - mental health remains a low priority on the national healthcare agenda. Government is still stuck in wrangles over the perceived financial costs of a comprehensive mental healthcare policy rather than waking up to the bigger costs of the fallout of doing too little, too passively.
Fallout, she says, are the people on the forgotten fringes and also people in the "ordinary middle" whose lives - like hers was two decades ago - are boxed in with anxiety and stress, [and] also aches and pains that are then too readily medicated. This is adding to a deepening opioid dependency crisis that South Africa is not immune to. Society's intolerance of dealing with emotions too, Robertson says, is matching up to a rising trend of more children being drug-dependent on crystal meth and nyaope who then end up needing mental health support.
"There is also no national blueprint for community psychiatry and no funding. There's also massive corruption. District and regional facilities are overwhelmed. Sometimes they don't even have the physical space to accommodate psychiatric care and doctors and nurses are not equipped to recognise mental health disorders. It is a disaster," she says.
Robertson though isn't scared off easily by "disasters" or "chaos" because, she says, "there is a lot that needs to change in the system" for the public healthcare sector to be ready for the coming mental health crisis.
Also, she jokes, she's well-practised in chaos management, having to push through Johannesburg's rush-hour traffic that comes with a sprinkling of loadshedding and potholes. It helps that she has Fleetwood Mac turned up loud - or Bob Dylan's Masters of War when she's really angry.
It helps too that she's accepted what her strengths are, and weaknesses too. It's more clarity on the bits that need working on and the bits to let go. For instance, she says she's a serial late-arriver. For the lost 10 or 15 minutes lost to the clock, she apologises to whoever's waiting, but she's also done beating herself up over it more than she needs to.
"I'm not a highly regulated person," she says, adding that she was more rebel than high achiever at school and didn't particularly charm the nuns at her Catholic schools growing up in Zambia and later at boarding school in England. But she is someone who'll stay the course.
There is also no national blueprint for community psychiatry and no funding. There's also massive corruption. District and regional facilities are overwhelmed. Sometimes they don't even have the physical space to accommodate psychiatric care and doctors and nurses are not equipped to recognise mental health disorders. It is a disaster
Not looking away
Her journey to becoming a doctor started with her BSc degree in nursing. "When I realised how hard I was working anyway, I decided to study medicine."
She qualified in 1990 and started her internship in the public health sector. It's her long career in public service and also her time in NGO-funded healthcare that honed her ability to face up to disaster.
The picture she paints is one where public healthcare can be about managing trade-offs and disappointments, looking for plan Bs, or at least not looking away.
"I remember at the height of the AIDS epidemic in South Africa, I was working in the Alexandra Clinic and later at the Pepfar-funded Witkoppen Clinic. I would see children at the clinics but then notice their parents who were HIV-positive who didn't have access to ARVs, were dependent on alcohol and were clearly in deep depression. I would phone up psychologists and psychiatrists asking them what to do," she says.
This would lead her to specialise in psychiatry in 2007. She was 43. By 2011, she joined the Sedibeng district health service, which serves the Vaal Triangle area.
Women do still have an unequal burden in society. I know that my own academic and career advancement was delayed because I wanted to raise my family
Today, still based in the Vaal, her role has shifted from clinical work to management. Her aim is to build new strengths beyond tick-box exercises because, she says, "On paper, the Gauteng Department of Health created about 350 posts in 2020 for mental health support but filling the posts and retaining staff is a whole different reality."
Robertson has focused on improving the essential medicines lists for psychiatric medicines (she is on the Essential Medicines List Committee) and shoring up community-based networks of churches, community groups, and assisted living homes as soft landings for people in need. She has also been working on changing bed allocation by making sure this is informed by the nuanced mental health needs of her district.
"It used to be that 70% of beds available for psychiatric patients were for men because women tended to not come forward for help. They didn't want to be hospitalised because they have children and homes to take care of. So we have worked on community-based support to accommodate women close to their homes because currently, 54% of our patients are female.
"Women do still have an unequal burden in society. I know that my own academic and career advancement was delayed because I wanted to raise my family," Robertson says.
Destigmatising mental healthcare
She has also embarked on documenting cases to build a defence in strong data to support the push for reform in mental health support.
In her district, there are nine primary healthcare facilities that offer psychiatric treatment. Robertson says she insists on working more closely with nurses and doctors to first recognise their mental health burden and then equip them to identify mental health conditions that might present in their consulting rooms disguised as something else.
"Many of the nurses and junior doctors in this first line of assessment are doing an incredible job. And if we can get them trained to flag when someone may need further psychiatric assessment, then it's a big win," she says.
But her key message always is that there is no need to rescue someone with a mental health condition and over-prescribing is a trap - far from a cure-all.
"Sometimes people don't need an intervention. Sometimes the doctor listening, accepting them as they are, is therapeutic," she says.
Robertson is also deliberate about destigmatising mental health.
It's sharing her own experiences and also using her position that straddles academia and public health to speak out and criticise even, in the name of accountability and vigilance. Last year, she wrote on Spotlight about the Thembisa woman who believed she had given birth to ten babies. Amid the media circus that ensued, Robertson underscored that the woman became tabloid fodder when she should have been offered help.
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Sometimes people don't need an intervention. Sometimes the doctor listening, accepting them as they are, is therapeutic
About balance
Robertson says a broader range of interventions for preventative care can start as simply as talking to a friend, calling a helpline, taking a walk, or meditating. Or maybe it's turning the music up loud.
She is herself recognising more the role of self-care because she's prone to being a workaholic. Added to this, she is married to an orthopaedic surgeon - Professor Anthony Robertson who works at Charlotte Maxeke Academic Hospital. The hospital's ongoing operational failings, exacerbated by delayed recovery in the wake of the April 2021 fire at the key Johannesburg health facility, bring a particular layer of professional frustration to their lives and it does mean work has often followed them home.
"I remember once when our daughter was a teenager, she wrote us a 'Dear Parents' letter. In it, she told us that the house needed more furniture because we didn't have much more than a hi-fi system and an exercise bike. She also asked why we didn't have any family photos displayed. And it was because we hadn't got round to framing any photos," she says.
Nowadays she strives for more balance. She turns off her computer over weekends because she knows another work day - Monday - will arrive soon enough to start again. She tends to her indigenous gardens, focuses on learning the plants' Latin names, and plays Soduku and Quordle. The family photos are framed - even her phone profile photo is a family selfie, and she's added enough furniture to build a home to share with the grown children who can now joke about the "Dear Parents" letter.
*This article is part of Spotlight's 2022 Women in Health series that is running throughout August.
