A dangerous world view on public waste

Anger at decisions that cost the lives of scores of mentally ill people is essential. But it should be aimed not only at the politicians and officials who were the immediate cause, but also at the view of the world that made it possible — and is shared by at least some of those who are outraged.

Most reaction has painted the deaths of at least 94 people after being removed from the Life Esidimeni care centre as the work of uncaring and incompetent public officials. But, while officials must clearly take the blame, this is only part of the story. The other part is how it could have been possible for Gauteng’s health department to move mentally ill patients from a place in which they were reasonably safe to sites where they died of neglect.

The deaths were not a consequence of an error no one foresaw. When Gauteng decided to move the patients, health professionals and activists warned they were at risk. And yet there was no public pressure in defence of the patients and not even our courts were willing to come to their rescue when doctors and campaigners tried to use the law to protect them.

When Gauteng admitted in September 2016 that 36 people had died after being moved, the reaction was largely restricted to professional and activist groups. So, the authorities were not ignorant — they took a policy decision with risks they knew. And they got away with it for so long because what they decided was a product of a way of thinking that has become popular in the mainstream. It portrays government programmes in defence of the weak as meddlesome interference and a waste of money and insists the job should be left to the market and NGOs. One of its political pioneers, former US president Ronald Reagan, is also notorious among health professionals for policies that left mentally ill people to fend for themselves.

Reagan, when governor of California, scrapped a law allowing authorities to hospitalise mentally ill people without their agreement. He also released more than half of the state’s mental health patients from public care. The technical name for this policy was “deinstitutionalisation” — removing the mentally ill from public institutions.

When he became president in 1980, he rejected a law that would have continued using government money to fund mental health centres, which meant people living with mental illness received no services from the government.

These changes were justified by an ideology that portrayed neglect as a blow for freedom — it was allowing people diagnosed as mentally ill to choose for themselves. As a happy by-product, taxes would not be “wasted” looking after people who did not need help. This ignored the obvious reality: mentally ill people may have no sense of reality and may not even know that they are ill. To withhold public support unless they realise they are ill is like refusing to treat cancer patients unless they can diagnose themselves.

The real reason for the policy was revealed by the decision not to fund mental institutions: the world view that insists people are better cared for by charities and private companies than by the governments they elect.

Gauteng may not have realised it was continuing Reagan’s legacy, but that is exactly what it was doing. It gave two reasons for moving people from Life Esidimeni: cost-cutting and the need to “deinstitutionalise” patients. The only difference between its approach and Reagan’s is that he sent patients away. Gauteng sent them to NGOs. But the effect was much the same. The patients did not die because NGOs harmed them but because they neglected them: even though they were not turned out onto the streets, they were left to fend for themselves.

And so, while Gauteng no doubt believed it was following the latest trends in public management, it was faithfully implementing a view of the world that sees public institutions as a waste and private care as the solution to all ills. To officials and others, this view allowed what it was doing to appear not callous but modern.

The horror visited on the people extruded from Life Esidimeni shows the dangers of this view. It is neither sound public management nor a recipe for freedom — it is a particularly callous form of refusing to care for people in need. The politicians and officials who made this happen should be held to account. But so should the thinking behind it.

A society that cares for people spends public money to look after those who cannot fend for themselves. Leaving them to the streets, the markets or NGOs is not modern — it is a return to the Dark Ages. And, if we change politicians and officials but act on the same way of thinking, we may invite new horrors.

THE PATIENTS DID NOT DIE BECAUSE NGOS HARMED THEM BUT BECAUSE THEY NEGLECTED THEM: THEY WERE LEFT TO FEND FOR THEMSELVES