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

DR PRETORIUS: Amongst Africans and Coloureds diseases such as tuberculosis, pneumonia, enteritis and other diarrhoeal diseases were the major causes of death.  In 1978 typhoid fever was 48 times more common amongst Blacks than Whites.  In 1971 deaths from diarrhoea were 100 times more common among Black children than White children in the Cape Town area.
 In 1987 African women had 3,5 times higher rates of cervical cancer than Whites.  The health system was, however, geared for disease patterns of the Whites who, for example, had higher levels of ischemic heart disease and diseases common in the western world.  On neither quality nor quantity of service can be completely correlated with the financial input.  It is certainly clear that without financial resources to provide adequate services health care will suffer.  
 The allocation of inequitable resources is probably the single most important factor for which the department can be held responsible, for that resulted in the inequities between the different areas in the country.  The per capital expenditure on health care ranged from, during 1985, for Africans, R115,00; for Coloureds R245,00; Indians R249,00 and for Whites R451,00.  During 1987 the figures were as follows.  For Africans R137,00; for Coloureds R340,00; for Indians R356,00 and for Whites R597,00.
 According to the Brown Commission in 1984/85 only 12% of the public health expenditure went to the Homelands where perhaps 40% of the population lived.
 I would like to refer now to the issues related to the health care of detainees.  Much has been said yesterday and today about the problems experienced by detainees, and rather than to repeat what was said I will confess that the way in which some of the staff of the Department of Health treated detainees and disposed of their roles as the watchdog of the health of the detainees was questionable to say the least.  And that as a result of that the health and human rights of many people were violated.  
 It was the duty of the district surgeon to record physical and mental signs of torture and abuse and to report these for the necessary action.  It appears from the evidence presented at this meeting that medical negligence was a factor in the deaths of a number of people in detention.  Many district surgeons were put in the invidious position of having to comply with the Prison Act and the Emergency Regulations and cooperate with the law enforcement authorities on the one hand, and the principles of their own medical ethics on the other hand. Most district surgeons appear to have opted for the former, either out of commitment to a political ideal or out of fear for not doing this.
 We have no evidence that doctors actively participated in torture, except one case that was mentioned yesterday, but nor did they expose torture when it was evident that it had occurred.  As the employer of district surgeons it is incumbent on the Department of Health to bear some responsibility for the fact that it created the mindset for the district surgeons to become accomplices to actions resulting in unnecessary illness and death.  However, it is important too, for the Department of Health to accept blame for not having taken sufficient action to enable district surgeons who wished to report on malpractices that became evident through their medical examination to do so without fear of victimisation.
 In the one case where a district surgeon did attempt to protect the rights of patients who were being tortured authorities in the Department of Health did not give their support and in fact even obstructed her.  
 Often youngsters and children were injured in clashes with the police.  When they went to the health services for care many were duly arrested either before or after initial treatment.  As result of this many people refused to go to the health services for treatment.  This resulted in the creation of community initiatives to care for the injured in clandestinely set up surgeries.  By not acting against such practices the Department of Health was in fact collaborating with the police services against the health interests of their patients.
 The Department of Health had little to protect the professional confidentiality and in fact collaborated with the police in producing information.   There are numerous reported incidents in which doctors, nurses and administrative staff were forced to give information, often with threats against the health worker or their family.  
  Like in other forms of medical care psychiatrists and psychologists were faced with the dilemma of fixing a person up to be returned for further abuse.  In such situations the practitioner cannot withhold treatment in order to avoid being an accomplice to further interrogation or torture.  With patients needing psychiatric care the chance of a fairly rapid decline was probably higher than with most other illnesses.  The onus was on the practitioner to recommend that the person be discharged, or at least put into a slightly more normal situation than, for example, solitary confinement or isolation.
 When a number of patients were referred to a hospital to be treated for various conditions, some of which may have related directly to the detention and some of which were unrelated illnesses they were handcuffed to the bed to ensure that they did not escape.  This included patients sent for psychiatric care as well.  The now Premier of the North West, Pope Molefi is reported to have been kept in leg irons while being treated for a lung infection.
 The Security Police took action against many people who opposed the apartheid system and a list of health personnel who were detained and harassed during that time is available.
 The proposed new policy on medico-legal services in South Africa has been accepted by the PHRC and will now be submitted to the MINMEC meeting for consideration, and I think that this is a major breakthrough to move away from the kind of problems that have been discussed over the two days.
 Much of the family planning services of the department were directed at controlling the size of the Black population.  In 1981 the director general of this department warned that sterilisation and abortion might have to be made compulsory unless certain ethnic groups accepted family planning measures.  Fortunately this was not enforced.  This reflected the underlying motivation of government for the Department to allocate higher priority to family planning than to its primary health care services.
 The allegations of human rights abuses in South African psychiatric institutions came to a head around the mid-1970's following a number of newspaper articles which documented violations in the mainly State subsidised institution, the Smith-Mitchell Company.  There was also major concern internationally that South Africa, like the USSR was committing political dissenters to psychiatric institutions.
 During 1978 the American Psychiatric Association visited South Africa to investigate all the Smith-Mitchell Hospitals.  They were, however, not given the same access to State institutions. 
 The following findings were recorded: 
An unduly high death rate;
 Substandard care;
 Some instances of abuse practices;
 Grossly inadequate professional staff;
 Possible exploitation of patient labour; and
 Apartheid had destructive implications on the mental health of Black South Africans.
