UNDERLYING CAUSES OF HUMAN RIGHTS VIOLATIONS
IN THE HEALTH CARE SECTOR

This chapter seeks to provide insight into the complex problem of the causes of human rights violations. It specifically addresses how members of the healing professions became an integral part of the apartheid system which deliberately inflicted sustained and untold suffering based on a racist ideology. In our analysis of causes of human rights violations, it is important to bear in mind that the suffering generated by apartheid was not limited only to the oppressed, as Allister Sparks points out; it undermined the humanity of the oppressors as well:

Slavery debases master as well as slave. The warden becomes a prisoner in his own jail; he is never free from the business of oppression and confinement. So, too, in Apartheid South Africa where white and black had been bound together in a web of mutual destructiveness. Apartheid, brutalizing the whites as it destroyed the self-esteem of the blacks, robbed both of their humanity.¹

A. The Primary Cause:
Racism in the Society

The primary and defining cause of the human rights violations in South Africa's health sector is clear. It is a profound and pervasive racism: the belief that whole populations are "inferior," less than human, and therefore not entitled to the most fundamental rights and protections of the human condition. This racism was embodied in an authoritarian political system and expressed in law and in the structures and policies of every institution in South African society. It was enforced by violence; torture, extrajudicial executions and massacres, detentions, dispossessions, the destruction of whole communities, and systematic humiliation comprise only part of the arsenal of oppression. Racism served as the immoral rationale for a massive system of political disenfranchisement and economic exploitation that approached (and sometimes included) outright slavery. Over decades, it cost hundreds of thousands of lives and stifled the potential of millions. Its cost to the human spirit is incalculable.

Racism was not and is not unique to South Africa. What is unique, at least among industrialized nations in the second half of the twentieth century, is the organization of an entire society on the principle of selective separation and inequity on the grounds of race. Apartheid was more than a state policy and more than a political economy. It was a culture, a system of beliefs and actions that profoundly affected every person in the nation—including the ruling caste of whites, variously moved to savagery and denial in defense of racial privilege.

Three aspects of this culture of apartheid are of particular concern to the protection of health and human rights. The first is the devastating effect of the South African apartheid system on the health of subject populations, primarily through the systematic and deliberate denial of adequate housing, food, sanitation, and environmental and occupational protection in contravention of every international standard. The second is the deliberate construction of a racially organized and caste-biased health care system that offered grossly inferior care to millions of South Africa's people of color and effectively accomplished the outright denial of care to millions more. The third is the extent to which the culture of apartheid poisoned the integrity of so many health professionals, so that—at best—they saw no conflict between the dictates of racism and the egalitarian commitments of medicine, and—at worst—they used their skills in active support of oppression and in violation of every ethical code relevant to their professions. These failures are more than individual. They reflect the extent to which a culture of racism can structure the social, environmental and political determinants of health and infect the core institutions of health care, including its professional schools and disciplinary bodies.

All these aspects are documented over and over again in the submissions to the Truth and Reconciliation Commission. It is this cumulative record that informs our analyses and recommendations. We recognize the profound and fundamental changes that have occurred in South African society, and the commitments of a new and democratic government. But we also know that the legacy of apartheid is manifest in the present in multiple ways, including health care and the determinants of health, and that it casts a long shadow on the future. Our own experience in the United States teaches the bitter lesson that racism dies hard, and slowly, but it is the purging of this primary cause that is the recommendation—and the task—that underlies all others.

B. Racism in the Health Care System

Health practitioners, of course, have a unique responsibility in society, as healers, to understand and alleviate causes of human suffering, and to promote health.² Although internationally recognized principles of bioethics should have prevented, or at least greatly mitigated, health practitioners' complicity in human rights violations, by and large they did not. The triumph of racism over ethical responsibilities was built into the structures and characteristics of the health sector and the health professions. It is useful, we believe, to describe how racism played itself out in practice in the health sector so that health professionals could participate without a great deal of thought in a system of intentional discrimination and the deliberate infliction of harm on the majority in South Africa.

