Special Hearings — Mental Health Workshop — 1997-11-20

PROF SIMPSON: ...[inaudible] we might call a light ...[indistinct]  I hope that Saths will forgive me if this presentation is fronted by myself, I hope he will look upon as a very, very pale darkie.  As former President of another of the progressive health organisations - OMEGA I think, that this presentation will also partly reflect their views.
 One point I'd like to make - extract from my report or my submission very early on, is to add to the suggestion that was made earlier by Saths about the value of recommending preference for State employment for recognised victims, I have made another in my submission and that is, just as the Government declared free State Health Care for pregnant woman and for children under six, it could and perhaps to the same for recognised victims.  
 And if that statement included the provision of mental health care specifically so named, it might also help to give a greater status and recognition to the fact that we are not looking after either the physical or mental health of our people properly so long as we continue to neglect mental health.
 The topic that I have been allocated, is one that arose after I had written my submission so I will tailor a presentation this afternoon based on parts of several submissions that I've made, including some that have not been publicly aired before.  
 In the full version of the submission which I hope you will make available to anybody here who needs it, and I have also supplied as an appendix, a range of my earlier publications on this.  We heard earlier on about the publish or perish syndrome, my experience was that once one began writing about torture in South Africa and it's effects, I experience a publish and perish syndrome and certainly the range of death threats and attempts picked up rather markedly, at least showing that some of the enemy read something.
 I'd like to focus on some examples of major mental health abuse problems that I think we need to attend to.  One example I mentioned briefly in the second part of my written submission which I don't think has been provided to the Committee yet, is the concern about human rights abuses within psychiatric hospitals.  I won't compete with or repeat what was said today earlier, but I would like to draw attention to - in part 2 of my report, the severe problems - one a general one and one a specific one.
 One is persisting problems about the use of straight-jackets and physical restraints - we remember that there was a fairly brief fuss after the death of Carol-Anne Meyers at Pollsmoor Prison, after being in a straight-jacket for a prolonged period but I know and I've given some details of a number of cases where problems have continued.  
 And even although there was a supposed prohibition on the use of straight-jackets, this often merely resulted in the replacement of abusive straight-jackets with the replacement - with the abuse of handcuffs, chains or other means of restraint.  And I have given details of a case where in one of the academic departments not very far from here, when a young doctor complained of patients being kept in handcuffs for a prolonged period, the doctor was in fact - soon found himself without a job and with a letter having been circulated to suitable people to ensure that he had great difficulty finding a job anywhere.
 The other more specific example that I will not go into in great detail during this session but that is in the second part of my report, are the situation of human rights abuses at Westfort Hospital which is now closed.  What I think the Commission may need to pay attention to in that as in other examples, is the fact that it is closed, doesn't end the problem.  One of the problems is that the local Professor o Psychiatry knew about those abuses and merely threatened or in other ways took action against anyone who made those complaints or tried to make those complaints public.  
 The Hospital Superintendent knew about them, the health authorities nationally and provisionally knew about them but for prolonged period - until this Minister of Health began to take action, nothing was done about it.  And what we need to do about examining examples like that, isn't a question of digging back into even the very recent past in terms of recriminations but we need to try and understand how can such things happen and continue to happen, even when the people who have a legal, moral and ethical responsibility to deal with them, prevent them and put them right, know about them and still don't do anything about them.
 Another point I raise in part 2 before I get back to part 1 briefly, is - I noticed according to news reports, that in the recent Faith Hearings the Dutch Reformed Church admitted that it received covert funding from the former regime to counter international criticism.  I believe - and I've given some details, that there are strong reasons to believe that some of the professional medical and psychiatric associations also received covert funding from the State - certainly, I was told this on a number of occasions.   
 Particularly at the stage when academic sanctions made it difficult to get speakers for the annual conferences and it had become a matter of great pride in medical conferences that: "Your speciality isn't as good as my speciality if I've got more overseas speakers than you have".  
 And there was a stage when professors were given Government fundings specifically to tour America, North America and Europe to speak to leading psychiatrists and to try and persuade them to overlook the sanctions and to come and speak to South Africa and every such visitor was regarded as a great propaganda victory for the State.   
 And of course the method of persuasion involved explaining to them about the enormous and amazing changes that have been made in mental health in South Africa and why they should therefore support these by coming out.
