SECTOR ANALYSES

Apartheid systematically and explicitly denied the human rights of people with mental retardation and mental illness. Racially segregated hospitals housed tens of thousands of people, and the facilities for the black majority received only a third of the funds available to whites.
Community-based programs have enabled people with mental disabilities throughout the world to escape stultifying custodial confinement, but in South Africa their availability was constricted by legal limitations, academic indifference, and a government interested principally in custodial confinement. Many of the most basic rights of people with mental disabilities were not—and still are not—recognized in law.

Apartheid inflicted pain and psychological trauma on millions of black South Africans, from the violence the regime inflicted on the young to the denial of human dignity embodied in the apartheid laws and their implementation. The impressive work of trauma centers in South Africa does not meet the enormous and continuing need for treatment and rehabilitation.

1. Human rights, mental illness and mental retardation

People with mental illness and mental retardation are especially vulnerable to discrimination and abuse in many parts of the world.⁶⁶ In South Africa, apartheid greatly exacerbated this problem since black people with mental illness and mental retardation were doubly stigmatized and systematically subject to discrimination on the basis of both race and disability. During the past twenty years, many reports have demonstrated the effect of apartheid on people with mental disabilities. A 1977 World Health Organization (WHO) report found "gross inequalities" in mental health care.⁶⁷ It also expressed grave concern about the institutionalization of thousands of South Africans in private facilities (then known as Smith Mitchell facilities) that provided only custodial care for people with chronic mental illness and mental retardation.

Reimbursement for patients in these facilities, WHO found, was three times greater for institutions housing white patients than for those housing blacks. Two years later, an American Psychiatric Association inspection of Smith Mitchell facilities found grossly inferior conditions for blacks as compared to those for whites, needless deaths in institutions, unacceptable medical practices, physical abuse, and inadequate hygiene, housing, and clothing. It also reported on the destructive impact of apartheid on black individuals and families.⁶⁸ In 1981, another WHO report focused on the lack of data on psychiatric morbidity or research into the impact on black individuals and families of apartheid practices such as the forced breakup of families and forced migrations.⁶⁹
As part of its 1989 report, Apartheid Medicine, the American Association for the Advancement of Science examined mental health services under apartheid. It noted the tiny number of blacks trained in Western mental health professions and the lack of incorporation of aspects of traditional healing into therapy. It reported on the continuing fragmentation of services by race, particularly in efforts to develop community-based services. In the area of mental retardation, AAAS noted that, in addition to other factors, urbanization and the disruption of the African family impeded the development of adequate support services. Institutional conditions had improved in the Smith Mitchell facility AAAS visited, but the quality of acute psychiatric care in three public hospitals was highly variable. Overall, AAAS found that apartheid prevented the rational allocation of mental health resources and made continuity of care extremely difficult.

In February 1995, Dr. Diamini-Zuma, Minister of Health for South Africa, appointed a Mental Health and Substance Abuse Committee to address issues relating to the provision of mental health services. The Committee was chaired by Professor T.B. Pretorious, and included representatives of universities, the Department of Health, the Medical Association of South Africa, Lawyers for Human Rights and others. In November 1995, the Committee issued its report, entitled "Human Rights Violations and Alleged Malpractices in Psychiatric Institutions."⁷⁰

The lengthy report was based on visits to dozens of public and private psychiatric institutions and addressed concerns ranging from basic living conditions to staff training to due process and human rights. The report identified major human rights violations, particularly in formerly black hospitals and formerly black sections of hospitals. Although the report has been criticized for methodological flaws, the raw observations of the Committee show how thoroughly and deeply institutions housing thousands of South Africans violate their human rights. These violations include gross inadequacies in housing, basic sanitation and nutrition; sexual abuse; racial discrimination; abuses in the use of physical restraints and denial of medical treatment; over-medication; lack of complaint systems; lack of privacy; and assaults on patients by staff. Some of the facilities were filthy. To our knowledge, no follow-up has taken place to the investigation and report.
In the fall of 1996, the American Psychiatric Association (APA) sent a delegation of thirteen professionals, led by its former president, Mary Jane England, to South Africa to assess the state of mental health services in South Africa. The delegation visited four medical school departments of psychiatry and met with government officials, TRC members and business leaders. It found major personnel shortages, dependence on an institutional model of services, lack of family or consumer participation and, among white professionals at least, a sense of paralysis regarding hopes for change. The report did not specifically address human rights, particularly among institutionalized people, nor mental retardation services.

