HISTORICAL BACKGROUND

The system of apartheid ("apartness" in Afrikaans) was a cornerstone of South African economic development and political policies from 1948 until 1994. South Africa's political and legal system classified people by race and accorded (or denied) specific rights to the identified "race" groups. After World War II, when many countries moved away from colonialism and racial laws, South Africa moved to preserve and increase discrimination. Apartheid ensured that the white minority government, dominated by the primarily Afrikaner National Party, maintained economic, military, and political power over the resources and population of South Africa.

Discrimination against the African, Asian, and mixed race populations has characterized the region's history since the arrival of Europeans on the continent of Africa. In the seventeenth and eighteenth centuries, Dutch, German, and French settlers (later known as "Boers" or "Afrikaners") established a colony in the Cape area, subjugating the indigenous population and importing other slave labor. Once the British took control of the Cape area in the early nineteenth century, they began competing with the Afrikaners for control over the economic and human resources of the region. In the following decades, the British and Afrikaners moved north and east, establishing colonies that gave little or no political rights to Asians, people of mixed race, and Africans.

In 1910, British and Afrikaner settlers agreed to unite the four previously independent states of Natal, Cape, Orange Free State, and the South African Republic (Transvaal) into the Union of South Africa. Racial discrimination became institutionalized at a national level. Legislation enacted by the all-white Parliament in 1913 and 1936 prohibited African land ownership in 86 percent of the country. "Native reserves" for Africans were set up in the remaining 14 percent of the land, although Africans comprised approximately three-fourths of the total population. Other restrictions limited where Africans could live and work in areas outside their "reserves."

After the electoral victory in Parliament of the National Party in 1948, the Party set the apartheid system in place. One of the principal foundations of that system was the Population Registration Act, passed by Parliament in 1950, which legally (and often arbitrarily) classified every person in South Africa as a member of the "white," "colored" (mixed race), "Indian" (Asian), or "black" (African) "race" or ethnic group.¹ The Group Areas Act of 1950, and its various amendments, defined separate areas that legally could be owned and occupied by white, African, mixed race, or Asian people in South Africa.² Three years later, the Reservation of Separate Amenities Act of 1953 mandated the reservation of separate (but usually unequal) buildings, services, and conveniences for each racial group.

In order to enforce the Group Areas Act and sustain the "native reserves" or "homelands" system, the government forcibly relocated people, primarily Africans, Asians, and people of mixed race. The Surplus People Project estimates that between 1960 and 1983, about 3,522,900 people were forcibly relocated. Africans were sent to one of ten homelands, which were established according to official cultural and linguistic definitions, or forced to become citizens of their assigned homeland even if they lived in urban, "white" South Africa.³ By the late 1970s, some 53 percent of the total African population resided in the homelands, ten percent more than in 1950. The government also initiated policies to transform these reserved lands into politically autonomous African states. Four "independent" homelands, recognized as independent countries only by South Africa, and six "self-governing" homelands were created. Residents of the homelands were stripped of their South African citizenship.

A. Apartheid Structures that
Affected Health Status

The apartheid policies of the South African government had a deleterious effect on the health of the majority of South Africans. When the government created the homelands and forcibly relocated people to these and other rural places, it did so with little concern for the capacity of these areas to sustain a population or to develop an economic base. The government frequently did not provide adequate housing, water, sanitation, schools, hospitals, and other public services.

Most blacks were not allowed to live near their urban workplaces, and many endured long commutes on public transportation (some up to three hours one way) to the cities from their homes. For those who left their homes to work as contract laborers, their housing consisted of single-sex hostels in urban areas and near mining camps where they lived for approximately eleven months out the year. Moreover, those Africans who remained in the homelands—mainly the elderly, women, and children—were forced to rely on income from migrant or commuter labor and pensions because there were few sources of employment there.

The repeal of the Pass Laws in 1986 eased legal restrictions on the migration from rural areas to the cities and townships by people searching for work. But the migration also caused a proliferation of "squatter" communities on the periphery of urban centers. Physical conditions in these overcrowded and ill-served townships and squatter communities, such as make-shift housing, lack of protected water, and the absence of sanitary facilities, threatened the health of residents and encouraged the spread of disease. In addition, police surveillance, and the lack of jobs, privacy, and designated and clean recreational sites created much mental and physical strain on the families living in these areas.⁴

As an apartheid legacy, few people in townships and squatter areas have had access to safe and adequate water supplies. In some areas, outdoor water spigots serve large numbers of families. In 1989 members of the AAAS mission found that in an area near Durban there was only one water spigot for an estimated 15,000 to 20,000 persons. Women and children, often traveling substantial distances, are required to collect water in containers ranging from bottles and cans to huge plastic jugs weighing thirty pounds or more.