 There are some specific examples which were contained in the full version of my report to the Health Sector Hearings which I would to elude to just briefly.  At that stage we didn't have either the time nor had the individuals been notified, so we couldn't mention examples but I'd like to draw this Committee's attention to some of the examples that we quoted there, particularly because some of them I believe, are still very cogent.  
 I echo - I felt a very strong internal echo to Saths Cooper's comment this morning that: "It is difficult for some of us who took an active part in the struggle, to find those who struggled against us now still in senior positions and being paid for by the victims to remain in those senior positions and we cannot expect them - even if they change their rhetoric to keep their job, to actually have a sincere interest in the principles that are supposedly governing our new system of health care".
 In my earlier report I identified - and will not go into it today, some examples where racism and other issues in the treatment of patients let to deaths of patients.  I also mentioned examples which I think are instructive in a number of ways and one of the points that comes across very clearly in some of the people that I have named earlier - like a Doctor Verster and a Doctor Plomp in Pretoria, was that those people were officially in private practice but they - in some cases, even testified to the fact that they worked solely in producing medical legal reports and psychiatric and mental health reports for the security police. 
 And that was the sort of privatisation of State violence in the same way as your report you eluded to earlier of the psychologists.  I'm quite sure that that was partly done in order - as was many of the other human rights abuses, to preserve deniability.  If I employ a psychiatrist full time in my military police or rather security establishment and they are actively involved in assisting - either with the commission or the perfection of methods of torture or with the cover-up of torture, it may difficult for me to deny later that I knew about that.
 However, if I make sure that my staff hires outside people - mental health professionals who can do that, it may be much more valuable.  And I would urge the TRC investigators to act through the Department of Justice - through the State Attorneys and Attorneys General, to get the information about what payments were made to what individuals for services in the so-called human rights and political cases.  
 Because I know these gentlemen at times - when we were trying to scrape together funds on the defence team to see if we could afford a cup of tea during the tea break, would boast about getting R6.000-00 to R8.000-00 per day - even when they were on stand-by.
 We have a number - I think many of the experiences we had there, also suggest that there was a broader pattern that we should find sinister.  One type of example that I've given in some of my submissions is, there were a number of instances - for example in regard to the Twala case in Pietermaritzburg, where the State Attorneys in court made submissions to the court based on what they believed or what they stated the defence would do.
 And the only way that they could possibly have obtained knowledge about what had happened in consultations between myself as a psychiatrist and the defence lawyers, were if there had be bugging of our private conversations - either in the lawyers chambers or in the rooms provided for us at prisons when we went to speak to the political detainees.
 We had one example in Pietermaritzburg Prison where one of the more junior lawyers joined our consultation rather late and afterwards revealed to us that when he went in and said he was here about the Twala matter, they guy behind the desk at the entrance to the prison said: "Have you come for the tapes"? and he realised afterwards - when we put the pattern together of the referrals that were made later to what we had been discussing, it seemed highly likely that there had been a taping of a - there was an ongoing taping of our consultations and they thought that this was someone sent to fetch them.
 I have a concern in another area which I think we will need to discuss and that is, in areas where - we understand that the Truth Commission doesn't have the budget, the time or the personnel to fully investigate all of the complaints and matters that are raised with them, that's unfortunate but it's a reality that we have to face - one problem with the fact that whole categories such as this category of the improper behaviour of some psychiatrists and psychologists in regards to major human rights abuses, is both that the individuals feel fully exculpated by the fact that there has been no action.  
 I have information from a couple of sources that one or two of the individuals who were named in earlier evidence - when they received their phone call from the TRC, were observed to go green for a week or two.  But because there was nothing else that happened, have since relaxed and continued in their usual inconsiderate manners - suggesting that they feel that nothing else will happen.
 I am concerned that the only mechanism that may appear to be open to us - and it may not be an adequate one for the purpose, is to refer to the normal Professional Associations or structures.  We are fortunate that SEISA has reconstituted itself and SEISA may be able to take some of the necessary action.  Certainly, there has been absolutely no transformation whatsoever of the Society of Psychiatrists of South Africa and I would consider - on the basis of their past history and their current constitution, that it is absolutely impossible to conceive of them taking any action against the people that your Commission are interested in.
 Similarly, while there have been some expressions - in the other submissions I've heard, of some confidence in the Professional Board for Psychology.   I have documented a long history of the failures, the recurrent and deliberate failures of the South African Medical and Dental Council also insufficiently transformed, to act on clear evidence of such abuses.  
