Spotlight Interview with Dr. Laila Asmal

“By otherizing, you create this niche space to deal with the problem while still going about your business. There’s a term for it: it is a ghettoization of a field. It is not global mental health to me, it is just mental health. ” –Dr. Asmal

Location: Cape Town, South Africa

Bio: Dr. Laila Asmal is an Associate Professor and Consultant Psychiatrist at Stellenbosch University in Cape Town, South Africa. She also holds an MSc in Clinical Epidemiology and a PhD in Psychiatry. Laila directed clinical neuropsychiatry services at Tygerberg Hospital in Cape Town from 2010-2020 before taking on a fulltime academic position in psychosis research and neuropsychiatry training at the University. She has a special research interest in how a developing country environment shapes the epidemiology of risk, clinical features, treatment and outcome of schizophrenia.

Let’s begin with what is your definition of global mental health?

“I suppose I have a fundamental issue with the term global mental health. The way I see it framed, which may or may not be the intention of proponents of it, is that it ultimately “other-izes.” I think this is seen in intersectional research and theory that describes how society highlights certain difficulties that disenfranchised people have, without recognizing that the problem is reflective of the overarching system that is in place. By otherizing, you create this niche space to deal with the problem while still going about your business. There’s a term for it: it is a ghettoization of a field. It is not global mental health to me, it is just mental health. It perpetuates the status quo of a high-income country’s frame of health, when in reality low- and middle-income countries carry a much greater burden of mental health issues. Essentially, it doesn’t address the fact that this basic frame of mental health is problematic. I ask, why is this a specialization? You are looking at some of the most vulnerable people in the world, why do we need a separate field to address inequality and accessibility? When people start from a dominant frame of reference you are immediately having the disenfranchised needing to define themselves and their identity according to that frame of mental health.”

Where did you first start your work?

“I studied medicine in South Africa. We do a one-year, supervised internship and then one year of community service. My community service was at a historically Black African psychiatric hospital in a suburban “township”, a South African term for ghetto. I was the only full-time doctor for 700 patients. I wasn’t even a psychiatrist at that time. And that was my first exposure to any critical psychiatry.”

What does your day-to-day look like?

“I resigned from my Department of Health Clinical position in March 2020 to take on a University post. Like many of my colleagues in South Africa, I found working in full time public health clinical services as I previously did, extremely challenging. One of the difficulties of being an academic doctor in a disadvantaged country is that you have to wear different hats with limited support. The expectation is to provide high quality patient care, write research papers, submit grant applications, and teach while taking on management roles in a system that is generally under-resourced. I find my current university post incredibly rewarding. I consult with patients twice a week in teaching sessions, I research and write. I have time to think. It’s a great job.”

Can you discuss your experience as a researcher in a low-and middle- income country (LMIC)?

“There is such a contrast between patients that I see in my clinical services and how things are sort of sterilized for research purposes. There is a certain way in which the needs of psychiatric and mental health service users from LMICs are packaged for digestion in international journals and conferences. I feel that there are certain narratives that are more “acceptable” to hear and that the complexities of what we have to deal with in LMICs is a little bit harder for us to sell. The reality is, our status quo entering this millennium was 90% of the global population living in LMICs but only 5% of the mental health research in high-impact medical journals coming from LMICs. There’s a preferred way to position yourself as a researcher in a LMIC to get to that 5% and I totally experience this. It plays out subtly but definitively with every conference, journal and funding proposal submission. So many LMIC researchers that I know adjust their work focus to respond to this bias rather than the needs of the population or their academic curiosity. It isn’t an easy game for us to play but in a LMIC research environment where success is often limited, it’s one of the few ways to get ahead.”

Reflecting on where you are now, did you ever expect to be a doctor doing this kind of work?

“My father was a doctor and he deeply loved his job. He was a small-town GP who did house calls, delivered babies, and even extracted teeth! He was really inspiring and I guess I had a long apprenticeship without even realizing it. I’ve found the practice of medicine is almost like being in a relationship. There’ve been moments of uncertainty and doubt along the way and I’ve needed to commit to being a doctor many times over the years but it’s been very fulfilling.”

Can you talk about your specialty in neuropsychiatry?

“Neuropsychiatry is a field of medical conditions, predominantly neurological conditions that have psychological manifestations (e.g., brain tumors, epilepsy, etc.) Actually, the first time I met Dr. David Henderson was when I did a short fellowship at Massachusetts General Hospital in neuropsychiatry back in 2008. Neuropsychiatric conditions in a high-income country (HIC) are quite different from what you would see in a LMIC. For example, in a HIC you would see more classic conditions such as neurogenetic problems or Parkinson’s disease versus my average patient who would have layers of neurological injury from previous traumas. In South Africa, the typical person who experiences a head injury is quite different from, say for example, an American football player with a head injury; the patients that I see are more at risk for interpersonal violence, malnutrition, obstetric abnormalities, HIV, low school education, and other contextual issues.”  

How has the pandemic affected your life?

“I resigned from a permanent clinical job prior to the pandemic and took on a contract teaching and research post. The uncertainty of access to funding has definitely made it more anxiety provoking. Online teaching has also been trickier due to issues of accessibility and connectivity for students. There is a lot of quiet suffering that the pandemic has brought on, particularly for those with chronic mental illnesses and clinical services tend to be overwhelmed in-between COVID waves Overall, I have seen an increase amongst health professionals respecting their own and companions’ mental health and a general increase in awareness of the importance of mental health.”

Why do you think there is a stigma surrounding mental health and how do we address it? And specifically in LMICs?

“That’s a really difficult question to answer and many approaches have been tried in different communities with varying success. On a pretty basic level, I think doctors need to have mental health education and education about related stigma better integrated into their basic training. If we can decrease stigma surrounding mental health amongst health care professionals then we can better help patients and health professionals understand the different ways psychological distress is expressed. Ultimately, a lot of it comes down to the lack of understanding we have for each other. Prejudice and fear are linked; the fears we have as humans and lack of control of your being, that is terrifying to people. If we can find a relatable language to describe the experience of mental illness as mental health users and as treating practitioners, we can at least open the door to discussion within our communities. It asks a lot of the person experiencing the prejudice to rise up and destigmatize it. We need all health professionals, the dominant frame, to take a step back and really look at how we can do better to advocate for our patients.”

Could you talk about your partnership with Boston Medical Center?

“It is inspiring to work with Dr. Henderson. Despite him being so busy, he genuinely cares and puts effort into things that matter and not things that will give you a claim.”

What is your favorite part of your job?

“My favorite part is consulting with patients, but also having the time to teach, to speak with people, to have the mental space to write and be an academic.”

What is your least favorite part of your job?

“My least favorite part is the long process of applications for funding opportunities. “

What is one lesson in your life that you would like to share?

“Be less busy! Busyness, multitasking and seriousness is really overrated.”

Any advice to youth who are interested in pursuing a career in this field?

“You must be curious about yourself and how you connect with the world to be a good mental health practitioner. “

By Joanne Won, December 2021