Sewage disposal has been another problem. Some townships have pit latrines; others have portable toilets, but often in inadequate numbers. Many residents use open buckets within their homes. The lack of adequate sewage disposal, combined with heavy rains, hot temperatures, and accidental spilling of these buckets, obviously creates enormous health problems—in particular, infectious diarrhea, other gastrointestinal disorders, and worm infestations. Flies and rodents are omnipresent vectors. Other sanitation problems arise in the disposal of garbage. Many open areas near houses serve as garbage dumps.

A household health survey conducted by the Community Agency for Social Enquiry (CASE) in 1994 of a nationally representative sample of 4,000 households in South Africa found that approximately two-thirds of the African population is affected by poor public health conditions: overcrowding; lack of electricity, clean water, or sanitation. Only 20 percent of African households reported having a water tap inside the home, compared to nearly 100 percent of white and Indian households. Sixteen percent of African households have no toilet of any kind. Nearly 60 percent of African households lack electricity.⁵

Poverty in South Africa was and continues to be a primary cause of many health problems.⁶ It creates financial obstacles for persons seeking health care and affects their living conditions. It is therefore significant that close to two-thirds of all African households (more than three-quarters in rural areas) have monthly incomes below the minimum living level of R900 and nearly one-fourth have a monthly income below R300. In comparison, in 1994, nearly two-thirds of white households reported a monthly income of more than R2000.⁷ Combined with the lack of education about health, those who are most in need of public health services (for example, immunizations, pre-natal care, tuberculosis testing and treatment) often do not receive medical care. Diseases such as tuberculosis, cholera, and measles, and widespread hunger and malnutrition are common among the economically deprived population groups. Many diseases that are preventable with good immunization programs, improved sanitation and water supply, and better nutrition, and that have been all but eliminated among the white population, continue to plague blacks in South Africa. The epidemiology of the HIV/AIDS epidemic also demonstrates the link between poverty, low status and vulnerability to infection.

B. Fragmentation, Privatization, and
Access to Care

After the formation of the South African state in 1910, health services in South Africa were characterized by a multiplicity of authorities and systems responsible for providing health care, rather than a unified system. The South African health care system was divided according to race, geographic area, the public sector (further divided into local, provincial, and central health authorities), and the private sector. Each of the ten homelands had its own health department.

Significant inequalities in the provision of health care therefore emerged between blacks and whites, between rural and urban areas, between primary and tertiary health care programs and between the homelands and the rest of South Africa. The four "independent" homelands of Transkei, Ciskei, Venda and Bophuthatswana, for instance, were almost totally dependent on aid from the South African government, and were reported to have generally worse health statistics than the rest of South Africa.

The Second Carnegie Inquiry into Poverty and Development in Southern Africa characterized the South African Health Service as "not a federal arrangement with rational, clearly defined regional boundaries; [it] is an arrangement almost tailor-made to encourage the growth of a bureaucratic jungle whilst minimizing its efficiency."⁸ During apartheid, most physicians favored the replacement of the inefficient 14 separate health ministries and the hundreds of local health authorities with a more unified approach.

Most blacks in South Africa have not had easy access to health professionals and health care facilities. In 1990, there were approximately 22,000 doctors registered in South Africa, of whom only about 1,000 were black. At that time there were 3,581 dentists, of whom only 25 were black. Socio-economic factors induce most doctors to practice in the developed areas of South Africa where potential patients can afford the fees and where more patients are likely to be covered by medical aid schemes. Thus in 1990 the ratio of general practitioners to population was 1:900 in the urban areas as compared with 1:4100 in the rural areas.⁹ Mobile clinics travel through some rural areas to provide health care, but these are too few for the large populations they serve. During apartheid, persons often did not have access to the hospital nearest to them because the hospital was designated for another race or was located in an area which did not serve them (for example, a person residing in one homeland could not be served by another homeland's clinic even if it was closer.)

Although there was a sliding scale of payment based on income for medical services at the public hospitals, many people still were unable to pay for health services, nor could they afford the transportation costs to a far-away health facility. The majority of blacks did not have health insurance of any kind. Private purchase of health insurance was far beyond their economic means, and many employers did not offer blacks health coverage as a work-related benefit. As a legacy of apartheid, most Africans continue to rely on the public health service, whereas whites and Indians utilize private health care.¹⁰

The segregation of hospital care was one of the most visible manifestations of apartheid practices in health. Almost all public hospitals in South Africa had segregated wards or were designated entirely for a specific "race" group.