 I noticed during the Health Hearings, that the Medical and Dental Council's representatives gave a very clear impression to the Commission that - with exception of the doctors in the Biko case and one other that they mentioned briefly, that there had been no other complaints to them about doctors' conduct in major human rights abuses and therefore they could not comment on that and this was entirely, deliberately and comprehensively a false statement to the Truth Commission.  We have very clear evidence, not only with the names of numerous other submissions that were made.   
 I have letters signed by the Registrar of the Council who was sitting there when they made that submission to you, dealing with other complaints that have been made.  Complaints about doctors like Doctor Sirgay Portem, now perhaps ...[indistinct] for Mental Health in South Africa ...[indistinct] who - in one case we had affidavits from him about how a detainee who developed severe symptoms while severe interrogation, how he had explained to him that the fact that he was here was entirely his own fault and that all he needed to do to be released was to tell the police exactly what they needed and therefore it was very foolish of him not to do so.  
 And he said in his affidavit that he had recommended to the police that they should finish their interrogation as soon as possible, by whatever means they thought fit.  The Medical Council sat on that complaint that was made by five of us from Durban - five senior physicians, psychiatrists and psychologists, for over a year and then did nothing.
 In that same submission we specifically and in detail, asked the Medical Council to remember that South Africa was a signatory to the Declarations of Geneva and Helsinki and various other - and Tokyo and other relevant declarations. And that they asked them to issue a statement to all registered psychiatrists, psychologists and physicians, that they would be expected to keep to these international terms of ethical conduct and if they didn't, they should be regarded as prima facie evidence of unprofessional conduct.  
 And the Council didn't even bother to reply to that part of our letter, let alone did they bother to take that action.  My concern is that, on the basis of such prior history and the continuing involvement of most of the same administrative personnel and other members of the council, I would still be pessimistic about whether they would attend seriously to the sort of complaints that need to and should be made to them.
 I have identified elsewhere in my full submission to the Health Hearings, other examples of misconduct and unethical conduct by the Medical and Dental Council which adds to our concern.
 I think there are other experiences and I address some of the specific examples that I have given in my submissions because I don't believe they were unique.  When my phone fails five times in a week I have two alternative theories, one is that we have a lousy phone service and the other is that there is a specific: "Get Simpson" instruction out in the phone service - I find the latter paranoid and unlikely.  
 If such problems happen to me repeatedly, the likeliest conclusion I think is that these are general patterns and frequent patterns and that is why I think - not because they happen to me but because they may represent a general pattern, that they may be a serious problem.  
 There are examples - for example in the case of ...[indistinct] Sony in which Saths and I were both to be witnesses, of the interesting example that when we had - I believe, extremely good evidence of how badly damaged he had been during his detention and interrogation, the State approached his attorneys and they came to me the weekend before the case was due to be heard in court on the Monday and said: "The State has said they will release him unconditionally on condition that you as the psychiatrist who says that he has PTSD and other psychiatric conditions and that he would be damaged by further interrogation, the State will release him if you will help them to interrogate him for another hour or two - they don't need more than that.  
 And if you believe that this might be damaging to him, you can ask the questions doctor, you can provide him with sedation - use any drugs or other means you wish to sedate him and relax him, and you may then ask the questions but they have some questions they want answers to and on that condition they will withdraw all charges and release him immediately". 
 Well firstly, I was surprised that human rights lawyers could even bring such a suggestion to me unless they felt it to be amusing.  Secondly, it seemed to me that if the State had made such a suggestion, they either didn't know me as well as I thought they did or they were scared that we would in fact win the case in court.  
 I refused of course, the lawyers refused of course and on the following Monday morning when we arrived at court - and I remember Saths and I pacing in the corridor outside waiting for it to start, the State arrived and said: "Oh by the way, we released him last night - the case has been withdrawn".
 The problem about cases like that also is, they strongly suggest to me that they wouldn't have brought such a proposal to me alone specially tailored for me, if that was not something that they had done frequently to other people with results that were more favourable to them than that.
 I will not go into other details of other cases that I have given but I recommend that we examine those in the same sense of the problems that need to be addressed.  One other case that I think is indicative of this type of involvement, is the case of a man Ibrahim Ishmail Ibrahim - now a member of Parliament, who during his detention at John Vorster Square was tortured, was treated badly and was very severely damaged by this.  
