SECTOR ANALYSES

Health education has far-reaching and long-lasting effects for health personnel and their health practices. It has a formative effect on conceptualizations of health and human suffering, and consequently the scope of professional interests in society. Furthermore, educators provide role models which students often emulate, and ideas about questioning authority and one's role in relation to the state.

In South Africa, education and training in the health sector played an important role supporting the racist ideology of apartheid. Support of the political aims of apartheid is evident in years of highly discriminatory selection processes of medical and other health professional students and discriminatory and demeaning treatment of students of color. Such discrimination served to establish and maintain a health care system that primarily served the health interests of white South Africans.

Under the University Extension Act of 1959, "non-white" students were accepted into universities only with ministerial permission. The University Extension Act and the Bantu education system effectively excluded most Africans from being educated as health practitioners. Indian, colored and Chinese students were generally given approval for admission into medical school, but Africans were usually refused ministerial consent. According to the Ministry of Health, in 1978, 83 percent of Indian and 95 percent of colored applicants were granted permission, compared to only 29 percent of African applicants. Between 1968 and 1977, 88 percent of all new doctors were white (whose percentage of the population was less than 20 percent) and 3 percent were African (who comprised about 70 percent of the population).²⁴

Discrimination in the selection of health professional students has had profound effects on the composition and geographical distribution of health care providers in South Africa. According to Kale, more than 25,000 doctors are registered in South Africa to serve a population of about 40 million. The number of doctors who are actually in practice is probably lower because of emigration. Between 1975 and 1981, as many as 30 percent of graduates from the English-speaking universities left South Africa. In 1985, 94 percent of specialists and 83 percent of all doctors were white. The number of non-white students admitted to medical colleges has increased in recent years. The distribution of doctors is skewed in favor of urban areas and the Western Cape province, which has nine times more doctors than the northern Transvaal. More than half of South Africa's doctors are in the private sector, which serves only 20 percent of the population. In 1990, of the nearly 155,000 nurses in South Africa, over half were Africans, a third were white and over 21,000 were colored. The distribution of nurses is also skewed. The Western Cape area has three and a half times as many nurses as the northern Transvaal.
Dentists, pharmacists, and other supplementary health professionals are also maldistributed. Most of the 2,900 community pharmacists are concentrated in urban areas. One pharmacy serves 616 white people, whereas black people have only one pharmacy to every 232,992 people. Fewer than 4,000 dentists serve South Africa's 40 million people and most are in private practice. Those who are not in the private sector do little more than pull teeth. The dentist to population ratio in the northern Transvaal region is 1:50,000, and is even lower in the former homelands. ²⁵

During apartheid, the government developed educational programs in the health sector specifically for black students. Many believe that the founding of Medical University of Southern Africa (MEDUNSA) in 1976 was part of the "grand apartheid" plan, which was aimed at having fewer black doctors trained at "white" universities. Increasing the number of black doctors and other health professionals also served to maintain the health of the black labor force and to prevent the spread of diseases from black migrant laborers and domestic workers to white communities. MEDUNSA has produced more African doctors than any other medical school in South Africa. Some consider health education at MEDUNSA to be racist and second class, while others see it as affirmative action for those denied access to white institutions due to the inadequacy of Bantu education.

During the apartheid years, students in the health sector experienced discriminatory and demeaning treatment. In many cases, health educators served as models of supporting extreme discrimination. Most training institutions that were attached to white hospitals prohibited black trainees from examining and treating white patients. White students, on the other hand, were able to examine and treat all patients. When black students were allowed into the "European" hospitals, they were often not allowed to wear their white coats or stethoscopes. Black students generally were not allowed to attend professorial ward rounds since they were conducted in white hospitals. In the 1980s, black students were permitted to examine white patients, but not those who had obstetric or gynecological problems. For many years, black students were not allowed to attend post-mortem examinations of white bodies. Because of the Group Areas Act, black students trained at "white" universities were not allowed to stay at any of the official university residences for many years. This meant that students had to find their own accommodations and finance their daily commute to the medical school and health facilities. Personnel working in the same facility and with the same qualifications had separate toilets and separate tea rooms. At the University of Natal, black students were not allowed to use the sports facilities or library on the main campus. In fact, black students were not allowed to wear the blazer with the emblem of the University. Such discriminatory conditions persisted after graduation in the form of less pay for equal work and being bypassed for promotion and appointments to administrative positions. Marked differences in resources and funding of health facilities which served people of color had a major influence on the quality of education for non-white students in the health professions.²⁶