Groote Schuur Hospital, an internationally renowned medical center affiliated with the University of Cape Town, was the only South African hospital that offered services to all races. The Hospital, which opened in the 1930s, originally had separate entrances and wards for black and white patients. The result was severe overcrowding in the black wards and empty beds in the white wards. In the mid-1980s, the hospital staff began to integrate its services without official permission. The construction of a new hospital complex led to considerable controversy over whether the facilities would be segregated. However, at the insistence of physicians, medical students, and administrators at the University and health organizations, desegregation occurred despite opposition from the provincial government.

C. Segregation in Medical Education

Formal education in South Africa during apartheid disproportionately benefited the white minority. The apartheid policy segregated students from elementary school on up, allocated resources unequally among the white, "colored," Indian, and African populations, and offered better quality education to whites. State expenditure for white children in 1985 was estimated to be seven times higher per child than the expenditure for Indian, mixed race, and African children.¹¹ Unrest and subsequent school disruptions and boycotts also contributed to the comparatively poorer education of blacks. The number of black students who were academically able (not to mention financially able) to pursue higher education was thus limited. As schools for the health professions began to lower the color bar, the paucity of adequately educated Africans emerged as a major barrier to expanding the ranks of African doctors, nurses, and other health care providers.

Segregation also prevented black medical students from attending to white patients on the same basis as white medical students. Only in the final years of apartheid were some black medical students allowed to attend to white patients at all, and even this varied from medical school to medical school. The students at the University of Cape Town were the only students who had an essentially desegregated hospital as one of their major clinical settings. Medical students of all "races" at the English-language universities conducted their clinical rotations at both white and black hospitals. White medical students at the Afrikaans-speaking universities were allowed to rotate through both white and black hospital wards. However, the small number of black medical students (usually Asians) who attended these universities were not allowed to rotate through the white hospitals. Some medical students at several universities refused to rotate to hospitals that cared only for white patients, as a means of pressing for desegregation.

For many years, blacks had a difficult time gaining admission to medical schools. From 1959 to 1984, the Extension of University Education Act provided that anyone of color accepted by a medical school had to obtain individual ministerial consent from the ethnically relevant ministry in order to attend the university. Such consent was not readily given to all qualified applicants, and was disproportionately denied to Africans. The consent system was lifted for medical schools in 1986.¹² But because apartheid still existed in education, blacks still had a limited number of schools to which they could apply.

The universities of the Witwatersrand, Cape Town, and Natal admitted any qualified student, regardless of race, to their medical schools. They designed premedical and medical school tutoring programs for those blacks who needed some educational assistance, often as a consequence of segregated and inadequate premedical education. These were of uneven quality. They also allowed blacks two years to complete their first year of medical school. The University of Natal Medical School, originally intended to provide medical education opportunities for Africans, had a primarily Asian student population. Even so, black students at these schools experienced severe forms of discrimination, both in access to education and in living conditions. Black medical students at Natal were not even permitted to wear clothes with the university insignia.

Generally the English-speaking medical schools enrolled more blacks than the Afrikaans-speaking medical schools. In 1989, only about 12 percent of Stellenbosch's 600 medical students were black (i.e. mixed race, Asian, or African). One reason cited for this was that most Africans did not speak Afrikaans, the language of instruction there.

MEDUNSA, the Medical University of Southern Africa, was originally established in 1976 by Parliament through the University of Pretoria as a medical school for blacks. Admission preference was given to Africans. Africans from other African countries studied there as well. Because MEDUNSA was a creature of apartheid, some held it in disdain. During the apartheid era, few blacks held leadership posts at the school, and most of the faculty was white.

The loss of trained medical practitioners due to emigration was another serious problem. Physicians at the University of Witwatersrand estimated in 1989 that 50 percent of its medical graduates, white and black, left the country within ten years of graduation. A similar situation existed at the University of Cape Town. A considerable number of white male graduates left to avoid military service, which was mandatory. Those who emigrated tended to be English-speakers with the means to resettle elsewhere.

D. Political Detainees, Health, and
Human Rights

Human rights organizations in South Africa estimate that between 1960 and 1989, some 73,000 detentions—the imprisonment of people without charge or trial—took place. Seventy percent of those, or approximately 51,000 detentions, occurred between 1984 and 1988.¹³ In the first two years of the national state of emergency (June 1986 through June 1988), an estimated 30,000 people were detained without trial under the emergency regulations, of whom up to 40 percent were believed to be children under the age of 18.¹⁴ Exact figures on the numbers of people detained in South Africa and the "independent" homelands are impossible to verify because the government refused to publish such information.

