SECTOR ANALYSES

During the long decades of apartheid, and in the century or more of essentially colonial and racist governance that preceded it, many organizations, groups and individuals contributed to the massive violations of human rights in the health sector. Chief among these, of course, were the successive Departments of Health (later, ominously, renamed the Department of Health and Population Control) as the authors of the policies and regulations that legalized and furthered rigid segregation, gross inequity and neglect, and pervasive racial discrimination in every aspect of the provision of health services.

A wide variety of health professional organizations served as willing—even eager—handmaidens to these efforts, by actively defending the apartheid social order and its structures and policies in the health sector, ignoring or denying its consequences to the health of subject populations and refusing to acknowledge, until far too late in the day, its violations of fundamental principles of medical ethics and human rights. On an individual level, a cumulative total of hundreds of thousands of physicians, dentists, nurses, psychologists and other health workers in both the private and public sectors, in varying degrees, supported apartheid health care or acceded to it without complaint, maintained segregated offices, delivered racially inequitable care, and in numerous instances were directly complicit in human rights and medical ethics violations that resulted in injury and death. A subset of this number—some of the district surgeons responsible for the care of prisoners and detainees—acted as coconspirators with security police in torture, denial or neglect of even minimal medical care, violation of physicianpatient confidentiality, falsification of records and other abuses.

In sum, apartheid support and racist ideologies and practices were pervasive in the health professions and their professional organizations, a chilling indication of the ease with which the basic commitments of medicine and its allied professions can be coopted by political ideology. By no means, however, was this surrender total.

Any analysis must also recognize that there were thousands of physicians and other health workers who openly and persistently opposed apartheid and its health practices, often at great personal risk, and formed professional organizations that actively conducted the struggle on both the national and international levels.

1. The Medical Association of South Africa

The Medical Association of South Africa (MASA) is the national organization of physicians in South Africa, representing well over 10,000 doctors. MASA's decades of compliance with—and often active support of—apartheid's human rights violations are well documented in detail in a multitude of formal submissions to the TRC, most notably and extensively that of the Health and Human Rights Project, Professional Accountability in South Africa,¹ and, in fairness, by the candid release of numerous and sometimes damning internal documents and records in MASA's own submission.²

There is no need here to repeat that history, so amply documented from so many sources. A brief summary analysis of its major features might be presented as follows:

· MASA never opposed, nor acknowledged, the health consequences of the Group Areas Act, the forced relocation of millions of people of color, and the lifethreatening conditions and lack of health care in the resulting "homelands;"

· MASA consistently ignored the disastrous health consequences of virtually all other apartheid policies;

· MASA published pseudoscientific racist articles in its journal and never questioned the false biological and social premises underlying apartheid's racial policies and legislation;

· For most of its existence, until 1989, MASA did not oppose racial segregation and, more recently, attempted to justify it by suggesting that "separate but equal" was a satisfactory policy;

· MASA cooperated actively with the apartheid Department of Health, bestowed honors on senior apartheid leaders, and developed a culture of being entirely comfortable with repressive and discriminatory
policies;

· In the Biko case, MASA effectively supported the decision of the preliminary inquiry that absolved the physicians of any misconduct, accepted and supported the same ruling by the full South African Medical and Dental Council, argued against any reopening of the case, attacked criticisms of these decisions as "political," and suppressed the publication of dissenting articles and letters (including many from its own members) in its journal;³

· MASA refused to acknowledge or investigate the many subsequent and massively reported instances of torture, police brutality and other abuses of detainees, including those cases in which the participation of district surgeons in assistance, cover-up or neglect was reported, and refused to support district surgeons like Wendy Orr who brought detention abuses to light.

