ITSHOKENG KEKANA | What happens to mental health in the absence of diagnosis?

In many areas in South Africa mental health does not fail quietly; it fails structurally.

Estimates from the World Health Organisation and South African health system studies suggest that between 75% and 90% of people with mental health conditions have never received treatment, with some public sector analyses showing even higher gaps.

This means that for most people living with mental illness, there is no clinical entry point into diagnosis. And what already exists instead is absence, and in that absence, interpretation becomes the default system of meaning.

When nearly nine in 10 cases go untreated, illness does not remain in medical categories. It is translated into everyday language that can function without clinical confirmation.

Symptoms are reduced into familiar explanations: stress, sugar or nerves, and this is not because they are accurate but because they are usable. In systems where diagnosis is statistically unlikely, explanation shifts from medicine to social survival.

This shift has consequences beyond language. Mental health in South Africa affects about one in three people over a lifetime yet receives only about 4% to 5% of the public health budget.

That imbalance creates a predictable outcome: demand vastly exceeds diagnostic capacity. When systems are structurally underresourced at that scale, conditions that require sustained clinical attention are routinely left unconfirmed.

In that gap, interpretation becomes classification. Behavioural and cognitive conditions are not simply untreated; they are renamed.

A child with an undiagnosed learning or attention disorder is not positioned in a clinical framework but in a behavioural judgment. The absence of diagnosis produces a replacement system of meaning, where difficulty is interpreted as defiance and difference is turned into character.

The impact of this is amplified by uneven access to care. Mental health services and specialists remain heavily concentrated in urban and private systems, while rural and public sectors face severe shortages.

Diagnosis is not just delayed; it is geographically restricted. Where access is structurally limited, interpretation becomes the only available system of explanation.

In more severe cases, this interpretive gap extends beyond behaviour into belief. Where medical explanation is absent, communities may draw on spiritual or cultural frameworks to make sense of symptoms.

This is not a random misunderstanding; it is a predictable response to diagnostic scarcity. When formal systems are inaccessible, alternative systems fill the vacuum, including explanations that can carry stigma or harm, particularly for elderly individuals showing signs of cognitive decline.

These statistics reveal not simply underresourcing but system substitution. When up to 90% of cases remain untreated and diagnosis is unevenly distributed across geography and class, interpretation is not a cultural layer added onto medicine; it becomes a parallel system operating in medicine’s absence.

Communities do not reject diagnoses; they are forced to operate without them, and the consequence is that illness becomes socially stabilised before it becomes medically identified. Once a condition is repeatedly interpreted in non-clinical terms, those meanings harden. The longer diagnosis is delayed, the more established these interpretations become, making later clinical correction more difficult and sometimes socially resisted.

This is why the issue is not only access to healthcare but also access to diagnostic authority. Without it, illness does not remain biologically neutral; it becomes socially authored, and in a context where most conditions remain outside formal treatment systems, those authorship systems are not marginal; they are dominant.

Ultimately, what the data shows is that interpretation is not an informal cultural response to illness. It is what emerges when diagnostic systems fail at scale. Where treatment gaps approach or exceed 90%, interpretation is not supplementary; it is structural. It determines how illness is seen long before medicine arrives.

To understand health in South Africa is, therefore, not only to examine clinical systems but also to examine what replaces them when they are absent because where diagnosis is statistically unavailable, interpretation becomes inevitable, and that inevitability shapes how people are understood, treated and ultimately lived.

The issue is not only the absence of healthcare but also the absence of diagnostic authority. For those without medical aid or reliable access to public healthcare, illness is not first encountered in clinics or through formal assessment; it is encountered in daily life, interpreted through the limits of what is available at that time. And in a system where treatment gaps for mental health conditions can reach or exceed 90%, interpretation is not an exception to medicine; it is what replaces it.

A system that allocates only around 4% to 5% of its health budget to mental health, with most of that funding directed toward inpatient psychiatric hospitals rather than expanded to community-based services, inevitably produces a reactive rather than preventative model of care.

This means the system is designed to respond at the point of crisis, not at the point of early warning. Community clinics, schools and primary healthcare settings where early identification and intervention would normally occur remain underresourced and unevenly supported.

The result is that many conditions are only recognised once they have significantly worsened, often requiring hospitalisation rather than manageable outpatient care. For those without medical aid, this gap is even more pronounced; diagnosis is delayed, and treatment is fragmented and, in many cases, absent altogether.

This has consequences that extend far beyond treatment outcomes. When diagnosis is inaccessible, meaning becomes unevenly distributed, and those with access to private care or consistent public health support are more likely to have their conditions named, documented and treated within clinical frameworks.

Those without are more likely to have their conditions defined through observation, cultural language or inherited belief systems. The result is not just a gap in treatment but a gap in recognition.

Over time, this shapes how individuals are understood long before they enter a medical space. A child struggling with attention may already be labelled in ways that define their identity before any clinical explanation is possible; an elderly person showing signs of cognitive decline may already be placed in a moral or spiritual narrative before dementia is considered as a diagnosis.

In this sense, inequality does not only determine who gets treated; it determines who gets understood correctly in the first place.

What makes this particularly significant is that interpretation, once stabilised, does not disappear when a diagnosis arrives. It resists correction. It has already become part of how families, schools and communities make sense of behaviour and illness. This means that delayed diagnosis is not neutral. It is formative, therefore allowing alternative explanations to harden into social truth.

The challenge is not simply to expand healthcare access but to recognise that access to diagnosis is itself a form of power, one that determines who gets to define illness and who must live within definitions created without medicine. In contexts where public systems are overstretched, this power is unevenly distributed.

Addressing health inequality in South Africa is therefore not only expanding services. It is to confront the fact that for many, illness is already being interpreted long before it is diagnosed, and those interpretations carry weight that no later clinical correction can undo.

• Kekana is an independent writer focusing on social commentary and spatial inequality in South Africa