After 1986, health professional schools were permitted to admit black students to the student body. Affirmative action programs developed at a number of institutions. From 1986 until 1990, the University of Cape Town Medical School admitted into its six-year year MBChB program the top African applicants who were eligible (by virtue of completing some college), irrespective of these students' competitiveness with applicants of other races. This affirmative action program proved unsuccessful in the absence of academic support programs; only 46 percent of these students passed the first year on the first attempt, and by the fourth year, only 15 percent were still on track and 36 percent had been excluded from the school.²⁷

In 1991, the University of Cape Town Medical School instituted the Medical Academic Support Program (MEDASP) and African students achieved greater success. The program enabled the students to complete the first three pre-clinical years of the regular program over four years, and sought to enhance the students' study and language skills and to supplement their backgrounds in physics and chemistry. Students then entered their clinical training on an equal footing with the regular program colleagues. Forty-five percent of students in their fourth MEDSAP year were still on track (having reached the third year of the regular program) and, while 23 percent had been excluded, these exclusions mostly occurred at the end of the first year. In 1994, Africans accounted for 24 percent of admitees, whites made up 45.3 percent and 30.7 percent were from other minority groups.²⁸ Academic support programs achieved similar results at other institutions. A number of medical schools have now committed to increasing black enrollment.
During apartheid, health education failed to include human rights and bioethics concerns in virtually all health institutions. Health education and practice in South Africa focused primarily on tertiary medical care.²⁹ Historically, health educators have provided students with disease-based conceptualizations of health and human suffering which neglected the importance of social determinates of health. National regulatory bodies such as the SAMDC and SANC are responsible for setting standards in health education. In 1986, the SAMDC required only one hour of "medical ethics" training among undergraduate medical students.³⁰ Consequently, most students in the health sector have received little or no formal training in bioethics. Despite the lack of leadership among national health regulatory bodies, traditional bioethics training has developed at the University of Cape Town and Witwatersrand medical schools in recent years through considerable efforts of individual health educators at these institutions.

The importance of including human rights concerns in education is only just beginning to be recognized in the health sector. Unfortunately, bioethics training in South Africa has focused primarily on codes of conduct which regulate clinical encounters with individual patients. Such codes of conduct have not been applied to the health consequences of human rights violations; nor have they been interpreted as a mandate to protect and promote rights as a means of promoting the conditions for health and well-being. Bioethicists and individual health educators are increasingly recognizing the importance of human rights education for health practitioners. Over the past few years, several elective courses in health and human rights have been offered, particularly at the University of Cape Town School of Medicine. Such courses represent important steps in understanding the relationship between health and human rights and actively engaging health practitioners in the protection and promotion of human rights.

In the future, systematic inclusion of human rights concerns in health education will depend largely on leadership from national health regulatory bodies and health professional organizations. Given the intimate relationship between these organizations and the apartheid state in the past, it is not surprising that human rights concerns were excluded from health education. What is perhaps more disturbing is the persistent lack of concern for human rights education among these organizations today. The health sector hearings demonstrated that these organizations have not embraced the notion that health promotion requires health practitioners to protect and promote human rights nor recognized their responsibility to provide effective leadership to this end. The TRC's health sector recommendations hopefully will serve as a wake-up call for the effective inclusion of human rights education in the health sector.

NOTES

²⁴ Department of Health.

²⁵ Kale. "South Africa's Health: New South Africa's Doctors: A State of Flux." British Medical Journal, 1995; 310:1307-11.

²⁶ "University of Natal Medical School Submission to the Truth and Reconciliation Commission," 1997.

²⁷ RP Colborn. "Affirmative Action and Academic Support: African Medical Students at the University of Cape Town. Medical Education," 29:110-118, 1995.

²⁸ Ibid.

²⁹ In 1995, Kale (p. 1397-9) reported that 75% of the health budget was spent on hospitals and academic institutions.

³⁰ Benatar SR. "Teaching medical ethics in South Africa." South African Medical Journal. 73: 449-452, 1986.