 The APA also found that treatment of Black patients were substantially worse than those of White patients.  They also made findings, such as, that patients were provided neither with toilet paper nor washbasins adjacent to toilet facilities.  Black patients, by policy, are not provided with sheets, and that the majority of Black patients answered in the affirmative to the question of whether they had been beaten or assaulted by staff.
 The then Department of Health found the APA report to be completely unacceptable and is rejected as prejudiced, biased and a masterpiece of malicious misinterpretation of facts.  We have no reason to believe that the APA had reason to misinterpret the facts.  This together with similar allegations contained in a 1996 investigation into psychiatric institutions led us to assert that most of the contents of this investigation were in fact true. The APA deserves an apology from the Department for, in essence, calling them liars.
 As with all health services emergency services, including ambulance services were separated by race.  Inevitably patients died because they were not given timeous treatment which they could have received had they not been of a different race group.  Because admission to hospitals was racially based patients were forced to go to hospitals which were not necessarily the nearest or the most accessible.  In terms of ambulances they were despatched to emergency situations based on race.  As a result if an ambulance serving the Black population group was in use a patient would have to wait rather than an ambulance reserved for Whites being despatched.
 The task team responsible for the development of a new emergency health care service policy has advanced fairly well and will be on - the coming Friday, will discuss the final policy document which will then, if accepted then, be submitted to the PHRC and the MINMEC for consideration.
 Personnel abuses:   Many hundreds of South Africans can justifiably blame the Department of Health for the fact that they were not given the opportunity to advance into a medical or related career.  While much of the blame for this must be borne by the Department of Education, for example, the Bantu Education and University Extension Act which essentially barred most Blacks from being educated as medical and related practitioners the Health Department must also carry some responsibility.  
 Under the Extension of University Education Act of 1995(?) non-White students were accepted into universities only with Ministerial permission.  During 1978 83% of Indian and 95% of Coloured applicants were granted permission while only 29% of African applicants were accepted, or were given permission.  Between 1986 and 1977 88% of all new doctors who were White and 3% were African.  The indignity of having to ask permission from a Minister to study was heartfelt by students.  
 The issue of discriminatory rules with regard to the training of Black students in White institutions were mentioned by a number of speakers and therefore I will not refer to it in any further detail.
 Other professional groups were similarly prejudiced in terms of admission and training.  The opening of the Medical University of South Africa was part of the grand apartheid plan which was aimed at having fewer Black doctors trained at White universities.  
 Despite equitable qualifications between White and Black personnel for most of the period under review discriminatory salaries were paid to Blacks.  This includes nurses and other professionals.  In addition facilities and conditions were separate and unequal.  Personnel working in the same facility and with the same qualification had separate toilets, separate tea rooms and separate accommodation.  
 Despite Black health personnel sometimes having better qualifications and experience White personnel were promoted above them.  It was seen as unacceptable to have Blacks in position of authority over Whites. Within the Department of Health no Black person had been appointed at director level or above until the new democratic dispensation.
 With minor exceptions women were also not appointed to senior management level.  The new human resource policy that deals effectively with these concerns is in its final stages of development.
 In accurate representations by the Department of Health:  We believe now that the Department of Health and other government departments were responsible for giving inaccurate and distorted perceptions of health and health care in South Africa.  These were often done deliberately to promote South Africa's standing in the world and for other propagandistic reasons.
 Conclusions:   Apartheid could not have existed without the apparatus which constituted it.  The Department of Health was one such apparatus.  In this historical overview of the health services over the past years it became quite clear that the Department of Health played a significant role in creating and maintaining apartheid.  In terms of human suffering this Department has much to answer for and much to apologise for.  
 Rather than allowing health to be the driving force of its policy this Department concentrated most of its efforts and resources on only part of the population in line with the political objectives of the apartheid state.
 The Department also became part of the oppressive apparatus of State by not taking stands and intervening when medical ethics were being violated even by their own employees.
 At a number of points in this submission we have suggested how the Department may have acted differently.  We make apologies to those discriminated against in terms of the poor or no health services resulting from the inequitable and racist allocation of resources. 
 We make apologies to those detainees and their families who did not receive adequate health care, or who were abused by employees of this Department by commission or omission.
 We apologise as the Department of Health for not taking the actions necessary to ensure that such abuses did not occur and for not supporting those who did object to torture and other abuses of medical ethics.
 We apologise to those activists who were not protected by the Health Department and may have died or have permanent injury as a result. 
 We apologise to the patients who have been violated at psychiatric institutions.  
 People who have suffered as a result of emergency services' practice along racial grounds.
 We apologise to people who would have wished to become part of the health personnel but were not allowed due to race.
 To practitioners who were discriminated against in terms of training, salaries, facilities and for acting against apartheid. Those who suffered as a result of this Department's policies.
 But before I conclude, I would also like to use this opportunity to thank the large numbers of dedicated health workers who have, on many occasions, worked long hours under sub-optimal conditions to fulfil the professional mission of a caring health service.
 As the Department of Health we will be doing all within our knowledge and power to ensure that the wrongs of the past are not repeated.  However, we would welcome any input from the Truth and Reconciliation Commission to assist and guide us in creating a quality health care system.
 I thank you.