Behind the Masks: Mental Health, Marginalisation and COVID-19

Rebecca Walker and Jo Vearey discuss how COVID-19 is impacting mental health and existing inequalities in South Africa

As the numbers of people vaccinated against Covid-19 in high-income countries increase and lockdown restrictions on movement, travel and social interaction relax, just how far South Africa and many other low and middle-income countries are being left-behind is increasingly realised. By definition, a pandemic is global, and an international, justice-driven public health response is needed. Yet awareness of the clear gaps in our response to the pandemic only increases distress and a sense of despair in a country that is already fragile and wounded. Questions about how people can deal with so much loss of life; of livelihoods; of routine; of safety; of social contact and, for many the last threads of security frame many national and local conversations.

In countries like South Africa – still caught in the third wave – concerns about the extent of the mental, emotional and psychological distress are heightened by the absence of a tangible ‘end date’ to the pandemic. While the vaccine rollout has recently been stepped up and, at the time of writing approximately 7% of the adult population have been vaccinated, this remains inadequate, particularly given the extent of vaccine hesitancy and failures to clearly address the challenges of those without documents to access the vaccine. Yet with the increasing recognition that life has fundamentally changed in many ways people still want – and need – to be able to talk about a time ‘after Covid-19’ and, behind the masks, the grief, anxiety, fear and frustrations that result from living through a pandemic continue to grow.

Image credit: Senzo Shabangu @senza_shabangu, used with the artist’s permission

Masking mental health

Uncertainty about the future fused with ongoing fears about Covid-19 means that critical conversations about mental health come into sharper focus. Determined by various social, economic, and physical contexts with risk factors heavily associated with broad social inequalities many people face increased levels of risk to mental health as well as access to appropriate support and treatment. In fact, as research from the UK has recently shown, the societal response to the pandemic in the form of lockdown and social distancing ‘will both increase inequalities in exposure to the virus and inequalities in the social determinants of health’.

Support for mental health can be accessed through multiple forms of help-seeking, including both the public biomedical healthcare system and private healthcare. In South Africa – as elsewhere – many people also draw on other help-seeking strategies such as churches and faith-based communities, non-governmental organisations (NGOs), traditional medicine and other forms of support. Often framed as ‘alternatives’ to the biomedical system, these forms of help-seeking coexist and are commonly combined with more formalised strategies for seeking support. Thus, whether it is through a government healthcare facility or through a community church, these strategies are all a part of efforts to maintain wellbeing and mitigate the challenges and stresses of daily life – including poor mental health. The loss of or restricted access to help-seeking that results from the pandemic including lock-downs and physical distancing measures, combined with heightened risks to mental ill-health since the onset of Covid-19, creates an issue of significant concern.

This is particularly the case for many cross-border migrants in South Africa – including asylum-seekers, refugees and undocumented migrants. As a part of a broader study exploring forced displacement and mental health across sub-saharan Africa, our recent research with professionals working in the healthcare sector (both public and private) and non-governmental organisations (NGOs) supporting migrants in South Africa brought to light the specific impacts of the pandemic on persistently marginalised populations.[1] This includes undocumented non-citizens, many of whom face multiple structural challenges when attempting to access help, and healthcare more generally. Although pre-dating the emergence of Covid-19, as with so many endemic and entrenched forms of injustice, these challenges have been amplified by the pandemic. Therefore, those rendered marginalised by the increasing inequality and resultant inequities established in the country are – during the time of Covid-19 – once again the most affected.

While not all cross-border migrants are undocumented and not all undocumented cross-border migrants have mental health challenges, there are also many who are and do – not least due to the impact of discrimination and violence faced on a daily basis in South Africa. From attempts to renew documents and apply for asylum, to prevalent xenophobic attitudes from both political leaders and wider society, the energy required to deal with never-ending daily stressors is being drained more than ever before. As such, non-citizens reliant on the public sector and other help-seeking strategies – as is the case for the majority of South African citizens – face heightened challenges in the struggle to access appropriate health care – including for mental health.

Mental health in Crisis

The prevalence and burden of mental illness in South Africa are relatively high compared to other similar countries: one in six South Africans is reported to suffer from anxiety, depression, or a substance use disorder, while nearly half of all citizens (47.5%) are reportedly at risk of developing a psychiatric disorder in their lifetime. This and other data presents just a glimpse of what is likely to be a far bigger and rapidly escalating mental health crisis in South Africa – impacted further by the COVID-19 pandemic.

South Africa has taken some significant steps as a response to the global commitment to recognise mental health among the highest priorities for investment as a health, humanitarian and development priority. This includes the adoption of the National Health Insurance (NHI) Policy (2017) to promote equity in health service delivery towards Universal Health Care (UHC). However, the realities on the ground expose a very different picture. The South African Human Research Council describe this picture as a state of ‘…chronic and systemic neglect, coupled with mismanagement and a dire lack of resources’. This is further impacted by the absence of any sustainable plans to implement inclusive and accessible mental healthcare especially for the most vulnerable – including citizens and migrants alike – in South Africa.