The APA team recommended technical assistance to nurses, social workers, families and consumers, and psychiatrists regarding multi-disciplinary community-based systems of mental health care, de-institutionalization, support for families and consumers, and guidelines and treatment protocols.

The submission of the Society of Psychiatrists of South Africa to the TRC summarized the circumstances of people with mental illness and mental retardation in South Africa succinctly: "Psychiatric patients remain a vulnerable group for discrimination and abuse of Human Rights. Both the mentally ill and the mentally handicapped [retarded] are clearly stigmatized and thus discriminated against."⁷¹

During the apartheid period, however, the Society failed to provide significant leadership in addressing these abuses. As a tiny organization whose membership ranged from 100 to 150 members over the years, the Society felt under siege from the stream of reports attacking apartheid and psychiatrists' role in it. In 1984, a call was made to expel the Society from the World Psychiatric Association. Though this movement and similar efforts later in the decade failed, the Society acted defensively rather than taking the initiative to promote human rights.

In 1985 the Society took the position that it would strive for the elimination of all forms of discrimination that harm mental health, but it fell short of calling for an end to apartheid, and many of its statements were equivocal at best. For example, in 1986, it issued a statement on the mental health effects of criminal detention. The statement notes vaguely that "detention in isolation, solitary confinement and immoderate interrogation may, in our opinion, damage the mental health of many persons so detained." It noted, however, that "justice must be done and security maintained," and advised that "this should not be done in a manner that diminishes the dignity of the individual or the integrity of his or her mind and body." It did not call for any specific actions to release political prisoners, stop torture, or otherwise protect human rights. As in the other professional societies, it was left to courageous individuals to speak up strongly against apartheid and its policies.

The leadership of the Ministry of Health is acutely aware of the staggering problem of mental health services in South Africa. The Ministry has reached out internationally to gain technical assistance in the area of mental health services, particularly to develop strategies to develop a training and service infrastructure for community-based mental health programs. In addition, the TRC has requested the National Institute of Mental Health in the United States to make recommendations concerning the impact of torture trauma on South Africans, and what can be done to address it.

Our visit focused exclusively on human rights, not on the state of mental health and mental retardation services in South Africa. It is impossible, however, to ignore the human rights implications of the organization of services, including widespread custodial institutionalization, denial of opportunities to live decent, independent lives, and blatant and rampant discrimination on the basis of mental disability.

We note the limitations of our inquiry. We visited only one psychiatric hospital and met with only a few individuals in government, NGOs and universities. We did not visit any forensic unit. The individuals we did meet with, however, have a great deal of knowledge about the system and included responsible officials in the Ministry of Health and Guateng Province. We also reviewed the South African Mental Health Act, which deeply affects the human rights of people subject to it. Our findings and recommendations thus constitute an outline of a human rights evaluation in mental health and mental retardation, rather than firm conclusions.

We found the following human rights violations against people with mental disabilities (the term encompasses people with mental retardation and mental illness):
(a) There is inadequate recognition in law and in the culture that people with mental health problems or mental retardation have human rights

The very first step in assuring respect for rights is to recognize that they exist. For people with mental illness and mental retardation, these rights include the right to be treated with dignity and equality as a human being, to have treatment in one's own community in a manner that is responsive to one's needs, and to be treated in accordance with basic notions of due process. Despite the existence both of constitutional provisions stating that all people enjoy equal rights and forbidding discrimination on the basis of disability, and of international standards,⁷² there is very little recognition of the fundamental human rights of a person with mental illness or mental retardation. Similarly, in accordance with international standards, consumers and families should have a right to participate in planning and carrying out treatment.⁷³