Under emergency legislation, people could be detained incommunicado and without charge or trial for a period up to 30 days, after which the Minister of Law and Order could authorize an extension of the period of detention. Any member of the security forces had the power to arrest and detain any person who, in the opinion of the security force officer, might pose a threat to the "safety of the public or the maintenance of public order" or to "the termination of the state of emergency." The
detainees might be held indefinitely during the declared emergency and without reconsideration of their individual cases as successive states of emergency were declared. Many emergency detainees were held continuously from June 1986 until early 1989 when, following a series of hunger strikes, the majority of those detainees were released. Lawyers and family members had no automatic right of access to the detainee or any official information about the detainee, unless the Minister of Law and Order or Commissioner of Police permitted it.¹⁵

Detention could also occur under the Internal Security Act (ISA) No. 74 of 1982 (and its equivalents in the homelands) for purposes of interrogation, to serve as a witness, or as a "preventive" measure. Between 1986 and 1988, at least 5,700 persons were detained under this security legislation.¹⁶ Under Section 29, a frequently-used provision of the ISA, the detainee could be held indefinitely for purposes of interrogation, at the discretion of the arresting officer and the Minister of Law and Order. The other sections of the Act limited the initial time period for detention but allowed for renewal. The court had almost no jurisdiction over the circumstances of Section 29 detainees. The detainee could be held incommunicado and in solitary confinement, without any access to a lawyer. Persons held under Section 29 were at particularly great risk of torture. Only the Minister of Law and Order, the Commissioner of Police or their designated agents had direct access to information about these detainees.

In the final years of apartheid, the primary targets of detention were trade union leaders, educators, religious workers, students, health workers, lawyers, members of the media, and community organizers. Often relatives were not promptly informed of the detention of a family member until weeks or months later, despite prolonged and sometimes desperate attempts to learn the whereabouts and fate of the person or even to obtain assurances that the detainee was still alive. An overwhelming majority of those detained were eventually released without charge or trial.¹⁷ Of those charged, fewer than five percent were ever convicted of any offense.

E. Deaths in Detention

The Johannesburg-based Human Rights Commission, founded in 1988 by six legal, medical, religious and anti-apartheid organizations, reported in 1989 that at least 68 deaths in detention had occurred since 1963, when laws were first introduced allowing detention without trial. By law, any unnatural death must be investigated by an inquest court, presided over by a magistrate (who is a civil servant) to determine the cause of death. The court may also rule, but rarely did, on the separate issue of responsibility for the death. The courts ruled, often without adequate evidence, that many of the deaths were suicides or accidents, and that others were due to natural causes. In some cases of death in detention, medical negligence was an important contributing factor.

Perhaps the most famous case where medical negligence contributed to the death of a detainee was that of Black Consciousness leader Steven Biko. On 12 September 1977, Mr. Biko died in a prison cell in Pretoria, six days after being interrogated by police. An inquest found that the likely cause of death was a "head injury with associated extensive brain injury, followed by contusion of the blood circulation, disseminated intravascular coagulation as well as renal failure with uremia."¹⁸ In early 1978, an ombudsman with the South African Council of Churches submitted a complaint to the South African Medical and Dental Council (SAMDC), alleging indifferent and irresponsible medical care by the physicians who had attended to Mr. Biko between the time of his assault and the time of his death—medical care that was exposed during the inquest proceedings. The SAMDC is the statutory body responsible for licensing physicians and investigating breaches of professional medical conduct.

In 1980, a SAMDC inquiry committee announced publicly that it had found no prima facie evidence of improper or disgraceful conduct by the doctors who attended Mr. Biko, and the full Council confirmed the finding by a majority vote. Significant portions of the South African medical community, troubled by the failure of the SAMDC to investigate, asked the Medical Association of South Africa (MASA) to consider the matter. The MASA executive committee supported the decision of the SAMDC and criticized those who had brought the charges, asserting that the critics had relied on flawed newspaper reports. The South African Medical Journal refused to publish letters representing views opposed to the leadership. Several prominent MASA members subsequently resigned in protest. A MASA member then persuaded the organization to set up a select committee to examine the ethical issues raised by the medical treatment of Mr. Biko. The committee's findings disagreed with those of the SAMDC. Encouraged by this, several physicians lodged complaints with the SAMDC, but to no avail. The complainants then successfully petitioned the Supreme Court, which set aside the SAMDC's initial findings and ordered the SAMDC to initiate a new inquiry. In July 1985, the SAMDC finally held disciplinary hearings against the doctors who had treated Biko. Two physicians were found guilty of improper behavior; one was eventually stripped of his medical qualifications, the other received a reprimand.¹⁹