 In the documentation that I was able to obtain in preparing a report for his case, we discovered absolutely clear proof in writing - and we are providing copies of the documentation of this to the TRC, that in fact his severe condition was recognised by one of the district surgeons, Doctor Edward Krousy who behaved honourably in this matter.  
 He recommended that the man who was in such severe distress should be transferred to the Department of Psychiatry at Wits University.  His senior district surgeon, a Doctor Willem Johannes Marthinus Petrus Lindeque, in his notes stated that he had intercepted these records - he considered the recommendation inappropriate.  He had phoned Brigadier Erasmus of the security police and in his own words in writing - in consultation with the Brigadier, had decided that instead of sending him to the clinical facilities at Wits Department of Psychiatry, he would transfer him to Pretoria Prison.  
 At the Pretoria Prison he was put - not even in the medical section of the maximum security section, but it was said that he was transferred in order to give him access to the outstanding skills - very extreme words were used, of a Professor Plomp there.  
 Professor Plomp - he's one of the people who has been named to the Commission, has testified that during those years he never treated patients, he exclusively wrote medical legal reports on cases referred to him by the security police.  And in my experience - however badly the person had been tortured, the most extreme diagnosis he was ever reluctantly able to make in them was a transient situational disturbance.
 Yes, I guess torture will do that to you, in my experience it does a hell of a lot more than that.  It was interesting though that the clinical instruction to provide mental health care to someone in need, was intercepted, discussed with the security police and resulted in a referral to someone whose only skill that was relevant, was in writing exculpatory reports for court.
 There was a problem because Doctor Plomp's initial consultation - according to his notes, believed that this man who was a Muslim tea-totaler was perhaps suffering from alcoholism which didn't turn out to be the case.
 I won't go into other examples from that section but I would recommend that we need to study those sort of cases in order - if perhaps a medical model in one of the areas where a medical model may be helpful, one believes generally that it's difficult to prescribe a treatment unless you have understood the pathology.  It's difficult to describe how to get something right until you've understood how it went wrong.
 Briefly in my other part of my submission prepared for today's hearing, I'd like to just mention the headlines of a section I wrote suggesting that there are a number of misunderstandings I have found to be current with regard to the nature of trauma and how it effects people, that I believe we need to consider otherwise we may go astray in how we recommend what form of assistance for victims of trauma.
 The first point is that there are many different types of problems that arise from exposure to serious trauma.  We have the issue of PTSD and there's no question that it's been established in people of all races, all religions, all cultural backgrounds, that something closely resembling this syndrome is found in a high proportion of people who've met serious problems.
 We had the difficulty in the face of the sort of expert testimony that is now being made available to the perpetrators that was never available to the victims, that they used to say that - what I find ironical about the same point that we heard just before lunch - of the perverted and bizarre testimony that is being allowed to be presented unchallenged to the Amnesty Commission, is that is some cases the same lawyers and some of the same experts who in case after case held that there is no such thing as PTSD, there are no bad effects from torture, standing for 25 hours at a time can't possibly cause you any harm, lack of sleep for long periods can't possibly be a stress, that the same people who swore that there wasn't one single victim of torture who ever suffered from any serious consequences, now apparently would have us to believe that these are common occurrences in the torturers.  That is something about which we must be highly sceptical.
 I had assembled - I began it in order to provide backing for the human rights court cases in which I gave expert testimony - something like now 15 and a half thousand item bibliography on my computer, on trauma and it's effects.  In all of that I have found one single paper on earth - and we cover most major languages as well as most journals, in which there was a report of - I think, it was two cases of possible PTSD in perpetrators and those were people who had committed murder within a family setting of immense emotional stress for all participants in which, which part was caused by the act of murder and by the proceeding stress was very unclear.
 Compared to the millions of cases of PTSD that have been diagnosed in victims, if it is the proposal of some of our colleagues that this is now a sudden epidemic of PTSD in South African perpetrators and torturers, then this is something I think they need to write up urgently for the world psychiatric and psychological literature as we are in the presence of a major epidemic completely unknown to science.
 It is also important to register - from those of us who have been studying the effects of trauma on memory, that no case is on record as yet on earth in which case major - exposure to major trauma, particularly as a witness - which is the situation of these people, have led to the extraordinary convenient variety of memory disorders that seem to be being described in this case.