The South African Mental Health Act does contain some protection for certain personal and property rights, but this is insufficient and, in any event, lacks mechanisms to assure that individuals are aware of these rights and can enforce them.

i. The law does not provide that people with mental illness and mental retardation have the civil, political, economic, social, and cultural rights other citizens enjoy. Nor does it provide that no inference should be drawn in the absence of an adjudication of incompetency regarding a person's lack of competence to exercise such rights.

ii. It does not provide for non-discrimination in services.

iii. It does not recognize a person's right to live and work in a community. On the contrary, the law is entirely based on an institutional model of services.

iv. It does not recognize the right to treatment suited to a person's cultural background.

v. It does not recognize the right to treatment in the least restrictive environment appropriate to the individual's health status.

vi. It contains no definable standard for involuntary civil commitment. Instead, a person may be hospitalized under a circular rule, that the person has "mental illness to such a degree that he should be committed to an institution."

vii. It provides for no due process in civil commitment proceedings. Under the law, a magistrate receives reports from one or two medical practitioners about the person's condition, which is the basis for an order by the magistrate. The person subject to such an order has no right to notice of the content of the evaluations nor a hearing to contest them. The law contains no provisions for lawyers to represent individuals subjected to these proceedings, much less at state expense. Hearings are entirely at the discretion of magistrates. When proceedings are held at all, they are held in private.

viii. It does not recognize the right of institutionalized people to confidentiality, to visitors, to mail, to decent living conditions, or to treatment in accordance with professional standards.

ix. It does not provide adequate safeguards with respect to the deprivation of control over property or medical decision-making for a person with a mental disability. Magistrates are empowered to make inquiry as they deem necessary, including summoning the person to a hearing regarding an allegation that the person is incapable of handling property or funds. But the person is not entitled to a hearing, nor to representation by counsel before his or her decision-making power is removed.

x. It does not recognize or protect the right to consent to treatment.

xi. Although the law takes some account of the existence of mechanical restraints and seclusion, it does not provide adequate substantive standards or procedural safeguards regarding their use.

xii. It does not provide for resources or mechanisms for patient advocacy. On the contrary, the law makes it a criminal offense to make false reports without taking reasonable steps to verify information about conditions in facilities, with the burden on the person accused to prove that reasonable attempts were made to verify the information. A consequence has been to stifle outside reviews.

xii. It does not provide patients with safeguards as potential research subjects.
xiii. It does not distinguish individuals with mental retardation from people with mental illness. The consequence is that people with mental retardation are often placed in psychiatric institutions where they do not belong and which have no programs designed to meet their needs.

To its credit, the Ministry of Health is in the process of developing a new mental health law. It plans to involve stakeholders in the process.

(b) A continuing legacy of racial segregation in institutions

The government has ended official segregation, and the public psychiatric facility we visited in Pretoria was indeed integrated. The problem is that many custodial institutions have such a low turnover of residents and such long lengths of stay that they remain substantially segregated and will remain so unless people are released.

Historically, white institutions have had a far higher reimbursement rate than black institutions.⁷⁴ Elements of this disparity remain today. Funding levels among historically black facilities remain lower in many instances than those facilities that were historically white.

(c) A legacy of an institutional model of services long after the model had been abandoned in the mental health and mental retardation fields

In the past three decades, the fields of mental health and mental retardation services have undergone a virtual transformation, in part due to the recognition that individuals with mental disabilities have human rights. One of the most fundamental of these is the right not to be locked up in an institution simply by virtue of carrying a diagnosis of mental illness or mental retardation.

This transformation has been a product, too, of the emergence of interventions to promote the human rights of people with mental disabilities, such as education and support of children with disabilities and training in independent living. The world over, people with mental illness and mental retardation are being treated in the community and trained in the skills of daily living, work, and independent or quasi-independent living. Children with mental retardation and serious emotional problems attend public schools. As a result, large facilities that once housed people with mental illness and mental retardation for life, and thus denied them an opportunity to participate in community life, are closing, replaced by normal housing with supports.

