Special Hearings — Health Sector Hearings — 1997-06-18

UNKNOWN: We have of course made a written submission and received some questions yesterday.  We'll leave that for you to ask which questions you want us to address, so I will take out some of the highlights - issues from our submission.
 The first point that I'd like to make is that this is a process initiated by yourselves in response to your request in the Faculty and has now received faculty support and is a form of Faculty submission rather than an individual submission, and the process itself has been a useful one in uncovering a lot of issues in the Faculty and we'll return to that at the end. 
 The submission relates to what I think is one of the TRC's mandates, namely to understand the societal conditions that could have allowed violations to take place, violations in which health professionals participated and to make recommendations that will relate to faculties of health sciences, medical schools for the future.
 The submission from Wits is an attempt to record a very summarised and incomplete history of apartheid in medical education, and I again need to emphasise that this is not comprehensive in the time available and we recognise the many omissions and would be happy to supplement this preliminary  submission.  
 It's a record of apartheid in medical education as well as the Faculty's response to that in the belief that this was part of the context which contributed to the values to which our graduates ultimately subscribed.
 We look specifically at the failure of the Faculty to address human rights and ethics as a substantive and formal component of the curriculum prior to approximately 1983 and '84 at which point it was introduced formally, and we make recommendations regarding the incorporation of human rights culture and ethics as a subject in the teaching of health science students for the future.  
 We also highlight the need for academic institutions to guard their autonomy and independence from political authorities so that they can maintain a critical stance with respect to government policy.
 In our submission, as well as in some of the others we've heard yesterday and today a key theme is the tension between what is the responsibility of an institution or an organisation in civil society, and what is the responsibility of government and legislation constraints set externally.  And a lot of what we are talking about in our submission is that tension.  
 The discussions in the Faculty, triggered by this submission as I said, have revealed that there is still an enormous amount of anger and bitterness within the Faculty and in the end we will return to how we think this should be addressed.
 The first set of issues is the relationship between university and government, and what I am going to do is select just a few examples that illustrate this relationship to help understand what the possibilities are for a Faculty and what the constraints are.  
 In most faculties of medicine, and certainly in ours, more than half of our staff are employed by the province, the provincial health authority, not by the university.  They are appointed as joint staff but all of the clinical staff in fact receive their salaries from the Province, their conditions of employment are determined by the Province and discipline is managed by the Province. And so the University has unfortunately limited control and authority over some of these issues.
 One example that illustrates this is the selection of people and particularly the selection of chairs, and we give an example of a professor, a man of colour who Wits, at the selection committee wished to appoint as the head of a clinical department in 1987 and the representative on the selection committee from the Province vetoed this.  The Faculty responded by refusing to make any other appointment, although there was an eligible candidate until in fact the candidate concerned withdrew his application 18 months later, at which point the chair was filled by another candidate. 
 In other words, even the appointment of professors in the Faculty are constrained, both sides of course have a veto, the university has a veto as well, over that process.  Promotion of staff within the Faculty was frequently subverted by irrelevant considerations like race and political affiliations and anti-apartheid activism, and the case of Dr Joe Veriavo(?) who has helped us prepare this submission but unfortunately is overseas at this moment could not be here, is a case in point.
 Staff who were active in expressing opposition to the provincial policies were often victimised in other ways besides promotions. One example is of a Faculty member whose sabbatical was terminated at short notice, forcing him to resign because he couldn't get back in time to take up the job, to continue working in the hospital.
 Another example arises out of the protest letters written by doctors at Baragwanath protesting at the conditions of health care at Baragwanath.  The letter was published in the Medical Journal and the Director of Hospital Services called in all of the 101 doctors and asked them to submit a letter of apology to the Medical Journal withdrawing what they had said or else their jobs would be terminated and those who were on short term contracts like interns and registrars who relied on reappointments on an annual basis would not be reappointed.  
 The submission details some of that case which resulted in many of the doctors writing a letter of apology because otherwise they would have lost their jobs.  Others took the province to court and one in fact, was reinstated by the courts as a result of this.  But in the mean time had lost something like a year and a half of clinical time,  experience and employment.
 Some members of the Faculty would have liked the university to take a much stronger line of opposition to this sort of action by the provincial administration. 
Perhaps the Faculty should have refused to fill the posts where it's chosen candidate was blocked. Perhaps senior staff should have resigned in protest against provincial harassment of staff.  To have done so might well have resulted in a post being vacant for a long period of time, as in the case I mentioned, with possible harm to patients and students whose teaching would have been compromised, but perhaps on the other hand it would have precipitated an earlier change in policy and this is obviously one of the issues we have to think about in thinking about the future.
