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

MAPULE RAMASHALA: Thank you Dr Pretorius.  I am going to approach this in somewhat the same way that I approached the SAMS.  The numerous questions that I have, and if I have to go through the questions we'll be here until tomorrow.  What I would like to recommend is that I go through the questions for the public record, where you want to comment very, very briefly, like one second, you may, but what I would like to do is to have you respond to these in writing, in fact some of these questions will require that you do some research.
 Thanks to the AAAS in reinforcing the way I've categorised the questions we somewhat agree about the broader range of issues, I've approached it from the perspective that as a national health service your primary responsibility is policy and accountability.  So there are four broad categories that I want to outline and then I'll go into the questions.
 The first one, which is exactly the same as the AAAS recommendation, is the issue of regulation and enforcement. And under regulation fall the issue of financing of services, organisation of services and even management of services.
 The second one is accountability which is a part of enforcement.  Under that comes monitoring.  How do you know in fact that the health services that are provided are of quality, they are accessible, all of those things?   And corrective measures under accountability, and that relates to the issue of the code of conduct of health professionals.
 The third one is capacity development which you allude to in your document very briefly.  I would like to know if the Department in fact has a grand plan, and we are talking here not only about the issue of redress but accessibility of services with the difficult populations like the elderly and in rural areas.  What is the Department's grand plan in capacity development.
 And the last one is the issue of education, and I've divided it into two.  The first one is education including skills development, that is the training of medical professionals.  The second one is re-education and rehabilitation, and that speaks to the issue of abuses beginning with district surgeons all the way through the system.
 Let me go through the questions and I think you have a preliminary copy of that.  I may have variations.
 The first one is,
1. Could you briefly discuss whether there were specific national health policies which were formulated at the time which would account for the following in terms of differences, and I've only chosen four areas.  You've identified a whole lot in your document, but I just want to deal with four for the purpose of the record and then you can deal with the rest.
 The differences in life expectancy rates in South Africa.   Which means you are going to have to take all the populations.
 The second, infant mortality rates, particularly between Africans, Coloureds and Whites.
 The third one, urban - rural differences taking into consideration the fact that the poorest services are in rural areas and that's where the majority of older people, very poor people and children are.
 And finally under that question, diseases of the poor.  And in this case I've used malnutrition.  Not much has changed, the poor are still poor.  The poor still don't have running water.  The poor still don't have electricity.  The poor still don't have good sanitation.  
 And so we've got to address the diseases of the poor and I'm looking at the issue of health in the broader perspective not just as the absence of disease.
The second question is inspired by a section in your document and I'll quote
"In 1978 typhoid fever was 48 times more common among Blacks than Whites.  In 1971 deaths from diarrhoea were 100 times more common among Black children than White children particularly in the Cape Town area".
 Could you examine policies which formed the bases for the allocation of health resources at the time, with specific focus on prevention strategies versus curative strategies for both Blacks and Whites.
 I mean we didn't just thumb-suck per capita expenditure something guided us in terms of the allocation of funding for services, and it is that something that I'd like you to go back to your legislative morgue so-to-speak and dig out those policies that guided these decisions.
The second question under that;
 What was the thinking on the part of the Department at the time toward health care policies specific to prevention services and who were the main beneficiaries?
 Again this was not just a thumb-suck, there was some thinking, somewhere in the Department and it's very important for us to know what that thinking is.
 I think it is wonderful to apologise but I think until we know the basis for these decisions it will be difficult for us to move forward.
The third question, I refer to page 4 of your submission under "Resource distribution", you note that, and I quote,
"The allocation of inequitable resources is probably the single most important factor for which the Department can be held responsible for past illness and death".
 Again do you have a record of policies and procedures which provided the basis for the allocation of resources in the Department of Health?  And I'd like you to enlighten us on that.
 Fourth question, refer to page 6 of your document and I quote and I won't quote the whole sentence,
"The exact effects of segregation 'cannot be allowed to be repeated'.  The separation of health care facilities, particularly hospitals, was a nationwide practice with deleterious health effects especially on Blacks".
 Would you please refer to policies which were the basis for such separation and how the Department proposes to address the still continuing inequities?
 Again this was not a thumb-suck in South Africa to separate facilities, something guided us, and I think it's important to go back to that something which guided us.
5. Would you please give an overview of the 1984/85 Brown Commission Report focusing especially on its recommendations and the Department's follow-up of these recommendations.
 6. Do you have a record of areas, and I'm talking about geographic areas, where district surgeons failed to perform their duties as outlined on page 7 of your submission?
 7. Would you give us your thinking about underlying factors which contributed to the neglect of duty by district surgeons.