Bureaucratic fragmentation fostered the development of pervasive racial discrimination in health care. The separation of South African medical services into myriad bureaucratic entities, administered or overseen by different levels of government and responsible for providing care to different racial groups, meant that practitioners within each clinical setting saw relatively homogeneous populations of patients. However widely the standards of care and the norms of respect for patients varied among clinical settings, practitioners in any one clinical setting tended to apply the same or similar standards to the patients they treated in that setting. Racial discrimination operated for the most part at a higher level, through large differences in the per capita resources deployed to different clinical settings, as well as through differences in the mechanisms of governance. The typical practitioner, working in a single professional setting, did not encounter these differences up close, on a daily basis.

The individual practitioner, to be sure, made the system of racial discrimination work, day in and day out, by adhering to protocols and rules that were race-biased in both effect and design. When patients of different races came to the same facility, they were often sent to separate waiting rooms, seen in separate areas, and given different priorities, according to race. But practitioners within a given setting more commonly saw patients of only one race and did not personally face the ethical and human rights affront of different clinical protocols and rules for patients of different races. This made it easier for clinicians to go along with the system without experiencing themselves as active perpetrators of racism. So long as they turned a blind eye toward the larger, race-biased context of their clinical work, they could see their own conduct as consonant with their ethical duty to treat patients without regard to race.³ This enabled large numbers of physicians who were not proponents of apartheid to rationalize the crucial support they lent to the system by practicing within its rules.

Bureaucratic fragmentation also fostered medical apartheid by giving legislative and administrative policy-makers the economic and budgeting tools to maintain patterns of racial discrimination. South Africa's huge black-white disparity in economic status enabled markets to do much of the work of medical apartheid, by setting prices for private health services and insurance sufficiently high to deny almost all blacks access to private sector care. Public subsidies could have empowered black South Africans to gain access to private health services, thereby achieving a measure of racial integration through the marketplace, but the national and provincial governments eschewed any such approach in favor of a separate, government-run system for the largely non-white poor.

The importance of this foundational policy decision cannot be overstated. Had the South African government either introduced subsidies sufficient to give all poor people access to private sector care⁴ or created a public system of health care provision sufficiently attractive to draw substantial numbers of middle class whites,⁵ it could have achieved considerable racial integration in the health sphere. To say the least, either approach would have made medical apartheid more difficult to impose. Public subsidies sufficient to give blacks access to private services would have required the state to be more heavy-handed in order to maintain racial segregation in the private sector. Public financing or provision of care good enough to attract many whites would also have required the apartheid state to more aggressively impose segregation in the medical sphere.

Within South Africa's state-run health services, bureaucratic fragmentation facilitated budgeting practices that helped to maintain medical apartheid. The separation of government authority over medical matters into separate departments of health for the nation as a whole, the provinces, and the so-called black "homelands," and the 1983 division of provincial health departments into black, "colored," and Indian "own affairs" sections, enabled legislative and administrative policy makers to budget grossly unequal per capita resources to programs serving members of different racial groups. These budgetary decisions, made by officials committed to apartheid ideology and remote from public clinics, hospitals, and the suffering people they served, translated into large racial differences in access to care within the public system. Residents of the virtually all-black "homelands" were particularly hard hit by low per capita allocations from the national government.

Confronted with these racial inequalities, physicians and other health professionals who worked in public settings made do with what they had. They can be fairly faulted for making do without demurring—for not protesting the fact that clinical settings frequented by people of different races brought vastly different per capita resources to bear on the same medical problems and followed very different practice protocols as a result. But bureaucratic fragmentation made such protest less likely, by making these inequities less conspicuous to practitioners. Engaged, for the most part, within one or a few institutional settings, practitioners were simultaneously well situated to see the clinical impact of their own resource constraints but poorly positioned to discern system-wide resource disparities and consequent inequities in clinical practice and results. These system-wide inequities tended to remain out of sight and out of mind, at least as a matter of daily clinical experience. This inattention and inaction was of a piece with the general tendency of people working in bureaucratic settings to accept and even justify role constraints rather than resisting them, and to evolve institutional norms to fit these constraints.⁶ The larger South African cultural context of race-based hierarchy and contempt eased the way for health professionals to do so, and the fragmentation of the health sector lessened the power of the ethical tradition of medicine as a counterweight.
C. Other Factors

Like other countries, there were other factors in South Africa that contributed to human rights violations in the health sector. Unlike most other countries, however, these structural, educational, and behavioral problems interacted with the underlying racism both manifesting and compounding its effect.