In South Africa, until the 1970s, the law actually prohibited the government from operating community-based mental health services. Today 90 percent of state funds remain committed to institutions. A few NGOs have established community-based programs, and they have a good record. But they are few in number. The imbalance in types of services has also impeded the emergence of professionals skilled in community-based services for people with serious mental illness. In particular, social workers, who play a central role in organizing and providing these services, have virtually no role in service provision to this population.

People with mental retardation are not even recognized by the government as a group with a separate and distinct set of needs from people with mental illness. They are housed in the same hospitals, despite the fact that hospitalization is almost never appropriate for a person with mental retardation not otherwise in need of medical care. Community-based training and housing programs are rare.

The Ministry of Health is seeking ways both to develop community mental health programs and to integrate mental health treatment into general health services. The obstacles to this effort are serious and include the need for professional training and development (particularly in the field of social work), the lack of any tradition of community psychiatry for people with severe mental illness within the field of psychiatry, the severe shortage of funds for developing community resources, lack of a strong advocacy movement, the need to avoid discharges when there are no community programs in place, and resistance to change among staff working in institutions. The Ministry of Health has sought international assistance for a transition to a community-based, integrated model of services, and some model programs are under development, but the challenges remain staggering.

(d) To the extent that community-based programs were established at all, they were designed primarily for whites

The legacy of apartheid is also evident in community-based services, where blacks were systematically starved of programs and funds.⁷⁵ The scope of the problem was illustrated by a paper written by Dr. Ruth Zwi, Director of Mental Health services for Guateng Province at the time of our visit, that showed how devastating racial segregation was to the effort to provide mental health services.⁷⁶ In the 1970s and early 80s, Johannesburg established community clinics, half-way houses, sheltered workshops and other services on the floor of one building. A multi-disciplinary team of psychiatrists, social workers, nurses and occupational therapists addressed the needs—albeit without nearly meeting the demand—of people of all races.

As these services evolved, however, all community-based services were segregated, with employees of each system reporting to supervisors in that system rather than working together. They were divided into separate buildings. All non-nursing positions remained in the white sector, so that no psychologists, psychiatrists or occupational therapists were available any longer to anyone but whites. One of the psychiatrists saw some black patients under a contractual arrangement, but there were about ten times as many black patients as white.

According to Lage Vitus, Director of the South African Federation for Mental Health, the pattern of funding only programs serving whites was repeated throughout the country.⁷⁷

The same policies were in place for mental retardation services. Indeed, the Mentally Retarded Children's Training Act of 1975 defined "child" as "white child."

(e) Continuing reports of major human rights violations among institutionalized people

As noted above, a 1995 review of dozens of facilities for the Ministry of Health found serious human rights violations involving patient abuse by staff, unsafe living conditions, lack of adequate nutrition, and physical restraints. There is no reason to believe the human rights situation has changed dramatically.

In our tour of Weskoppies Hospital, it was evident that staff had a strong commitment to a therapeutic environment, and were coping with lack of staff, funding shortages, and other impediments to the assurance of decent living conditions. All but one of the wards reflected that effort. Still, it is primarily a custodial facility. Moreover, one ward grossly violated the human rights of its inhabitants. There, men spent days in a barren courtyard or in a filthy day room and nights locked in rooms so tiny that there was barely room for the mattress on the floor situated adjacent to the bucket that substituted for a toilet or latrine. The door of the room contained nothing but a slotted opening. Their clothing consisted of a "uniform" of striped pajamas.

(f) Reports of involuntary sterilization of people with mental retardation

In the past, it was state policy to sterilize young women at state institutions and homes operated by NGOs.⁷⁸ We received multiple reports that this policy is largely unchanged, and that large numbers of people with mental retardation were and continue to be sterilized involuntarily. We were unable to confirm whether this practice takes place or, if it does, how widespread it is, but believe it warrants investigation as a major human rights violation.