 Let me give you feedback, that it is of concern nationally that these very perpetrators or people who neglected duty, and I think we've Sectioned 30 Dr Lang for example, he is sighted all over, that he in fact has been returned to duty by the Department.  And a question that I have about this is how can we guarantee non-repetition of these practices, has Dr Lang and others gone through a rehabilitation process to ensure that such neglect does not continue?
8. Again I refer to pages 8,9, what follow-up strategies have been undertaken to address the cases that you identify on pages 8 and 9 of your submission, particularly with respect to corrective measures?
 I think by apologising as a Department you are letting off the hook the real perpetrators, the Dr Lang's, it is very important that we get an accounting of this and how the Department plans to deal with it.  Dr Lang should not be allowed to continue to practice unless he's gone through a rehabilitation process.
 9. Would you give an overview of the 1978/1982 regulations as highlighted on page 10, I think they are important.  What is the current status of these regulations?  And comment on whether these regulations are sufficient to address recurring problems.
 10. Refer to page 11, the last paragraph, what provisions has the Department made to follow up on the many people who were tortured and injured in other ways throughout the struggle, particularly those who were physically and emotionally disabled as a result?
 Has the Department investigated the effects of the violations, particularly the long-term effects?
 Are these patients receiving treatment?  Actually let me call them persons because I don't know if they are receiving any treatment.
 If the Department has not done any follow-up how then can we be certain that their health problems will be addressed?
 I am acknowledging that the Department has more pressing priorities, but I would like the Department to deal with that.
11. Clearly access, both financial and geographic is an important aspect of health care, would you please address the issues raised on, and I quote, "Independent panel of doctors" on page 12, and the comments you make on the last paragraph.
 And as I am talking about the issue of access earlier in your document you sight the figures for the four population groups in terms of per capita expenditure for health and you sight the African figure as 137,  I would like to correct that and suggest that I don't think you factored in the fact that the hospitals were located at a distance and for Africans they had to have transportation to get there and so the figure is much lower.  And so when you recalculate please take that into consideration.
12. Page 15, and I quote,
 "The Department did not provide guidelines for such situations....."
 which you identify on page 15, could you comment further on this especially on whether the Department has since addressed this issue which is crucial?
 13. We know that certain family planning practices, for example, the case of depo provera were forced on Black women.  These practices we know have long term effects.  Have studies been done in South Africa, particularly by the Department to follow-up on these women, especially with respect to long term infertility and cancer?
 14. Comment specifically on the abuse of patients, including what seemed like condonation of this behaviour by other ministries.  You allude to it, wetting our appetite, but you don't go into it.  You see we want to see how other ministries colluded with the Department in these practices.
 15. Review of human rights violations in psychiatric institutions, what is the current status of the conditions in psychiatric institutions?  I know that you referred to a study.
 16. What is the status of the plan tabled by the current Department for ensuring non-repetition of abuses in psychiatric institutions?
 17. Under emergency services we used to joke about it and say if you are Black don't you dare have an accident in a White area, now of course Whites were safe they couldn't have accidents in Black areas, but in order to survive we joked about it, we would like to know the way forward specific to what you address on inequitable access to emergency services.
 18. And then you talk about capacity development briefly.  It is important to address the issue of capacity development in the medical and health professionals broadly, including physicians, nurses, allied health professions etc.  
 Does the Department have a grand plan, especially to assess issues related to access to Black areas and to rural areas, the more difficult areas of health need?
 19. And on the issue of misinformation you very honestly outline the areas of misinformation, particularly to the international community about the health status in South Africa.
 What are the proposed strategies, first, to correct his misinformation?  And further to deal with the issues of inequity that are still persisting and how the nation gets to know about them?
 20. There is a question that I have received from one of my panel and it says,
 Our research indicates that until the 1940's South African mental hospitals were under the Departmental of Prisons, do you think locating mental health within the Department of Health has made a difference in terms of patient care?  If so in what way?
 21. My last question, that is the way forward from the broader perspective, but specific to three issues:
 The first issue is the treatment of people in correctional institutions and the treatment of detainees.
 And the Department's role in involvement with the TRC, but with other more permanent structures, that will go on after the TRC, in formulating issues related to rehabilitation policy.  
 I sent you our document, I hope you received it, which really clearly categorises our findings of what was presented to us in terms of medical problems, emotional problems and other problems that are related.  We would like to involve the Department in re-working that framework so that when the TRC leaves at least the Department can be left to address those issues.
 Finally, what is the Department's strategy to ensure a culture of human rights within the broader health sector community?
 I think what is even more important is that the Department has to institute corrective measures, because it is devastating for people in the community when they see the same district surgeons who perpetrated abuses continuing in the same positions.  What is the Department doing about that?  We are not suggesting that we get rid of those people, I mean that would have been my preference but I am only an individual, what I am suggesting are corrective measures which would include education and rehabilitation.
 Thank you.  Do you have any comments or lack of clarity on this?