· In 1983, a MASA Ad Hoc Committee of Enquiry into the medical care of prisoners and detainees noting evidence of "physical as well as psychological coercion," asserted that it had not been able to establish conclusively the truth of many of the allegations, admitted that "there have been cases of serious maltreatment of detainees...that may have extremely serious and possibly permanent effects on (their) physical and mental health,"⁴ and proposed rigorous standards for the prevention of torture and the independence of district surgeons—and then suggested that all this be overseen by committees jointly appointed by MASA and the government responsible for the violations;

· Especially in the 1980s, MASA ignored the litany of deaths in detention and unquestioningly accepted the assurances of government officials that there were no human rights violations, despite evidence of abandonment of ethical responsibilities at every level from physical examination through diagnosis and treatment, to autopsy reporting, and including violations of confidentiality and physician identification of patients with gunshot wounds;

· Instead, MASA actively attacked those of its members who protested these policies, collected and published systematic evidence of abuses, or sought court interdiction to prevent them, and vehemently opposed or dismissed the efforts of NAMDA and other antiapartheid health organizations, both domestic and international;

· During much of the 1980s, at least, MASA's ruling body, the Federal Council, was effectively controlled in turn by physicianmembers of the Broederbond, and on occasion the Council published blatantly political statements describing township violence as a "Sovietinspired assault on South Africa" and "a MarxistLeninistinspired effort to bring political change by overthrowing the present South African government by any means." This faithfully echoed the rationale offered by the apartheid government: that a "total onslaught" justified the State of Emergency and all its attendant repressions.

No brief summary of this sort can adequately represent the thousands of pages of testimony about MASA's role that have been submitted to the TRC. Taken as a whole, they describe, for a significant majority of South Africa's white physicians and the professional organization that represented them, the effective abandonment of fundamental medical ethics and human rights commitments in defense of a political ideology and maintenance of a racist status quo. This history is hardly unique to South Africa; to a significant degree, it reprises the behavior of much of the medical profession and its organizations in Nazi Germany, the Soviet Union, and other totalitarian states in this century. The facility with which such commitments can be undermined, and the frequency with which this has occurred even after the Nuremberg trials and the formal adoption of international instruments defining the human rights obligations of health professionals, should be matters of grave concern.

Starting in about 1989, MASA started taking a very different posture than the one it had adopted in the past. It adopted the World Medical Association policy on hunger strikers, issued a statement deploring detention without trial, and called for a non-discriminatory society and the end of apartheid.

In its submission to the TRC, MASA highlighted these changes, contending that it has "assumed a role in social responsibility," begun to "develop a human rights initiative which has had a number of worthy successes," reexamined its principles and established a "law and ethics team" to offer practical assistance to doctors "faced with human rights dilemmas."
The centerpiece of the "new" MASA was its June 1995 public "apology" for its failure to oppose apartheid policies. It stated:

MASA has never embraced a racebased policy and its membership has always been open to all, irrespective of race, color or creed. However, the Association was perceived both at home and abroad, as an essentially white organization and a captive of the political [status quo]. In this respect, MASA remained silent about racebased public policies affecting the medical profession, the restriction of medical school admissions on race, segregation of hospitals and other health facilities, the maintenance of separate waiting rooms by members of the profession, the involvement of medical doctors in the treatment of prisoners and detainees, and there are others. Furthermore, the Association was perceived as, and probably was, insensitive and indifferent to the lot of its black members such as when branch meetings were scheduled at venues where they were legally barred. In the spirit of national reconciliation and to the extent that through these and possibly other acts of omission or commission, the Association may have caused offence or hurt to persons within and outside of the medical fraternity, MASA offers an unreserved apology. We are confident that our commitment to the MASA credo and the code of conduct will ensure that we can more explicitly and proactively address similar matters in future. This statement is a statement of intent and promise and we hope it will stand as a beacon of the completion of our transition.⁵

This formal apology was promptly questioned by critics as a selfdeclared and collective blanket amnesty, when many individual doctors had not disclosed their own involvement in human rights violations. In this view, the apology was a suspect and superficial transformation; it implicitly attempted to close the books on the past, and specifically to obviate the need for ongoing, casebycase investigation to achieve professional accountability for the physicians involved, through active participation, collusion, neglect or denial, in the tens of thousands of
documented cases of torture and other gross violations reported to the TRC. Other critics called attention to MASA's long acceptance of the "lesser" crimes of the apartheid medical establishment, such as the harshly restrictive and humiliating conditions of undergraduate and graduate medical training for nonwhites.