NOTES

¹ The South African government classified all persons in South Africa according to race. The four main groups officially recognized were "white," "Indian" (Asians), "colored" (mixed race) and "black" (black Africans). The term "black" was used by anti-apartheid organizations to refer to all persons who were disenfranchised or otherwise discriminated against under the apartheid system. As apartheid affected the Asian, mixed race, and African populations differently, it is necessary to distinguish people according to government race classifications of "Indian," "colored," and "black." When South Africans used the term "black," it was not always clear whether they meant "black" in the sense used by the anti-apartheid organizations or in specific reference to Africans. In this report, the term "black" is used inclusively to refer to all persons of color who were disenfranchised under apartheid.

² In 1984, under the Group Areas Act, 451 of the 899 total group areas were set aside for whites (13.9% of the population) covering 83.6% of the total designated areas. South African 1986: A Permanent State of Emergency. Washington DC: Lawyers' Committee for Civil Rights Under Law, 1987, p. 7.

³ The U.S. Committee for Refugees estimates that 3,570,000 persons were internal refugees in South Africa in 1988. This figure includes persons forcibly relocated in government resettlement programs as a result of their race, religion, ethnicity, social group, or imputed political opinion. Clark, Lance. "Internal Refugees—The Hidden Half." World Refugee Survey-1988 in Review. Washington DC: U.S. Committee for Refugees, 1989.

⁴ Wilson, F. and R. Mamphele. "Children in South Africa, Part I: A Crisis of Caring." Children on the Front Line. 3rd ed. New York: United Nations Children's Fund, 1989, p. 74-76.

⁵ The Community Agency for Social Enquiry. "A National Household Survey of Health Inequalities in South Africa." The Henry J. Kaiser Family Foundation, 1995, p. 10.

⁶ That apartheid policies contributed to the poverty and poor nutrition of many in South Africa has been well documented by UNICEF reports on South Africa and the Second Carnegie Inquiry into Poverty and Development in South Africa. See, for example, Children on the Front Line: A Report for UNICEF. New York, 1989.

⁷ The Community Agency for Social Enquiry, p.11.

⁸ Wilson, F. and M. Ramphele. Uprooting Poverty: The South African Challenge. New York: W.W. Norton and Company, 1989, p. 338.

⁹ Changing Health in South Africa: Towards New Perspectives in Research. Menlo Park, California: The Henry J. Kaiser Family Foundation, 1991, p. 41-42

¹⁰ The Community Agency for Social Enquiry, p.2.

¹¹ Wilson and Ramphele, p. 273.

¹² Medical school in South Africa is a six-year program. Students begin the program as first-year undergraduates at the University.

¹³ "Detention Without Trial." Human Rights Commission Fact Paper 1. Braamfontein: Human Rights Commission, 1988.

¹⁴ DPSC. "Law and Children Under Apartheid," from a summary of the proceedings of a London conference on Children, Apartheid and Repression, April 23, 1988.

¹⁵ In 1986, the denial of automatic right of legal access was successfully challenged in the courts. Although the Appeal Court ruled in 1987 that the state president did have the power to make emergency regulations that denied right of legal access, persistent lawyers have been able to obtain permission from the Commissioner of Police to see emergency detainees.

¹⁶ Human Rights Commission Fact Paper 1.

¹⁷ Ibid. The HRC reports that 75 to 80 percent of all detentions since 1981 resulted in release without charge.

¹⁸ Rayner, p. 26.

¹⁹ The SAMDC found Dr. Ivor Lang guilty of improper conduct on five counts that he (1) had issued an incorrect medical certificate and a misleading bed letter (medical record); (2) had failed to examine the patient properly; (3) had failed to inquire into and ascertain the possibilities of a head injury; (4) had failed to obtain a proper medical history of the patient; and (5) had failed to observe the patient and keep proper notes. Dr. Lang was given a caution and a reprimand. The SAMDC found Dr. Benjamin Tucker guilty of improper and disgraceful conduct on three counts that he (1) had failed to object to the patient's transportation in a Land Rover to Pretoria from Port Elizabeth (750 miles); (2) should have insisted upon transportation by ambulance with proper medical attendants and the patient's medical records; and (3) failed to make a proper medical check before stating that the patient's central nervous system had shown no changes between examinations. Dr. Tucker received a suspension of three months from the medical rolls, but the Council recommended that the punishment be delayed for two years, conditional on his not being found guilty by the Council of any other contravention during this period. He was later stripped of his medical qualifications. Rayner, p. 44-45.