1. Limited conceptualizations of health and human suffering

Principles of bioethics have evolved within a limited diseasebased and patient-centered conceptualization of health and human suffering and have usually not been applied to broader health concerns, nor particularly to matters of state interference with health or health practice. The codes of conduct usually regulate clinical encounters with individual patients and do not attempt to define health and wellbeing or address interference with health by the state. By tending to focus on suffering almost exclusively in the context of the physician offering treatment for injury or disease, these codes do not attend to the relation of health to the protection of human rights, nor to the physical, psychological and social health consequences of violations of human rights and humanitarian law. Consequently, they marginalize their role in society.

When conceptualizations of health and human suffering are devoid of human rights concerns, health personnel easily avoid coming to terms with the role they may be asked to play in a highly politicized environment, and thus can become willing and unwilling participants in human rights violations which serve the partisan interests of the state and other actors. In South Africa (and elsewhere), health professionals were ill equipped to respond to suffering caused by armed conflicts and human rights abuses and were more likely to focus narrowly on their own practices and turn away from even obvious violations of human rights.

Some health practitioners are quick to point out that there is a difference between active participation in human rights violations and "standing by." The assertion by MASA that standing by in the face of human rights violations constituted "complacency" rather than "complicity" deserves further attention. The assertion implies that doctors did not have a professional duty to intervene in the suffering caused by apartheid. Was this the case? After all, a concern for human rights in the conceptualization of health and human suffering is a relatively recent development.

Having said this, it is also true that internationally recognized principles have evolved that provided ample justification for physicians to respond to the suffering caused by apartheid. For example, the World Medical Association's "Declaration of Geneva"⁷ includes the pledge to serve humanity, to practice with conscience and dignity, to make patient health one's first consideration, to maintain the utmost respect for human life even under threat, and not to use medical knowledge contrary to the laws of humanity. Furthermore, bioethical principles of beneficence, justice and fidelity provide a firm foundation to confer on health professionals the responsibility for protecting and promoting human rights and humanitarian law. Given these principles, it is more accurate to describe the inaction and silence of health personnel as complicity rather than complacency. Such complicity constituted a failure of professional duty, and served to legitimize state abuses and the active participation of health practitioners in these abuses.

In sum, South African health personnel either knew or should have known that the discriminatory practices of apartheid would cause significant harm to black South Africans. Silence and inaction in the face of human rights violations represented moral choices of health practitioners. Such choices, in combination with a limited conceptualization of health and human suffering, were a prescription for complicity in human rights violations.

The truth and reconciliation process represents a critical opportunity for those in the health sector to reexamine their definitions of health and the scope of their professional responsibilities. Health practitioners do have a responsibility to protect and promote all human rights not only because human rights violations have devastating health consequences, but because protecting and promoting human rights (civil, political, economic, social and cultural) may be the most effective means to provide the conditions for health and wellbeing in a global civil society.

2. Ineffective leadership of health sector organizations

Although some progressive health professionals in South Africa worked for the protection and promotion of human rights during apartheid, most did not. A significant factor in the widespread disregard for human rights concerns was the lack of leadership within the health sector, including professional organizations, regulatory health councils, the Department of Health, health facilities and academic and research institutions. Such leaders were often an integral part of white South African society. Their failure to confront the health consequences of human rights violations legitimized the ruthless social engineering policies of apartheid and contributed greatly to the systematic dehumanization and disenfranchisement of generations of black South Africans.