The submission made by MASA to the Truth and Reconciliation Commission mirrors the apology; it is a mixture of forthright admissions and concessions on specific points of previously denied (but now documented) internal decisions and statements, on one hand, but halftruths, disingenuous and misleading qualifiers, euphemisms, internal contradictions and vague promises, on the other. In these respects it reflects the organization's slow and grudging movement from a sordid human rights past toward an accommodation with the commitments of postapartheid South Africa.

For example, in its introductory account of what it calls MASA's "human rights development," the submission concedes that from its inception in 1927, "MASA was relatively silent on human rights initiatives and was part of the apartheid system," but adds that this was true only "until 1977 (the year in which Steve Biko died)." In fact, MASA did not declare its unqualified opposition to apartheid medicine and apartheid itself until 1989, and was a systematic and unwavering supporter of apartheid abuses throughout most of the intervening years. During this 192781 phase, the submission states, "there were one or two minor incidents of conflict with other medical associations at the World Medical Association..." These "minor conflicts" include, among others, MASA's expulsion from the Commonwealth Medical Association and its effective expulsion (disguised as a voluntary resignation] from the World Medical Association in response to protests from outraged medical societies in many other nations.

In the next phase of its "human rights development," the written submission suggests that from 1982 88 "MASA actively began to address its human rights role" and then adds, without apparent irony, that "the period started with justification and defense of apartheid medicine." It goes on to claim that "MASA began a series of human rights initiatives surrounding children in detention and the care of prisoners and detainees, but these initiatives were not successful." In fact, as its own documentation and the TRC submissions of other organizations make clear, during this period MASA never opposed the detention without trial, interrogation and imprisonment of children—as many as 30,000 children, by reliable
estimates—but rather proposed terms and conditions to make such incarceration "acceptable." Similarly, its only active intervention regarding the medical care of adult prisoners and detainees was to negotiate a deal with the apartheid government under which a panel of volunteer MASA members, subject to screening and approval by security forces, would be available to such prisoners for "second opinions" on their medical problems, if prisoners requested their help and could afford to pay their fees.

Some of these issues are discussed in the final sections of MASA's formal submission to the TRC. These sections, particularly the one entitled "understanding the context," include much more detailed and specific admissions of culpability than does the brief "MASA Apology" mentioned above.

Most notably, the submission refers to attempts to change the structure of MASA's membership and governance by merger with "other doctor organizations"—its progressive opponents of the past. It calls for general human rights training within medical ethics education, special human rights training for district surgeons and forensic pathologists, and formation of a health and human rights organization to "provide a mechanism by which investigations into human rights violations may be conducted." These commitments were accompanied by publication of previously suppressed letters concerning MASA's behavior in the case of the Biko doctors in the June 1997 issue of its journal, the South African Medical Journal.

In our view, these are important initiatives and can be seen as hopeful signs of a new commitment to human rights. Paramount among them is the reported effort to form what would be in effect a truly new professional organization, combining MASA with the Progressive Doctors Group on terms that might, for the first time, give the interests of South Africa's majority population a dominant voice in the organization's leadership and policies. Of necessity, however, these are "topdown" initiatives. Any lasting transformation also requires "bottomup" change—that is, the full acknowledgement of past error (and, where it has occurred, individual involvement in violations) by all of South Africa's physicians, and the true incorporation of a human rights ethic into their daily practices.

At the same time, the leadership from the past must demonstrate its commitment over and over again not simply through statements of intent, but through action. The June issue of the South African Medical Journal editorialized that, "[a]n examination of medicine in our country suggests that racism, which has pervaded every aspect of our society, is the underlying cause that has resulted in the gross violations for which we bear collective responsibility."⁶ MASA states that it wants to cleanse that racism. It has taken some steps in that direction. It must take many more.