 You may have periods or patches of global amnesia but to remember exclusively and with extreme clarity, everything that might be exculpating or helpful to your application and to forget so selectively everything which isn't.  To be able to claim to have made a total submission and then claim amnesia only for those points which your victims were able to  establish you had omitted from your application.  
 If the Amnesty Committee continues to allow such testimony to go unchallenged by those of us who are competent experts to the contrary, then unfortunately the Amnesty Committee would have joined in human rights abuses and their condonation and this must not be tolerated by the Commission.
 To repeat the headlines of my point about trauma, there are - after we had established that PTSD occurs, a lot of other conditions we have to recognise.  Simple anxiety disorders and depressions and other common disorders are also much more common in victims of trauma.  There's a high degree of ...[indistinct] - in other words, they often have PTSD and other things.  There's a high degree of ...[indistinct] with substance abuse and all of this - all the treatment of any one of these complicates the treatment of another.  
 To ignore that - and there is a tendency in some quarters to see PTSD as the be it all and end all, to see it as the badge of honour or the badge of entry for concern and treatment is a problem.  You may be horribly traumatised and develop lots of long-lasting conditions but not PTSD.
 It's important to realise that there are often a mixture of physical as well as psychological problems, not only because the people are often physically damaged as well as psychologically damaged - and I believe that the evidence is that this was often done deliberately and not accidentally.   Just as I believe that there is evidence that is strongly suggested of the fact that the development of PTSD in political prisoners was not an accidental by-product, it wasn't like sawdust at a sawmill or just something that happens if you're doing something else.  
 I believe it was often the primary intent, if you couldn't buy your torturer and your cohesive and abusive interrogation - force somebody to tell you what you wanted them to know, at least you could return them to the community.  You could return to the community and act ...[indistinct] now sitting shivering in the corner and awake with nightmares all night and no darn use to further the cause that he or she had been fighting for and that is a dimension we have to recognise.
 But there's also sinister work and I think we must learn from other situations like the Holocaust, like the European Second World War and other situations where their period of trauma is further back, to know what we can expect.  There is a growing body of research that people who were severely traumatised in the Second World War and the Holocaust are also developing an increasing instance of physical illnesses, heart disease, they have a higher than average instance of arthritis and so on and therefore provision even for those who seem to have been psychologically damaged must include provision for physical health care.
 We mustn't underestimate the fact that there are many people who were traumatised in detention who today may seem fine and may consider themselves fine and let's pray that they remain fine.  But our experience internationally in other conflicts where there's been a longer term follow-up, is that there is a very much higher lifetime instance of problems that may not display now and that therefore we must expect that many people not now complaining of severe symptoms will develop them later.  
 And there's a particular sub-group of people who - as they get to their sixties and seventies, seem then - perhaps because there's a small degree of dementia, to then develop a great deal more symptoms that they didn't have before.
 We must recognise the spectrum of effects, we must recognise the chronisity of it, these conditions are fluctuating and somebody who has been ill and has now improved, may not stay improved and again we must recognise that if we're to make proper provisions for the care of the victims of apartheid, it's not something that will be done in 10 years or 12 years or 20 years, it is a lifetime problem.
 I would address to you - I can't give you a copy of the chapter as yet but I have given you with my submissions, a summary of it - there is a new book out this month in America, that is a multi-national study in which I have written a section on the multi-generational effects of trauma and that again we must not underestimate.
 And again, from the follow-up of Dutch resistance workers and Scandinavian resistance workers and of Holocaust victims, we know that there are real measurable and serious impacts on the second generation.  Even where the second generation - which is not the case in our country, was themselves in no way directly affected by the trauma - we are seeing third generation effects and we must again allow for that if we are to provide proper and comprehensive care. 
 I have outlined several other cautions which I think we need to look at.  The other point I'd like to pick from that to emphasise is, we need to gather information and we need proper relevant focused research and evaluation.  We need for example some epidemiological work in the country - epidemia already sounds boring and irrelevant but we can't really make proper provision for how to care for the trauma victims unless we know how many are there, where are they, how badly effected are they, what do they need, what is available to meet their needs and what isn't and this can be done on the basis of some properly designed focused ideas which we can then legitimately ...[indistinct] to the rest of the country and will help us to do that.
 I will - in the interests of time, reduce my claim to any further time but I hope that there will be time for you to read the full reports in detail, thank you for your time and your support.