Leadership is a critical factor in the determination of health policy and also serves as an example for health practice. Leaders within the health sector not only failed to recognize the relevance of human rights in health; they neglected to develop comprehensive codes of ethics or to enforce established codes of ethical conduct, and they failed to support and protect health personnel who took considerable risks in supporting human rights.

Many leaders within the health sector have provided the TRC with unqualified apologies for the conduct of health personnel during the era of "complacency," but how is one to believe that such conduct will change without evidence that the leadership within the health sector has also changed. The health sector hearings of the TRC clearly demonstrated little evidence of such a transformation on either level. Apologies and talk of building a "culture of human rights" are likely to become the instruments of surviving "transformation" intact, rather than promoting the health and human dignity of all South Africans. Furthermore, not one leader of a health professional organization or health regulatory body, nor SAMS, nor the Department of Health has offered a strategy to include human rights in health education. Without effective reform of the leadership that was responsible for the health sector's shameful silence and inaction under apartheid, the health sector's stunning opportunity for transformation may simply evaporate.

The effect of lack of leadership in promoting health and human rights in the health sector is compounded by efforts to maintain the status quo. Privatization of health care delivery has already become a major theme in the unity talks between MASA and the black physician organizations. Such interests in maintaining present reimbursement schemes and control over practice patterns appear to demonstrate MASA's preoccupation with the financial interests of its members, rather than the health and well-being of black South Africans.
3. Power without adequate accountability

Health professionals, particularly physicians, have a great deal of power in their relationship to patients. This asymmetry in power stems from differences in knowledge and language, and places health practitioners at an advantage in their clinical encounters and roles in society. Although many practitioners care greatly for their patients, their power needs to be held in check by the formal requirements of promoting health in society.

Because medical encounters are often characterized by an asymmetry in power, doctors and other health professionals have the potential to abuse that power. When health concerns are limited to the objective of curing disease, the likelihood increases that health professionals will not relate in a holistic manner to issues relating to the human worth and dignity of their patients. Such moral disengagement may be a critical factor in abusive behavior. Under such conditions, the body becomes the medium for doctors to achieve power, control and personal gain. Moreover, the fact that this power asymmetry is not formally recognized in health education suggests that it serves health providers rather than members of the community.

Structural mechanisms for accountability in the health sector generally consist of licensing and regulatory councils that function to prevent the abuse of individual patients. Their importance cannot be overstated, especially in the apartheid state. But there was no accountability, licensing or disciplinary system that valued ethics and human rights over the policies of apartheid.

4. Lack of independence in the health sector

South African physicians and other health workers under apartheid were widely expected to put the security and other interests of the state ahead of their ethical commitments to patient well-being. To some degree, medical institutions and professionals in all societies serve security-related and other non-therapeutic purposes—e.g. by performing forensic evaluations and treating members of the armed forces to maintain their combat-readiness. In apartheid-era South Africa, however, this non-therapeutic role was greatly magnified. The armed forces, police and prison officials, and the national and provincial departments of health looked to physicians to function as both active agents and passive adjuncts of the apartheid state's efforts to repress opposition, cover up torture and murder, and sustain the systematic practice of race-based hierarchy. South African physicians, for the most part, went along with these expectations.

Independence in the health sector is essential to ethical health practices and health policies because third party interests almost always compromise efforts to provide effective care and to promote health. In South Africa, lack of clinical independence was most pronounced in situations that the state perceived as threatening, i.e. medicolegal and forensic medicine, custodial care, and health services in the South African military service. Similarly, the lack of independence of institutions that were responsible for health policy greatly facilitated their permeation by the racist ideology of the state. Acts of omission and commission by statutory regulatory bodies such as the SAMDC and SANC, as well as the Department of Health, academic and research institutions, and health care facilities, clearly contributed to violations of human rights.

