Neuropsychology students at the University of Cape Town (UCT) face an ongoing dilemma. To qualify as neuropsychologists they need to work full-time in the public health sector for one year – completely unpaid.

For many this has meant choosing between working additional jobs and enduring undue stress, or abandoning their aspirations to qualify.

“[The neuropsychology interns] often sign up for multiple jobs to support themselves, which is a bit of a vicious cycle because you need to get paid to support yourself to do the internship, but now that you have less time, you’re unable to do the internship as effectively as you would have,” said Altay Turan, a master’s student in neuropsychology at UCT.

The Health Professions Council of South Africa (HPCSA) requires prospective clinical psychologists and neuropsychologists to complete a one-year internship at a public health facility, according to Professor Mark Solms, director of neuropsychology at UCT.

“In the Western Cape we have three universities that train clinical psychologists – [the University of the Western Cape], Stellenbosch and [UCT] – and all of their graduates get government-funded placements in the health service, but none of the neuropsychology students do,” he explained.

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UCT is the only university in South Africa that has an active master’s degree programme in neuropsychology. Graduates complete their internships at Groote Schuur and Red Cross Children’s hospitals.

On average, the UCT master’s class for neuropsychology is made up of six people, according to Turan.

Understanding neuropsychology

The neuropsychology programme at UCT was accredited by the HPCSA in 2012, according to Solms. Owing to administrative delays from the council, graduates were only registered in the professional category of neuropsychology from late 2019 onwards.

While the profession remains underrepresented in South Africa’s public health sector, Solms told Maverick Citizen it plays a fundamental role in the diagnosis and management of neurological patients in neurology and neurosurgery divisions.

“Neuropsychologists… perform a range of functions. The first and one of the most important ones is the diagnosis of brain disease,” said Solms. “Because the brain is the organ of the mind, many neurological diseases actually initially present only by way of mental changes.”

Examples of such neurological diseases are the different types of dementia. A major task of a neuropsychologist is to distinguish between the effects of normal ageing, and those of a neurodegenerative illness, he continued.

“We also have to distinguish those dementing illnesses from psychiatric disease. So, for example… a lot of elderly people get depressed. And we need to be able to distinguish what is a psychiatric change [from] what is a neurological change because… it has very different treatment implications.”

Other functions neuropsychologists can perform include:

• Determining whether a patient with a neurological disease needs to be medically boarded;
• Treating the cognitive and emotional fallout from neurological disease; and
• Assisting with medico-legal claims. An example of this would be assessing the neurological impact of a head injury in a car accident, so as to quantify the compensation needed through an insurance claim.

There are no posts for qualified neuropsychologists in the public health sector. As such, the only neuropsychology services available to patients in  public health are those provided by unpaid interns at Groote Schuur and Red Cross hospitals.

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“We see many cases ourselves, the [UCT] faculty, we see the more complex cases, but we’re also supervising the work that the interns do – all of that is also not paid. It’s very high-level services delivered to the public hospitals, but they do not pay one cent for them,” said Solms.

Mahmood Akhalwaya, another master’s neuropsychology student, said the situation allows the Health Department to use the neuropsychology interns where needed, without paying them.

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“What it basically boils down to is we have no other option, nowhere else to go to complete this degree. We know we’re between a rock and a hard place,” he said.

Barriers to entry

The current system of unpaid internships favours those from privileged backgrounds who are able to secure support from family or through loans, according to Solms. For students from historically disadvantaged backgrounds, it is a barrier to entering the field.

“There’s… the financial barriers, because I’m from a small town in the Eastern Cape,” said Nwabisa Mlandu, a neuropsychology intern. “I came to Cape Town, to UCT… I’ve always had funding from the university itself. This year it was quite a challenge, thinking about how am I going to survive? How am I going to pay rent? Sustaining myself, food, all of the essentials, were just hanging in the air.”

Mlandu is working a part-time job in addition to the full-time internship, while taking on odd jobs here and there to fill the gaps. She is also completing her master’s thesis for the end of the year.

Nwabisa Mlandu (25) is completing her required one-year internship to qualify as a clinical neuropsychologist. Aside from the full-time unpaid internship, she is also juggling part-time jobs and the work required to finish her master’s thesis. (Photo: Supplied / Nwabisa Mlandu)

“I wouldn’t want anyone else, especially another black woman, having to go through all of this, get multiple jobs, because you’re not having the best experience of your internship,” she said.

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A letter co-signed by the dean of humanities and the dean of health sciences at UCT was sent to then acting health minister Mmamoloko Kubayi in 2021, requesting that the situation facing neuropsychology interns be addressed. However, no response beyond an acknowledgement of receipt has yet been received, according to Solms.

“It’s [the Western Cape health department’s] responsibility to deliver the public healthcare in the province,” he said. “If they feel that their national budget allocation doesn’t allow for it, then it’s their job to approach national [government] to receive the extra funding that’s required in order to support the internships.”

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Maverick Citizen reached out to the Western Cape health department about the lack of paid internships for neuropsychology interns and any plans to fund the programme.

“Internships are an HPCSA statutory requirement and as UCT offers this course, for which there is mandatory training… they are encouraged to engage both National and Provincial Departments of Health,” responded department spokesperson Maret Lesch.

“Funding should ultimately be provided by the National Department of Health through the Statutory Human Resource Grant, and placements should also be done via the National Internship and Community Service Programme, as with other medical interns.” DM/MC