2. The National Medical and Dental Association

The history of the National Medical and Dental Association (NAMDA) is testimony to the fact that compliance and complicity with apartheid and apartheid medicine did not uniformly characterize South Africa's physicians.⁷ Among their number were more than a thousand men and women of all racial groups who were willing to act openly and vehemently to oppose the abuses, and ethical and human rights violations of the apartheid system; to document its effects; and to campaign on both national and international levels for change. (There were undoubtedly thousands more who shared this opposition. Many elected to emigrate; others were silent or merely financial supporters rather than formal organization members.) In the process, they created an alternative to MASA—a professional organization that viewed apartheid medicine as intrinsically unethical, acted on that principle, and demanded professional accountability.

They did so at substantial risk. Members were harassed and sometimes arrested and detained without trial by security police. The homes of some NAMDA leaders were bombed, and many others received death threats. NAMDA offices were raided, probably by security police, and computer files and other documents were stolen. Members were effectively barred from employment in the health system's public sector, which was controlled by the government. And, from its inception, NAMDA was systematically criticized and vehemently denounced by MASA, its dental counterpart, DASA (the Dental Association of South Africa), by their respective journals, and by the government. Many medical student members had to flee into exile to avoid imprisonment.

NAMDA was formed by 52 physicians in December 1982, in concert with the creation of the Health Workers Association, which enlisted non-physician health workers in the same cause. During the ensuing decade it worked closely with its professional and lay counterparts, including the Organization for Appropriate Social Services for South Africa (OASSSA), the Detainees' Parents Support Committee, the South African Council of Churches, and a number of local ad hoc medical and dental committees. Although its base was strongest at academic medical centers, NAMDA's membership included doctors and dentists in private practice and in both urban and rural areas.

From 1982 to 1992, when it merged with other progressive organizations to form the South African Health and Social Services Organization (SAHSSO), NAMDA conducted seven major programs:

· Care of former political prisoners and detainees and their families. Jointly with OASSSA and the Detainees' Parents Support Committee, NAMDA established clinics for the physical and psychological examination of released detainees who had suffered trauma, and arranged for follow-up medical and psychological care and counseling.

· Provision of emergency medical care for victims of state violence. NAMDA sent doctors into townships after police assaults on peaceful demonstrators, since victims (often with gunshot wounds) were either blocked from access to hospitals or feared arrest if they were seen there. Doctors treated such patients in churches and other safe facilities. When this program was systematically hampered by police harassment of the physicians, NAMDA helped to form a National Emergency Services Groups Network, at seven regional bases across South Africa, to train local community residents as community health workers. Training committees of doctors, psychologists, and nurses provided materials and instruction in basic trauma and psycho-supportive first aid.

· Documentation of the standardized interviews with recently released detainees. NAMDA provided evidence that shocking percentages—from 75 to 96 percent—had been beaten, tortured with electrical shocks, subjected to partial suffocation, burned with acid, held in solitary confinement for long periods, or subjected to other abuses under detention. More than half of the respondents had never been seen by a district surgeon; of those who were, more than 65 percent believed the medical history and physical examination to be inadequate. The NAMDA survey, widely reported though denied official publication in South Africa, provided some of the strongest evidence to refute government denials of abuse.
· Conduct of a national campaign to expose the effects of apartheid on health. NAMDA campaigned to end the segregation of hospitals by race, to open all hospital facilities to all races, and to achieve de facto integration of in-patient facilities.

· Research and initiatives on health policy. NAMDA prepared and publicized detailed policy papers on a national health system for South Africa, health care financing, and medical education.

· International campaigns. These were among the most important and effective of the organization's initiatives. NAMDA members published papers on the health effects of apartheid medicine, detention and other abuses in medical journals in the United States, the United Kingdom, the Scandinavian countries and elsewhere. The organization established contact with human rights organizations in the U.S., Europe and the Third World, and cooperated in the formation of NAMDA support organizations in those countries.