 The issue has come up several times in these hearings of discriminatory employment practices, salaries, benefits etc and again I think it worth highlighting that this is the sole discretion of the province.  In 1969 for example, Black interns were earning roughly half of what White interns earned and African women earned less than African men within the spectrum of doctors.  Black staff did not get travel allowances or thirteenth cheques, they received 25% less leave. These policies obviously created tensions in the Faculty and certainly black staff believed that the university did not bring appropriate pressure to  bear on the authorities to change these discriminatory practises.
 One example which has come to light since making the written submission is of a group of students who attempted to get White staff to sacrifice some of their salaries into a pool which would be used to equalise salaries across staff and this was not supported by White staff at the time. So although the responsibility for salaries and benefits is a provincial one it could certainly be argued, and I think it's true, that the university did not protest as it might have.
 That section then had related to the Department of Health or the Ministry of Health, its provincial arms and the employment practices in the Faculty given that we have joint staff.
 The next section looks at the relationship with the Department of Education and Ministry of Education, another branch of Government, and here we deal firstly with the issue of submissions and the extent to which the  university was prevented from admitting Black students, African students in particular without ministerial consent.  That I think has been covered by some of the other submissions yesterday and I won't repeat that. 
 You also saw some graphs of student admissions yesterday and so I won't repeat that.
 After the 1959 Act which closed White universities to Black students we had very few Black students until the mid  '70's when it started increasing again when ministerial consent was granted a little more easily.  In the late '70's the Faculty embarked on an affirmative action programme which I can detail at great length if you're interested in the questions, some of that is covered in the submission.   So the question of submissions was the first question to do with the Ministry of Education.  The second relates to the segregation and training of undergraduate and post graduate students.  This segregation was again largely the result of the segregated hospital facilities where Black students and doctors were not allowed to treat White patients although White doctors were certainly allowed and required to treat Black patients in the Black hospitals.  Again, although primary responsibility must rest with the Province and the Separate Amenities Act which segregated the facilities, it can again, and it has been argued, and I think the Faculty accepts that it did not do as much as it should have and could have in protesting this segregation. The protest only really got under way during the 1980's and eventually became quite substantial with marches, sit-ins, attempts to desegregate the hospitals through just civil disobedience campaigns, but I think that was motivated as much by the Mass Democratic Movement and its attempts and the attempts of organisations like NAMDA to desegregate the facilities, as it was an internally driven process. Up until that point I think it was a process driven by individuals rather than an institutional policy. 
 I'm moving on to the next section which deals with the question of admission of patients and care of patients in segregated facilities.  Again we've heard quite a lot about the unequal care available to Black and White patients, the differential resources given to hospitals and clearly a form of discrimination which affected the Faculty since - we have for example, six hospitals in our complex which were segregated by race.
 One of the areas where the Faculty has been criticised for it's policy with respect to this unequal distribution of resources and which I think is valid, is the attitude the Faculty took to the building of the new Johannesburg hospital which was planned in the 1970's, where it was argued or it can be argued, that given the lack of resources in the Black hospitals, the Faculty should have refused to see a new hospital built which would have been for Whites until better facilities had been provided for Soweto and for the community served by Baragwanath and Coronation hospitals. Nevertheless the Faculty enthusiastically embraced the idea of a new academic hospital which was going to be located next to Medical School in central Johannesburg. 
 There had always been a few voices protesting the segregation of health facilities as I say, the real campaign gained momentum in the '80's and is described in some of the appendices.  
 One example where the Faculty did exert its power, perhaps belatedly but nevertheless an example of what the Faculty perhaps could have done if it had wished to at an earlier stage related to the episode around the JG Strydom Hospital, which after the Tricameral Parliament was instituted, Health Affairs were transferred and became an Own Affairs activity and JG Strydom, as a White hospital,
was transferred to the Own Affairs Department of Health instead of the General Affairs where it had previously been.  All the other academic hospitals remained under General Affairs.  The purpose of transferring JG to Own Affairs was in fact to keep it White because under General Affairs and as an academic hospital that would have been harder to do.     The Faculty responded by withdrawing academic affiliation and association from JG Strydom and it immediately lost almost all its staff and was unable to attract doctors to work there and so it was then transferred back to General Affairs and the Faculty reestablished its affiliation.  
 I think what that episode illustrates is that there were avenues which the Faculty could have exploited better in exerting authority or in challenging the State and its authority and sometimes these were used, very often they were not.
 The Section three of our report gives some examples of protest actions which occurred in the Faculty, I've mentioned the ...(indistinct) doctor's complaints.  It refers to the creation of the Professional and Ethical Standards Committee in 1981 which met frequently, and still meets, throughout the last 16 years.  The issues which that Committee dealt with, I should say that committee was set up as a direct response to the Biko doctors' affair and a perception that the Medical Association and the Medical Council could not be relied upon to protect ethical standards.