In any event, the law does not require informed consent to sterilization.

(g) Lack of advocacy or legal support under current law for people with mental disabilities

In other countries, the protection of human rights of people with mental illness and mental retardation has been a product of a strong and well-organized movement involving consumers and their families. Despite the strength of civil society in South Africa, people with mental illness and mental retardation and their families lack strong organizations compared to those that exist in many other parts of the world and there are few resources and little training in human rights and how to protect them.

As a result, not only do people with mental disabilities have few rights, but there are exceedingly few advocacy resources available to them. Institutionalized people especially have very little access to assistance from advocates for problems that arise in institutions, with concerns regarding their treatment, or with civil matters outside the institution. There is a pressing need for support of the development of consumer and family advocacy organizations.

2. The psychological legacy of apartheid

The turbulence caused by physical dislocation and the social stress stemming from apartheid has produced an exceedingly large number of social and psychological problems for individuals and the society. The impact of prolonged and intensive institutionalized state sanctioned oppression permeates every facet of national life and has affected hundreds of thousands of people.

Forced removal of some three to four million African people eroded social and personal relationships. Tens of thousand of people, overwhelmingly persons of color, and including women and children, have endured detention, torture, a persistent atmosphere of generalized violence and bereavement and the constant oppression of living under apartheid. The extent of violence against children under apartheid was extraordinarily high, and well documented. Unemployment still remains at 35-40 percent. It is those among the ranks of the oppressed, disproportionately black, powerless and poor, who are in greater need of help. Emotional damage is compounded by time and neglect. If not addressed it will cause dysfunction in society most likely to express itself in mental illness, dependence and violent behavior.

Even today, South Africa is a violent society, and this is perhaps one of apartheid's most insidious legacies. The violence of apartheid begot violence in the form of crime, child abuse, and violence against women. In the Eastern Cape Province, for example, we were told that there has been an explosion in cases of child abuse and in the number of children under the age of five diagnosed with sexually transmitted diseases.⁷⁹ Violence even takes place in the examining room of clinics, so much so that studies are underway to document the extent of violence against patients seeking obstetrical care. Many adolescents who may once have channeled their anger, sense of dislocation and hopelessness, and disconnection from social institutions into a political vanguard are now drawn to violent crime.

The suffering from the violence and degradation experienced by people under apartheid, combined with the extent of violence today, is one of South Africa's major social problems. Trust among neighbors essential to a sense of personal safety and security is compromised through proliferation of random acts of violence and disregard for human rights and personal property. Unrest and insecurity have had a corroding impact on family life and psychological wellbeing at all levels of society.

The process of healing is complicated by the cultural divides within South African society. This is a daunting task even in situations where therapist and client draw upon a common cultural base to guide the
process of thinking, perception, comprehension, memory and reasoning. In South Africa, where practitioners and patients are of profoundly different cultures, speak and/or think in different languages, and hold different beliefs about the purpose of life, God, disease, death and the hereafter, the ability to provide meaningful therapy is severely compromised.

In South Africa the obstacles to reciprocal understanding across cultural boundaries are profound. The majority population is African while the dominant models of practice within the mainstream are grounded in European thought and culture. These models are overwhelmingly controlled by professionals of European descent who are poorly prepared for cross-cultural practice.

Mental health resources within the formal sector are unequal to the task as the majority of those in need of treatment occupy worlds of thinking, perception, comprehension and reasoning outside the field of knowledge of the majority of practitioners. Western-grounded practitioners often are not trained in communication with ancestors whose participation is often perceived as essential to restoration of wholeness. The barriers of language and culture are formidable, even among black professionals. Very few black psychologists, for example, speak African languages.

There are, however, sources of strength to address these barriers. There are existing pools of traditional professionals such as healers and diviners as well as Africans trained in Western systems who are able to contribute powerfully toward overcoming barriers to care within the domain of formally recognized mental health workers.