NAMDA officers and members made international speaking tours (when they were able to obtain permits to travel outside South Africa). Directly and indirectly, NAMDA made repeated and effective appeals to international and national professional medical associations to exclude MASA and similar South African professional organizations from participation. To deepen the international pressure that was being applied to South Africa, NAMDA called for an academic boycott to limit outside professional contact and visits to MASA, DASA, South African government agencies and academic centers that supported apartheid. As a corollary, NAMDA engaged international agencies to provide support to enable black South Africans to receive health professional training abroad.

· Special programs. NAMDA physicians served as volunteer observers at post-mortem examinations of victims of apartheid state violence, provided funds for the funerals of such victims, assisted trade unions with health and safety programs, and, later, assisted with the health needs of returning South African exiles.

In many of these respects, NAMDA was thus a diametrically opposed image of MASA, and a signal that even under the most oppressive conditions there will be physicians who recognize social responsibilities and struggle to maintain ethical and human rights standards.
In 1992, NAMDA merged with other progressive organizations to form the South African Health and Social Services Organization (SAHSSO). Following the elections in 1994, many NAMDA leaders and members assumed senior positions in government service. A core group of former NAMDA doctors rallying around the umbrella of the Progressive Doctors' Group began discussions with MASA in 1995 about forming a united medical association and agreed to merge in October 1997. The future of the South African medical profession's commitment to human rights may well depend on the success of the former NAMDA members in influencing both the governance and the values of MASA members. The veterans of NAMDA's decade of work should be an important resource for the ongoing restructuring of South Africa's health care system, for provision of medical care to address the continuing physical and emotional needs of former detainees, and for the accomplishment of ethical and human rights training for the entire health work force.

3. Psychology

The profession of psychology in South Africa promulgated and reinforced many of the racist ideas underlying apartheid.⁸ By the 1920s, theories of black inferiority were becoming part of the "scholarship" of psychology in South Africa. Psychologists proposed legislation to limit job opportunities for blacks and severely penalize sexual relationships between the races. This tradition continued throughout most of the 20th century: theories of black inferiority flourished while little attention was paid to the problems of the effects of racism and oppression on the black majority in the country.

One of the profession's architects was Dr. Hendrik F. Verwoed, a professor of psychology at Stellenbosch, who later became prime minister. Verwoed embraced psychiatric genetics, which theorized that blacks are genetically inferior and suitable only for manual labor. He saw the future of South Africa at great risk if blacks were permitted to improve their skills and draw better wages. As the profession of psychology evolved, additional theories of black inferiority emerged. When he became prime minister, leading psychologists approached him to extend the Group Areas Act to ban meetings between blacks and whites.
The behavior of professional associations reflected this stance. In 1957, a black person applied for membership in the South African Psychological Association, fueling a debate that lasted for years. In 1962, blacks were finally admitted to the Association, which in turned triggered a walkout by whites who formed the explicitly pro-apartheid Psychological Institute of South Africa. The two organizations finally merged in 1983 to form the Psychological Association of South Africa (PASA), which had no racially exclusive clauses. However, as the Health and Human Rights Project points out, this merger did not amount to a political statement against apartheid and did not end control by conservative forces within the profession.⁹ On the contrary, race-based psychological theories remained tolerated and even encouraged within the Association. PASA did not take positions against apartheid, or even against pervasive use of torture.

Despite this stance by the institutions of the profession, psychology, like the other health professions, also included those who sought to fight apartheid. Some of these individuals joined with other social service workers to form the progressive Organization of Appropriate Social Services in South Africa (OASSSA). In 1987, the Institute for Clinical Psychology called for removal of apartheid structures, an end to indefinite detention without trial and solitary confinement, unconditional cessation of the detention of children, the reinstatement of freedom of speech and removal of restrictions on the media, and the lifting of the state of emergency.

Individual psychologists played an important role in human rights abuses under apartheid, particularly in the prisons. Some psychologists became agents of the security forces by seeking information from political prisoners and detainees. Others participated in torture.