That the state so extensively compromised the independence of the health sector should not come as a surprise. Such structural relationships develop because they serve the interests of the state and the health sector both. Under apartheid, what was at stake for the state was not simply winning a conflict, but the very legitimacy of its power to govern. The involvement of health professionals in human rights violations, and their pervasive acquiescence to such violations, served to legitimize the actions of the state. The apartheid government imposed its ideological claims to the detriment of the credibility of health practitioners. The intimate relation between the apartheid state and the health sector also served the interests of health practitioners. Apartheid policies provided practitioners with the means to realize the interests of physicians and other health professionals, at the expense of the health and well-being of black South Africans.

Clinicians employed in settings linked to institutions of state security tended to serve and even identify with these institutions' missions. Military physicians did so openly, putting their skills to use not only to keep armed services personnel combat-ready but also to campaign for the allegiance of civilians in contested rural areas and even to develop weapons technologies. The isolation of military physicians from the rest of South African medicine promoted their development of a distinct identity and culture, less patient-oriented and more responsive to the perceived security needs of the apartheid state. Although South Africa's district surgeons did not formally report to police or prison authorities,⁸ the professional isolation of many in the townships and rural areas weakened their self-perceived constraints on identification and alliance with these authorities when called upon to attend people in detention.

5. Lack of adequate human rights and bioethics education

Education has far-reaching and long-lasting effects for health personnel and health practices. The educational process has a formative effect on conceptualizations of health and human suffering, and thus on the scope of professional interests in society. It provides role models which students often emulate, as well as ideas about questioning authority and one's role in relation to the state.

Health education under apartheid clearly contributed to causes of human rights violations in the health sector. Under apartheid, health educators failed to include human rights and bioethics concerns and thereby contributed to the neglect of the health consequences of human rights violations. Health educators provided students with limited, disease-based conceptualizations of health and human suffering which disregarded the importance of social determinants of health. Furthermore, health educators served as models for the support of extreme discrimination in the delivery of health services and in health education. Student selection by health educators contributed to the institutionalization of racism in the health sector. The selection of privileged white students, combined with insufficient exposure to primary care experiences in black communities, reinforced the isolation of students from the health needs of the majority of South Africans. In addition, health educators have been criticized for discouraging students from questioning authority. This may have been a significant factor in the health sector's history of obedience to authority.

NOTES

¹ Sparks, Allister. Tomorrow Is Another Country: The Inside Story of South Africa's Negotiated Revolution. Struik Vook Distributors, South Africa, p 227.

² Health is defined as "a state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity." World Health Organization, (1978). Declaration of Alma Alta. World Health Organization, Primary Health Care. Geneva: World Health Organization.

³ Physicians whom we interviewed generally expressed the belief that during the apartheid period, they were ethically obligated to provide the same technical quality of care to their patients of all races. However, the Medical and Dental Council took the position that racial discrimination by itself did not merit professional discipline, so long as the patients discriminated against were not "treated unacceptably." Interview with R. J. Filmalter, M.D., Assistant Registrar for Professional Misconduct, Interim Medical and Dental Council. Many who said physicians were ethically obliged to provide the same technical quality of care regardless of race said they viewed segregation of health care facilities as ethically tolerable during the apartheid era.

⁴ The Medicaid program in the U.S. illustrates this possibility, albeit incompletely. Medicaid provides a combined federal and state subsidy to some poor people for the purchase of some medical care (less than that covered by comprehensive private insurance plans) in the private marketplace. The German system more completely subsidizes poor people's purchase of private insurance and medical care (while relying on private entities known as "sick funds" to pool middle class resources for the purchase of private care).

⁵ Great Britain's National Health Service, well-known to South Africans, is one example of a government-administered health care delivery system high enough in quality to attract most middle-class citizens. South African health care reformers have from time to time, without success, urged the creation of a British-style health service.

⁶ Wilson, JQ. Bureaucracy: What Government Agencies Do and Why They Do It. New York: Basic Books, 1989.

⁷ Amnesty International, p. 4. Declaration of Geneva, World Medical Association, 1975.

⁸ As district health system employees, they reported to provincial and local health agencies.