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Delivering Hope In South Africa

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Most changemakers can't exactly remember when it is they decided to commit themselves to attempting to better the world. They generally give vague answers to the question: the influence of a parent, or a general feeling of discontent about a particular issue.

Simone Honikman, however, remembers the moment vividly. A doctor in Cape Town, South Africa, Simone's first daughter had just turned one year old when she attended a weekend-long conference on maternal mental health. The year was 2002. The apartheid regime had ended only eight years back. Democratic South Africa was just starting to stand on its own two feet.

Listening to the presentations given by medical professionals from around the world, Honikman remembers being shocked to learn that the prevalence of postnatal depression in Khayelitsha, an informal (and impoverished) settlement on the outskirts of Cape Town, was a staggering 35 percent: one in three mothers, a rate nearly three times higher than the prevalence of post-partum depression in developed countries.

Growing up white and Jewish in South Africa, Honikman had always been acutely aware of issues of race, ethnicity and injustice. She had grown up haunted by the stories about the Holocaust she had read in young adult books. She had watched as her parents boycotted whites-only cinemas and illegally sheltered the kids of one domestic worker so that they would not be separated from their mother by pass laws. She connected the dots between the two issues.

But as an adult, she was not aware of the extent of the pandemic going on in her own backyard. Little was made of maternal mental health issues in medical training and in the public health arena. The HIV epidemic was the problem everyone was talking about. Even today, the severity and importance of maternal health issues such as post-natal depression have barely pierced public consciousness.

If the mental health conference set the stage for Simone's awakening, it was another event that same weekend that spurred her to action. In a grim twist of fate, on the Sunday of the conference, Simone received news that one of her ex-colleagues had shot herself dead. Lauren, the mother of an eight-month old baby, was, in Simone's words, "a beautiful, highly competent, and successful general practitioner." No one had seen it coming.

Honikman was devastated. "I was so struck," she recalls, "by the paradoxes of pain and motherhood - of deprivation and affluence. I felt compelled to do something - for the memory of Lauren and for the women in Khayelitsha and beyond. Not doing anything would have been intolerable."

And so Honikman set out to create the Postnatal Mental Health Project (PMHP), receiving the early support of the midwives and administrators of the hospital in which she worked. As of late 2007, the service had screened over 4,400 women, mostly from low-income communities, and provided counseling or psychological services for over 800 of them.

I first came across PMHP's work when I curated a Motherhood themed exhibit at the International Museum of Women. Through PMHP's office we received story after inspiring story about women benefiting from PMHP services, too many to publish them all.

There was Gloria from Cape Town, who had suffered her first severe depression when pregnant at fourteen, confused and worried about how she would support herself, not wanting to be a mother at such a young age. She suffered depression through two later pregnancies until she finally found PMHP. The counseling she received helped her stabilize the situation, turn towards a positive attitude about motherhood, and provide better care for her children.

There was Babalwe- verbally and physically abused by family members, shifted from home to home. Rootless, pregnant as a teenager, and suicidal, Babalwe's depression also made it difficult for her to work as a domestic to support herself--until she was able to get free counseling from PMHP.

All of these stories had common themes--about the intimate connections between poverty and powerlessness, the same connection that keeps maternal health issues relatively invisible on the public agenda. If the poor have no voice to advocate for their needs, it certainly does not help that over 2/3rds of those living in absolute poverty are women and girls.

While the stories of mothers receiving treatment were quite moving, I had a strong intuition that there was an equally important story that lay behind the founding of PMHP itself. And so Simone and I began an email correspondence. As I learned about Simone's path, I discovered it was full of familiar ironies and challenges.

For example, I was surprised, and simultaneously not so surprised, to learn that the funding situation for Simone's kind of work was rather bleak. "I've gotten so many pats on the back, I have callouses!" Simone told me. But accolades don't necessarily translate into financial support.

It wasn't that people didn't get it. The stories of women like Gloria were compelling, and Simone's clinic was acknowledged as being highly successful. It was that the issue wasn't considered a high enough priority. In post-apartheid, HIV ravished South Africa, the focus for public health funds was short-term: stop the AIDS crisis.

Such a focus seems sensible enough at the outset. But when one pauses to think about it, it becomes immediately clear that one can't tackle the HIV crisis without also taking a more holistic approach to tackling poverty in general. Mental health issues are endemic in poor populations. The effects of severe depression in new mothers bleed down through generations of broken families and alienated children, reinforcing lack of access to economic opportunity.

On the other hand, the weeks and months just before and after birth are an ideal time for intervention. New mothers are more willing to access medical and psychological care; and the support provided can provide the foundation for healthy families for decades to come. "We regularly hear stories of dead babies ending up in trash cans," Simone commented, "so we know what can happen when mothers don't get effective treatment."

Simone had also encouraged me to focus more on the stories of women benefiting from PMHP, rather than focusing on her personal story, when writing this article. I thought about her request for quite some time. She was humbly voicing the objection that many changemakers make, that focusing on an individual obscures the fact that change is always a group effort. In the case of PMHP, there is no doubt that it is not only Simone--but also the work of the extremely skilled team of nurses, midwives and counsellors--who have made the clinic a success. There was also remarkable support from the leadership of the hospital in which the clinic is situated.

And yet, it was Simone's story which had inspired me in the first place. It is always much easier to work on an a problem that is already generally recognized as a high priority issue. It is easy, likewise, to rationalize away doing something about the suffering of others if it requires . But Simone put her foot down. She decided she could not stand idly by when one in three mothers were suffering from a condition that could destroy their own lives and their children's. She decided she had to do something, even if might have been more convenient to do work in a more well-funded area of public health.

To that end, Honikman and the PMHP team continue on their path. There are signs the clinic may well have turned a corner. After losing public funding, they managed to secure housing for the organization in the University of Cape Town. She was recently invited to the World Health Organization in Geneva to share the expertise collected by years of work with PMHP.

One gets the sense with Honikman and her team that they will figure out how to make things work, regardless of where the project lands institutionally, and regardless of what business model the organization takes on. For better or worse, they've chosen an issue that requires more extensive education of funders and supporters than usual. Commitment and perseverance are at least half the battle.

Indeed, that unfailing commitment and perseverance on their behalf have already helped to save lives.

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Take Action:

To donate or learn more about the Postnatal Mental Health project, click here.

Lessons for Changemakers:
It's almost always harder to get funding and attention for addressing long-term issues, rather than shorter-term crises; the same goes for taking a holistic approach to social problems rather than addressing them each individually. But stick to your guns. Know that it's not about the worth of your work, but just that our understanding of social change hasn't caught up with what's really needed. You'll need to employ extra creativity, but by persisting with your approach, you're not only helping your direct beneficiaries, you're setting the foundation for improved strategies for social change in general.

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