When apartheid ended, the Psychological Association of South Africa dissolved, and a non-discriminatory organization, the Psychological Society of South Africa, now represents psychologists in South Africa. The society is still dominated by the 85-90 percent of members who are white. Of the few black psychologists in the profession, only a handful speak African languages.

With the end of apartheid, there is an enormous need for skilled professionals who can help people cope with trauma or post-traumatic stress. But psychology has remained focused as an academic field with little attention to the needs of the population as a whole. Efforts are underway to organize black psychologists and to encourage them to be responsive to the needs of South Africans.

4. Nursing¹⁰

The apartheid state went to great lengths to maintain segregation within the nursing profession. Laws enacted in 1957 and 1978 kept black nurses off the boards of the South African Nursing Association and the South African Nursing Council. Later, black nurses were excluded from the South African Nursing Association entirely. Registers segregated by race perpetuated separate and unequal professional standards. By 1973, the International Council of Nurses sanctioned the South African organization for its racist composition and policies.

Black nurses were especially ill-treated. Their education was inferior to that of white nurses, as they were forced to train in badly equipped hospitals and, later, nursing colleges. Their schools had far more limited resources than those of their white counterparts. Inferior education was matched by extraordinarily difficult working conditions, characterized by long hours, jobs at locations far from their homes, and degrading treatment by white superiors. They were routinely deprived of their dignity on the job. For example, no black nurse could supervise a more junior and less experienced white nurse. Black nurses on white wards were often relegated to menial tasks like emptying bedpans or serving tea. One result of these policies was to put patient health at risk, since the skills of black nurses were ignored even when they were essential for the well-being of patients. The black nurse was trained, most of all, to play a subservient role. Those who dared to speak out were labeled as troublemakers, dissidents, or even enemies of the state.

Nursing, however, was one of the first of the health professions to make a commitment to end discrimination within the profession. In 1978, the South African Nursing Association sought to end the policy allowing only whites to be represented on the Nursing Council. Still, its commitment to an anti-apartheid stance was not thoroughgoing: when, in 1985, black nurses engaged in a strike against apartheid and its denial of equal pay and working conditions, the Association condemned them for bringing the profession into disrepute by engaging in a prohibited strike.

Beginning in 1992, nursing organizations worked toward unifying the profession under principles of non-discrimination, finally resulting in the establishment of the Democratic Nursing Organization of South Africa (DENOSA) in 1995, which replaced the South African Nursing Association and associations from the homelands. The formation of the DENOSA is an important step toward the development of a culture of human rights among nursing professionals and a means of assuring that human rights are sustained in South Africa's health care system.

The challenges facing the nursing profession are daunting. Training institutions still tend to be separated: while formerly white institutions have brought black students in, formerly black institutions have remained largely black, principally as a result of their location in former homelands, poor infrastructure, and lack of adequate housing. The nurses' strike of 1995 illustrates the problems on the ground. It concerned working conditions including patient load (including as many as three patients to a bed), inadequate facilities, and a shortage of supplies.

NOTES

¹ HHRP. June 1997.

² Most of the data in this section are drawn from Third Draft of the Submission by MASA to the Truth and Reconciliation Commission, June 1997.

³ Id., p. 5-14.

⁴ Id., p.51. See also discussion on page 61 of this report.

⁵ Id., p. 30.

⁶ Kirsch, R.E. "Doctors and the TRC: Confronting Our Past," South African Medical Journal, vol. 87, June 1997, p. 711.

⁷ Most of the material in this section is drawn from the "Submission to the Truth and Reconciliation Commission on Behalf of the Progressive Doctors' Group (PDG) in respect of the National Medical and Dental Association," May 1997.

⁸ Nicholas, Lionel J. "The Response of South African Professional Psychology Associations to Apartheid," Journal of the History of the Behavioral Sciences," 1990.

⁹ HHRP, Chapter 3, Section 6.

¹⁰ Preliminary Submission to the Truth and Reconciliation Commission. Democratic Nursing Association of South Africa (DENOSA), May 26,1997.