Social Workers. About 20 percent of South African social workers are members of ethnic communities of color. Most of these professionals speak African languages and understand traditional African norms and values and were excluded from providing staff services for treatment programs that were based on a medical model. In 1993, the South African Association of Black Social Workers (SAABSW) Conference on Violence and the Consequences of Violence on Families and Communities recommended that community cultural systems treatment in addition to individually focused treatment and prevention be urgently implemented. As many black social workers themselves live within neighborhoods and communities experiencing extreme stress, the readiness to act and resolve to commit were high. The Association of Social Workers recognized the need for additional training, to enable practitioners to work more effectively in assessing needs and planning strategies to design and promote culturally appropriate models for treatment and prevention.

During our visit in June 1997, we revisited several of the organizers to assess their movement toward objectives identified in the 1993 conference. They faced the major obstacle that the hoped-for funding from government and international agencies had not materialized. Private agencies that previously provided funding have shifted resources to support of government agencies, which are perceived as less able to carry forward the mission of healing begun by NGOs during apartheid. Likewise, community programs focused on building trust and capacity lacked funding notwithstanding their demonstrated success. Still, these workers remain committed and many are directly involved in counseling abused persons on a volunteer basis. Several told of personal hardship in carrying out this role as their salaries were small. They are not paid for treating the victims of violence.

Revitalization of SAABSW's resolve to treat victims of violence is a strong potential resource as many have grounding in both traditional and Western cultures. Black social workers are an underutilized resource in efforts to treat trauma and provide the balm needed to build new relationships across ethnic and racial barriers. Professor Mazibuko of Natal University School of Social Work, the immediate past president of SAABSW, spoke eloquently and powerfully of the need to construct healing and treatment within a context of coherence for African peoples. She told of efforts to develop selfhelp support group methodologies that would be maintained by victims of disorders related to torture and dislocation. A study group commissioned by SAABSW proposed short- to intermediate-term training of a cadre of lay counselors who would then organize and facilitate support group activities for social workers who are themselves in need of intensive training in work with post-traumatic stress and related disorders. Professor Mazibuko believes this strategy to be the most promising of those considered to meet the urgent needs of the majority of people with mild to moderate dysfunction.⁸⁰

The Clergy. Pastoral counseling is a vital task for the clergy. Many clergy occupy positions of respect and trust within the communities they serve. Encouragement and perhaps an invitation to take courses to enhance understanding of common disorders and mechanisms for referral will enable them to improve and expand services to their communities.

Faith structures within the framework of ecumenical world bodies of Muslims, Christians, Jews, Hindus, Buddhists and others might be asked for help in designing appropriate curricula. The World Council of Churches in Geneva is well situated to provide leadership in this type of effort.

Healers and Diviners. The vast majority of South Africans suffering posttraumatic disorders seek help within the framework of traditional African mental health systems. They do not perceive Western practitioners as offering treatment responsive to their needs. For example, Western practitioners may not recognize the symbolism of dress and color important in traditional societies in the treatment process. Many African peoples distinguish between African illness and European illness. By the same token, visions, dreams and prophetic revelation as evil-cleansing forces are not well understood by most Western-trained providers.

When powerful cultures meet, syncretism or integration of world view is often the better pathway. Both African and Western patterns of treatment have much to offer. There are, within South African society, persons familiar with more than one cultural perspective. There are models of successful integration in various societies. The health of the Chinese people improved under a system able to integrate traditional and modern treatment systems. Indeed, the World Health Organization has called for dialogue toward integrating health care. One of the fastest-growing and most influential religious movements in South Africa, the Zionist Church, owes much of its appeal to the coherence it lends to those who must live in both European and African societies.

With its rich, culturally-grounded systems of healing, South Africa too may find this strategy key to provision of urgently needed care for its wounded. For example, Professor Mthobeli Guma of the University of Western Cape, trained in his youth as a diviner, also holds degrees in public health and anthropology. Such persons should be called upon to help build pathways to broadened understanding and cooperation across philosophical barriers. Work carried out by WHO should inform those charged with this task in South Africa. At the same time, the discussion of licensing healers and diviners is complex. Not every person who claims to be a traditional healer is such. The challenge of integration is daunting.

