Global Elective: Reflections from Dr. Katie Crist
“Perhaps, she’s just been strong for too long” sighed the UKZN chief resident, breaking the silence between us and the patient we were attempting to interview. My typical series of questions had fallen flat as the patient stared somewhere off to our left, until I wasn’t sure I had spoken at all. To be useful, I started to catalogue a differential: catatonia, unspecified psychosis, depression, delirium, dementia, HIV, tuberculosis, really anything was possible given the circumstances. But the interruption halted my list generating.
Met with my confusion, she elaborated. Black women have endured in South Africa. Shown resilience in spite of the ongoing racism instilled by the apartheid government and some of the highest rates of gender based violence in the world. Perhaps the patient’s presentation was a result of the accumulation of many years of traumatic experiences.
While in South Africa, I had the opportunity to meet with community based programs that furthered these points. A theme I commonly heard was that South Africa had developed good laws with often poor implementation. Survivors of gender based violence were not getting the resources they needed despite the laws that guaranteed them. The community based programs attempted to fill the gaps. Women who lead these organizations worked at all hours, were rarely paid as the government failed to fund what it promised, and often faced potential danger alongside the survivors they hoped to aid. But they keep working, keep fighting, and keep trying.
Understanding context proved to be one of the most important determining factors of diagnostic clarity and treatment planning while practicing psychiatry in Durban, South Africa. I learned that there just over 600 psychiatrists in the country, making expert mental healthcare relatively scarce. However, there were even fewer neurologists or other specialists, so psychiatrists often practiced neurology, renal medicine, and whatever else was needed to take care of their patients. This was particularly apparent when we were consulted for possible mania in a young woman who had been seeing a traditional healer for mood lability, impulsivity, and grandiosity. The UKZN, chief, psychiatry resident proceeded to conduct a neuro exam significant for papilledema and blindness in the right eye and ultimately the patient was found to have had a cerebrovascular accident of the anterior cerebral artery. Treatment options were often also limited, especially in the public hospitals that accepted patients without insurance. I understood this with startling clarity when we were consulted for a mother of two who was depressed in the setting of not being offered dialysis. Her lupus induced renal failure was considered long term and dialysis was only offered as a short term treatment option.
The reality was harsh, often unrelentingly so. Yet, I did not find the psychiatry residents I worked with discouraged from their practice. They discussed the multiple complexities of their patients’ presentations with undeterred curiosity. They shared their abundance of medical knowledge and understanding of cultural context with me. I learned about the importance of what is not in the textbooks, what is within the people and the place that determines so much of medical care, especially within psychiatry. Considering what was held within the silences, the experiences, and the perseverance shaped my understanding of medical care in South Africa and beyond.
Written by Dr. Katie Crist