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

UNKNOWN: I will just briefly address the question you asked us to focus on.  In our submission we did have a detailed section about district surgeons that attempt to illustrate some of the problems confronting the health professions under the system of apartheid.  Through their inability to resolve the role conflict between duty to their patients and duty to the apartheid state, the district surgeons serve as a prime example of the violation of international law and standards that Audrey has just spoken about, in the discharge of their professional role.
 In our written submission we state that while there was considerable variation in district surgeons' attitudes towards their patients, and in the quality of care they provided, district surgeons did, in the main, accommodate themselves to the dehumanising system in which they were operating.  
 District surgeons commonly participated in abuses by failing to record and investigate apparent signs of abuse by not insisting on appropriate treatment and by not respecting doctor/patient confidentiality.  While it appears that district surgeons did not generally participate actively in torture they rarely spoke against inhumane practices.  While there were a few bright spots, those few who did speak out against the abuses received little support from their colleagues as we have heard in testimony over the last day and a half, suggesting that the problem here was not restricted to a few bad apples, but in fact did represent a collective professional failure to responde appropriately.
 Fundamentally then, district surgeons failed to honour the responsibilities that they had to their detainee patients under, not just international law to which South Africa was not then States party, but even under South African law.
 This problem of complicity and torture, or the denial of treatment, the falsification of medical records, the violation of medical neutrality, as we've heard testified to yesterday in which patients were actually seized by security forces while under treatment, all point to this larger picture that we've heard in such graphic detail.
 We would like to make three principle recommendations which we will then follow-up in our longer detailed submission later in September. 
 First, the category of regulation and enforcement.  The discipline of physicians in South Africa under apartheid obviously was woefully inadequate and the Council failed to function in any meaningful way.  Based on the testimony submitted yesterday I have to say that I have concern that there is in place the kind of reform at that self-regulatory system that would be necessary to protect against future abuses.  I believe that there needs to be a complete restructuring and a recognition that self-regulation has not worked.  
 The SAMDC needs to be replaced by a pro-active group with representation by progressive community institutions such as women's organisations, labour unions and church groups.  What we heard this morning about the changes underway with the Nursing Council, I think provides an example that the physicians group might well look to.
 Second, accountability.  There needs to be a human rights monitoring body that is both independent and yet empowered to investigate allegations of human rights abuses, including access to patient records.  
 It is difficult for us, as a group of Americans, to suggest exactly the form that this might take to accommodate to the values and the mores of South Africa, but we do believe that part of a strong, civil society that is now beginning to emerge in South Africa will create a supportive ground for the creation of such an independent monitoring body.
 Third, education.  Education and health and human rights should be provided at all levels.  We've heard others testify to the same concern.  Within the health profession schools it must be linked to the examination system in order to assure that human rights education will not be marginalised or trivialised by faculty and students alike.
 Re-certification and re-licensure of graduates should include requirements for participation in human rights education and training.
 While we applaud the efforts described by MASA to work with the seven South African Medical Schools to develop ethics curricula, we do not believe that this goes far enough.  Given the apartheid past and its legacy we believe that education in the areas of social, cultural and economic rights, as well as civil and political rights go above and beyond bio-ethics in the context of the diadic doctor/patient relationship or nurse/patient relationship.   It is necessary, in order to understand fully the social determinants of health and disease in South Africa, to appreciate the nature and extent of psychological barriers that might prevent the full disclosure of symptoms and history by patients still wary of the system; to sensitise health professionals to the origins of the distrust which many patients will continue to feel in months and years to come, and to identify residual, structural impediments to the full guarantee of human rights to the citizens of South Africa, whether patient or health professional.
 Thank you.

WENDY ORR: Thank you very much, and thank you for being such remarkable timekeepers for yourselves.  I think district surgeons demonstrate par excellence the dilemma of the doctor with dual obligations, but obviously they are not the only doctors who have dual obligations.  They have obligations towards their patients which you and I believe should be paramount, but they also have obligations to the person or body or institution which is employing them.  We see that in the military, we see that in the Police, we see that in the Prison Services.  Do you have any thoughts as to how this tension can be addressed, this dual obligation tension?

UNKNOWN: I believe in the United States we have in our teaching of health professionals focused on the question of values clarification as a way of approaching ethical conflict when somebody confronts a dual loyalty situation.   One of the healthy things that I believe would be useful here would be to create regular fora in which people could come, almost like a clinical pathological conference and say in the last week I was faced with the choice to do this or that, I am not sure I made the right choice but this is what I did.
 Michael Balant(?), the late British psychiatrist in his classic work, The doctor, the patient, the illness", talked about the value of confidential small groups of health workers getting together on a regular basis to share the problems confronting them in practice, ethical, moral, legal problems.  A seductive patient, a problem where confidentiality breaches some other kind of family relationship problem, I think here, given the 45 years that you have just been through, that it would not be at all inappropriate to designate a regular opportunity for health workers to come together and to recognise that these are difficult tasks to sort out.  People haven't had a lot of experience in dealing with them and then to work that in to the curriculum for health and human rights.

WENDY ORR: Thank you.  I certainly find that a very useful suggestion.  I have no further questions.  I certainly look forward to working with you and your organisation in the months to come as we pool our final report and recommendations together, and want to thank you again for coming here today.

MS MKHIZE: I would also like to thank you for being part of this important step in the history of our country where professionals are re-looking at where they are coming from, re-defining their roles as Dr Orr has said.  We see you as our allies and hope that you will continue assisting in as much as you can.  Thank you very much for coming.

UNKNOWN: Thank you for having us.
DeNOSA  SUBMISSION