Trauma Centers. These centers, like the Center for the Study of Violence and Reconciliation and the Trauma Center for Victims of Violence and Torture, provide high-quality services for victims of trauma and violence that combine Western and traditional methods. The Trauma Center for Victims of Violence and Torture, for example, runs programs for returned exiles, refugees, torture survivors, former political prisoners, and victims of rural and urban violence. The Center for the Study of Violence and Reconciliation offers clinical treatment, outreach services, women's and children's services, and services for perpetrators and care-givers. At present, more than half of its caseload consists of victims of domestic violence and sexual assault.

Both centers use methods that combine Western and African modalities, especially in groups. The programs include family support for victims of violence. The overwhelming problem is that the demand for trauma center services astronomically exceeds the supply.

NOTES

⁶⁶ See, e.g., Mental Disability Rights International, Human Rights and Mental Health: Hungary (1997); Mental Disability Rights International, Human Rights and Mental Health: Uruguay (1995); UN Sub-Commission on Prevention of Discrimination and Protection of Minorities, Human Rights and Disability, UN Doc. E/CN.4/Sub.2/1991/31 (prepared by Leandro Despout); UN Sub-Commission on Prevention of Discrimination and Protection of Minorities, Principles, Guidelines, and Guarantees for the Protection of Persons Detained on Ground of Mental Illness or Suffering from Mental Disorder, UN Doc. E/CN.4/1983/17 (prepared by Erica-Irene Daes).

⁶⁷ WHO Report. "UN Special Committee Against Apartheid: Apartheid and Mental Health Care." MNH/77.5, Geneva 1977.

⁶⁸ Report of the Committee to Visit South Africa. Am. J. Psychiatry 1979 136:1498-1506.

⁶⁹ WHO Report. "Apartheid and Health." Geneva 1981.

⁷⁰ Mental Health and Substance Abuse Committee. "Human Rights Violations and Alleged Malpractices in Psychiatric Institution," November 1995.

⁷¹ "Submission to Health Sector of Truth and Reconciliation Committee by the Society of Psychiatrists of South Africa," p. 9.

⁷² See Principles for the Protection of Persons with Mental Illness and the Improvement of Mental Health Care, United National General Assembly Resolution 119, 46th Session, December 17, 1991, Report A/46/721., and Declaration of the Rights of Mentally Retarded Persons, General Assembly Resolution 2856, UN GAOR, 26th Sess., Supp. No. 29, UN Doc. A/8429 (1971).

⁷³ See Standard Rules on the Equalization of Opportunities for Persons with Disabilities. G.A. Res. 96, UN GAOR 48th Sess. (1983). See especially Preamble and Rules 2, 3, 14, and 15.

⁷⁴ Zwi.

⁷⁵ Don Foster and Sally Swartz note that in the 1970s there were gradual shifts "from incarceration to out-patient and community intervention" but that "apartheid policy saw to it that white persons were the main beneficiaries." Foster and Swartz. "Policy Considerations," in Mental Health Policy for South Africa, ed. D. Foster, M. Freeman, and Y. Pillay. Medical Association of South Africa, 1997.

⁷⁶ Zwi, Ruth MD. "Problems in Urban Community Psychiatric Care." Proceedings of 2 Symposia: Mental Health Care for a New South Africa. Center for the Study of Health Policy.

⁷⁷ Vitus, Lage (Director of the South African Federation for Mental Health). Interview by Leonard Rubenstein, June 26, 1997.

⁷⁸ The Abortion and Sterilization Act of 1975 authorized sterilization of persons with mental retardation.

⁷⁹ Thomas, Trudy, M.D.(Minister of Health, Eastern Cape Province). Interview by Robert S. Lawrence, June 15, 1997.

⁸⁰ Hatch, John. Interview, June 1997.