 Responding to crisis in context

In our research Key informants shared numerous stories of long waiting lists, people queueing for entire days only to be turned away as staff went off shift, and individuals – particularly those who are undocumented- being told that they have no right to healthcare despite South Africa’s laws stating otherwise. As a result, many in desperate need of help for mental health are without support and yet living within contexts in which these issues are not only exposed but exacerbated. And while many of the challenges faced by non-nationals in South Africa such as unemployment, poverty and limited access to quality healthcare affect both citizens and non-citizens, for those who may have already faced traumatic experiences in their home countries and en route to South Africa, the added layer of daily stressors and anxiety is likely to compound and amplify their struggle.

A social worker working for a local NGO in Johannesburg described how a client – a woman from the Democratic Republic of Congo (DRC) with three children – had lost her job during lockdown and now faces eviction from her accommodation because she cannot pay rent. Coping with the impact of multiple traumas experienced in the DRC, her journey to South Africa, and from the years spent trying to access documents, Covid-19 has not only cost her her job but also disrupted the fragile strategies she has built to carefully balance and navigate the ongoing stresses of everyday life. Although the social worker had referred the client to a psychiatrist at the local Government hospital over a year ago, she had not yet received an appointment. Her local support network through her local community and church had also dissolved due to the lockdown. For this client, unemployment left her more isolated and desperate than ever and facing increased mental health challenges alone.

For healthcare providers and others working with those at heightened risk and dealing with continuous trauma, the challenges are not only based on the lack of services and resources in formal and informal spaces but also the fact that – for clients – the inability to meet basic needs is at the very centre of their mental health experiences – and needs to be at the centre of any response too. In fact, as many key informants suggested, the sheer effort to survive, the exhaustion and desperation of trying to address basic needs requires a response based on context and learning to contain the crisis that can spill over from not being able to pay rent, feed children, buy medicine or stay at home during the Covid-19 lockdown. A Clinical Psychologist working with migrant communities in inner-city Johannesburg captured this need:

‘You cannot separate the symptoms from the external environment…people are hungry, they need nutritious food, they need to know they can pay the rent – that is responding to mental health in context not just responding to symptoms’

As such, those who are trying to support individuals with mental health challenges, and who often describe themselves as ‘filling the gap’ created by the state are developing approaches based on coping in the moment. As the Clinical Psychologist explained:

‘sometimes things are so bad that we say “let’s manage the stressor today”’.

She further explained this in terms of a cycle of stress for clients; stress would rise and fall from the beginning of the month to the end, following the pressures of when rent and other expenses were due. In the middle of each month there was a ‘small window’ after rent had been paid (‘through some means, somehow’) and just before it was due again when ‘stories would emerge’. Yet, she cautioned that these stories also had to be ‘handled with care’; soon clients would again be in states of extreme stress and anxiety ‘leaving them unable to go beyond these immediate stresses’. Therefore the need to balance what can be addressed now and what can wait is based on an assessment of context and whether an approach to ‘manage the stressor today’ was enough.

Managing the stressor today

Key informants recognised that deeply embedded structural and systematic weaknesses of the public mental health system could not be ‘fixed’ any time soon and that many of those working both within and external to the system are doing their very best – often with detriment to their own mental health. They also acknowledged that assisting with basic needs in terms of financial support was not sustainable and beyond the resources of already-stretched organisations

Unable to fix the system, those supporting migrants work on fixing a response instead, a response focused on immediate context and crisis and, with the hope for longer-term impacts. Therefore, ‘let’s manage the stressor today’ could be looking at how to cover rent, the next step in accessing documentation or putting food on the table for individuals and their families or how to navigate lockdown and still earn a living. Working with and responding to the cycles of stress means being able to locate those spaces and moments where talking is possible and those where it is not. With widespread recognition that a more sustainable approach is yet to come, there is a clear argument for responding to context and crisis through basic needs as the first step in an alternative approach.

Masking the future

Behind the masks there are many people, including cross border migrants, who are dealing with layers of loss and trauma, compounded by Covid-19 and with very few options in terms of support. Whilst the call to improve our understanding of and response to poor mental health in South Africa is not new, the pandemic has exposed just how much work needs to be done – including to better understand the various ways in which the determinants of poor mental health manifest, including the relationship between migration and health. The framing of Covid-19 as an ‘amplifier’ of existing social and economic disparities, and as a ‘spotlight’ on key issues of justice and equality, may now feel like a hollow clarion call for action. Yet the fact remains: as the levels of desperation and precarity deepen the pandemic exposes the urgency with which we need to reassess how we understand and respond to mental health, marginalisation and the deep inequalities in the country.

Dr Rebecca Walker is a Research Associate at the African Centre for Migration & Society (ACMS), University of the Witwatersrand and a research consultant. Rebecca works broadly on gender, migration and health with a specific focus on the experiences of asylum-seeking and refugee women in South Africa. Her recent work has looked at access to healthcare and migration and mental health in the context of displacement and forced migration.

Prof Jo Vearey is an Associate Professor and the Director of the African Centre for Migration & Society (ACMS). With a commitment to social justice, Jo’s research explores ways to generate and communicate knowledge to improve responses to migration, health and wellbeing in the southern African region. 


[1] The support of the Economic and Social Research Council (ESRC) (UK) is gratefully acknowledged.

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