SECTOR ANALYSES

The vast majority of South Africans receive their medical care from government-run clinics and hospitals. Throughout the apartheid era, black people were relegated to grossly inferior facilities within this segregated system, while the mostly middle and upper class white population had access to an elite sphere of private practitioners and hospitals. Large differences by race in wealth and income enforced clinical apartheid.⁸⁹ Within the elite, private sphere, white (and some Indian and "colored") South Africans could obtain care from physicians as committed to Hippocratic ideals of fidelity to patients as private practitioners in the U.S. or Europe. To be sure, these private physicians participated in apartheid culture and obeyed apartheid laws. Those who saw non-white patients tended both to have separate, less desirable waiting and consulting rooms and to admit them to non-white hospitals. Merely by following the norms of apartheid culture and obeying the segregation laws, they functioned, to some degree, as agents of the state and of white society at their non-white patients' expense, in violation of the ideal of undivided commitment to patients. Yet these private practitioners were far removed from the culture and lines of authority of the military, police, prisons, and other state security organs. They conceived of themselves as devoted exclusively to their patients and beyond the reach of the state's apparatus of repression. By contrast, the physicians who served the black poor in state-run settings were pushed in myriad ways toward an understanding of their role that entailed balancing the state's and patients' needs. Severe budgetary limitations, large numbers of patients, overcrowded facilities, and limited access to tertiary care compelled virtually all who cared for poor blacks in the townships and rural areas to engage in ongoing triage. Their employment relation to the apartheid state invited a measure of loyalty to its policies and perceived needs.

The typical state-employed clinician could satisfy this loyalty passively, by practicing within the framework of the system's racially discriminatory rules. Toleration of gross inequities in medical resource allocation, adherence to clinical practice patterns that took these inequities as givens, and compliance with the rules of racial separation were necessities for "getting by," day by day, without colliding with administrators or government authorities. Physicians in leadership roles within this system collaborated more actively, by participating in resource allocation decisions that explicitly disfavored blacks and developing practice guidelines that made access to many expensive clinical interventions effectively contingent on race.⁹⁰

The divided clinical loyalties of government physicians also led some to become collaborators in the apartheid regime's repression of opponents. The District Health System, in particular, functioned as a spawning ground for active and passive medical complicity in the torture and murder of apartheid opponents. Separate district health services, staffed by so-called district surgeons (actually general practitioners and internists, for the most part), provided medical care in many townships and rural areas to people unable to pay for private care. The district surgeons provided much of the care available to the country's black and "colored" populations and cared for prison inmates and other detainees.

District health services, which employed the district surgeons, were local agencies administered by provincial and municipal health authorities and overseen by the national Department of Health. National statutory and administrative law prescribed the district surgeons' care-giving and forensic duties but left daily management of their work to the provincial and municipal health authorities. In theory, this administrative scheme should have ensured the ethical and clinical independence of the district surgeons from prison, police, and military authorities. In practice, the low prestige and professional isolation associated with medical employment in black and "colored" townships and rural areas made the role of district surgeon ethically vulnerable.

South African medical graduates tended to view district surgeons' work as much less desirable than private practice and other career options, and the ranks of the district surgeons included many with weak credentials and few professional alternatives. In rural and township clinics, moreover, many had little or no regular contact with physician colleagues—and regular contact with police and prison officials who brought them clinical and forensic work. Indifferent local health authorities tended to pay little attention to district surgeons' performance. In such environments, physicians received little reinforcement from peers or supervisors for the quality of their work or for their adherence to the ethical standards of the profession. Notwithstanding their separate lines of authority to local health bureaucrats, they often developed closer ties to the prison and police officials with whom they worked regularly. Even in such environments, many district surgeons performed competently and ethically, providing the best care they could within resource constraints imposed by others, acting as advocates for their patients and thoroughly documenting medical evidence of abuse by the security authorities. Others, however, came to identify more with the purposes of the prison and police officials than with the distinct ethical role of the medical profession.

NOTES

⁸⁹ Ironically, some racial mixing of patients occurred at South Africa's premier hospitals, the academic medical centers of the University of Cape Town (UCT) and the University of the Witwatersrand. These publicly-supported tertiary care centers received referrals from both the elite, whites-only private health system and the largely black (and "colored") government-run clinics and hospitals. In the 1980s, UCT's Groote Schuur Hospital took the then-radical step of integrating its wards despite opposition from the provincial administration.

⁹⁰ Neither the TRC's investigation nor our own inquiries yielded evidence that clinical practice protocols expressly conditioned access to services on race. Rather, such discrimination was effected through the channeling of blacks and "coloreds" to separate facilities, with varying practice protocols that reflected their sharply different levels of resources.