 Our Faculty Committee looked at issues such as legal guidelines for health professionals in contact with police while treating unrest patients.  We addressed the issue of clinical independence of doctors in treating prisoners, a legal survey.  We addressed the question of medical students in national service and issues of conscientious objection, doctors ethical and legal responsibilities in times of conflict, guidelines for treating voluntary total fasting, in other words hunger strikes.  These guidelines were created for the use of our faculty members who were treating patients in our hospitals but certainly we evangelised with those guidelines to district surgeons, to MASA, to other doctors and international literature, and a particular feature of that has become accepted by the international medical community, namely that part of one's medical responsibility in treating a detainee is to refuse to allow them to be returned to the conditions of detention. It came to be known as 'Kalk's Refusal' after the author of that article.
 The committee developed a patients bill of rights which we tried to get distributed to the hospitals in which we work, addressed issues of handling of children in detention, the protocol for the medical examination of detainees and issue of confidentiality of medical records which became an issue because the police frequently raided our hospitals and clinics to obtain records of people who had been injured in unrest on the grounds that if they had been injured they must have been guilty and there is an annex describing in some detail the experience of Alexandria Health Centre and in particular, Dr Tim Wilson in protecting patients' records and the Faculty's attempt to support that.
 I won't go into that at length because I think it's easy for this to become a white wash, it's easy to present what was done because those things can be listed and then it looks like the Faculty made a substantial contribution resisting apartheid medicine whereas in many respects, the things that were not done, the sins of omission are not recorded, and in going through archives and in going through minutes of meetings etc, those things do not appear and also tend to be omitted from this.  So I think to maintain balance, I'm not going in this submission through all of those minutes of meetings and issues that were taken up.
 I want to turn finally to what I think is the question of the climate that was created in the faculty and how that contributes to the values that students acquire.  This relates to our recommendations in the last section, and if I may just read this last section then.
Rooted in the colonial racist society of the last 75 years, the Faculty of Medicine colluded with many features of apartheid medicine, protested against others, provided space for individuals to challenge the system, but did little that would have put itself at risk to present a serious challenge to segregated health care; constraints on student selection, restrictions of student access to clinical teaching material and gross human rights violations that were going on all the time.  Yet the Medical Faculty was not a monolithic collaborator.  Aside from individuals in the Faculty frequently including the leadership of the Faculty, the Faculty created committees such as the Committee on Apartheid and the Professional and Ethical Standards Committee which bombarded the authorities, the media and the staff and students with challenges to promote equity and human rights.  In considering what recommendations we could make to avoid health professionals becoming participants in gross human rights violations or even tainted by them through a failure to challenge the perpetrating authorities, our experience points to three aspects.
1. The teaching of ethics, in other words the sensitising of students to a broad spectrum of ethical issues throughout their careers as undergraduates and postgraduates and providing them with the skills for conceptual moral reasoning, to deal with the many moral issues which confront them in medical practice. Professor Jenkins has managed that process over the last decade and continues to develop that and if time allows and if you're interested we can expand on that a little.
 2. Creating a respect for everyone's equal human dignity.  We believe that a crucial factor contributing to the role played by many individuals in resisting apartheid was not the substantive content of courses on human ethics or human rights, but the value system they observed around them and imbibed from the Institution and Faculty members.  In one sense this should be easier than it was in the past.  The hospitals are no longer segregated and patients no longer obtain unequal care solely on the basis of race.  But other forms of division replace ethnic hierarchies and health care is certainly neither equal nor equitable. Those patients receiving inferior care are also frequently found in hospitals which are overcrowded, work loads are perhaps heavier than ever and where staff morale is low.  
 All these factors make it harder to demonstrate the concern, sensitivity and equal respect for each patient's dignity. This is the context in which it is easy to start thinking about patients, or some groups of patients as them, different from us. That is when the door is opened to regarding them as not entitled to the same respect, care and rights as us. So it's really the environment that we are saying creates the value system which students imbibe and which they continue to practise afterwards.
 3. Creating a relationship with the state which protects the university faculty and individual staff and students should they become critical of state actions, and within that, fostering the courage to challenge authority.  We believe that the activism of the 1970's and '80's, the many protests and petitions and public statements by deans and faculty members, the student activism, the tolerance by the university of dissent, even if it did not support those issues, however limited their real impact on policy, however limited all these issues were on policy, nevertheless they all contributed to the maturation of cohorts of health professionals who generally felt concerned about apartheid, about their role in challenging or perpetuating apartheid and about their responsibility for protecting patients' rights against the state. Unlike designing a curriculum or funding a senior post, this liberal milieu cannot be easily guaranteed.  
 There are certainly lessons relating to the need for autonomy of the university from State control, not only in relation to the Department of Education but also the Department of Health. 
 The control over appointments is an essential element of academic freedom, as is the freedom to protest and challenge without fear of losing funding and subsidies. 
 Furthermore the universities have to ensure they remain tolerant of dissent and encouraging of challenges to any authorities.
 The postscript to our submission discusses the internal process and it's just two paragraphs I'd like to ask Professor Jenkins to report on that.