DATE: 18 JUNE 1997
HELD AT: CAPE TOWN

Day 2, Part 2

• AAAS Submission
• DeNOSA Submission
• NAMDA Submission
• OASSSA Submission
• HHRP Submission
• Department of Health Submission

AAAS SUBMISSION

MS MKHIZE: Welcome to this afternoon's session. I would like to invite the representative of AAAS to come forward please.

To both of you, Professor Robert Lawrence and Dr Audrey Chapman I would like to welcome you. It's really a privilege to have you participating in this given your organisation's contribution, not only to this country but within the TRC itself. I will ask the two of you to stand so as to take an oath.

ROBERT LAWRENCE: (sworn states)

AUDREY CHAPMAN: (sworn states)

MS MKHIZE: Dr Wendy Orr will assist you in talking to your submission.

DR WENDY ORR: I want to reiterate our welcome and not only to you but to the rest of your delegation who have travelled all the way from the United States to help us in our work here. We are really very grateful to you and to the other international visitors.

You have sent us a preliminary submission and we have asked you to focus in your presentation on that part of your submission which focuses on district surgeons. The issues, the problems, the potential solutions, so I'd really like you just to move straight into that and we'll then take questions afterwards.

DR A CHAPMAN: Madam Chair, if it's alright what we'd like to do is an introduction that will provide a context for the district surgeons.

First, on behalf of all of the members of the AAAS team I'd like to express appreciation for the invitation of the TRC to participate in these historic hearings. Of the 16 Truth Commissions that have preceded South Africa's Truth and Reconciliation Commission we are not aware that any of them have undertaken a sectoral analysis and we think that this is one of the many contributions that South Africa will have to the process of a country coming to terms with its past.

For the people who don't know what AAAS is, the American Association for the Advancement of Science is the largest federation of scientific, medical and engineering societies in the world. It also has an individual membership of 143,000. For 20 years we have had a human rights programme that has dealt with issues affecting the health, the scientific and the engineering sectors as well as the application of scientific methodologies to the protection and promotion of human rights.

In 1989 the AAAS sponsored a medical mission of inquiry to South Africa that published a report "Apartheid Medicine", that examined how legal structures in the culture of apartheid denied the majority of South Africans decent medical care and contributed to massive violations by individuals and institutions in the health sector.

The report also examined the role South African professionals played in helping or hindering the promotion of human rights.

When we received the invitation of the TRC, AAAS assembled a consultative team, including the US-based NGO's, the Physicians for Human Rights, the Committee for Health in Southern Africa, the American Psychiatric Association, the American Public Health Association and the American Nurses Association. Six of the ten members of our team were introduced this morning. I would like to introduce the additional four members. Dr Barbara Nicholls, Miss Diane Kunz, Dr Gregory Bloch and Dr Jack Geiger.

Why has the international community been concerned about violations of human rights in the health sector in South Africa? Health professionals have a particular responsibility to protect and promote human rights, not only because human rights violations have devastating health consequences, but also the protection and promotion of human rights may be the most effective means to providing the conditions for health and well-being.

In South Africa in the past, and I might add in many other countries, a narrow conception of health and ethical responsibilities of health professionals has contributed greatly to silence and inaction in facing the suffering caused by human rights violations.

There is also another reason that international NGOs and academics have been so concerned, and that is that the violations which took place in this country, and which we've heard about in great detail in the last two days, have been systematic violations of international human rights standards, and international codes of medical ethics.

Next year will be the 50th anniversary of the Universal Declaration of Human Rights. In the aftermath of the holocaust and the Nuremburg Trials, to which Bishop Tutu alluded at the opening of the hearings, the international community said "never again", and to that end formulated an international bill of human rights.

Beginning with the Universal Declaration of human rights adopted by the United Nations General Assembly in 1948 the international community has drafted a series of instruments that recognise the inherent dignity and equal and inalienable rights of all members of the human family. The Universal Declaration, broadly considered to be a common standard of achievement for all peoples and nations, enumerates some two dozen specific rights to which all persons are entitled without distinction of any kind, such as race, colour, sex, language, religion, political or other opinion, national or social origin, property, birth or other status.

Two of the most fundamental protections are the right to life, liberty and security of person and the right to freedom from discrimination.

Other basic civil and political rights that are articulated in freedom from torture and cruel, inhuman or degrading punishment, freedom from arbitrary arrest and detention and the right to a fair trial.

In addition the text of the Universal Declaration sets forth a series of social and economic rights, among them that everyone has a right to a standard of living adequate for the health and well-being of himself and his family including food, clothing, housing, medical care and other social services.

The principles enumerated in the Universal Declaration are further developed in a series of human rights conventions. States which ratified these instruments and thereby become States parties are legally bound by their provisions. Well over 130 countries, including virtually all major nations, have ratified the two most important of the instruments, the International Covenant on Civil and Political Rights, and the International Covenant on Economic, Social and Cultural Rights.

Our submission goes into some of the specifics of the standards that are in each one of these covenants that provide a framework for the health sector in South Africa. Given the fact that we are running short of time I won't go into that.

But I would like to point out that in 1949, the year after the Universal Declaration was formulated there was, of course, the momentous election in South Africa which set the country on the course of apartheid, which in its very nature violated these fundamental standards.

I think that it's something that we can all celebrate that as we move into the 50th Anniversary of the Universal Declaration of Human Rights, that the political system here has changed fundamentally and symbolically as well as South Africa has begun to ratify the International Conventions. We hope that they will provide an active set of standards that the new and reformed medical sector will now seek to embody.

PROF R LAWRENCE: I will just briefly address the question you asked us to focus on. In our submission we did have a detailed section about district surgeons that attempt to illustrate some of the problems confronting the health professions under the system of apartheid. Through their inability to resolve the role conflict between duty to their patients and duty to the apartheid state, the district surgeons serve as a prime example of the violation of international law and standards that Audrey has just spoken about, in the discharge of their professional role.

In our written submission we state that while there was considerable variation in district surgeons' attitudes towards their patients, and in the quality of care they provided, district surgeons did, in the main, accommodate themselves to the dehumanising system in which they were operating.

District surgeons commonly participated in abuses by failing to record and investigate apparent signs of abuse by not insisting on appropriate treatment and by not respecting doctor/patient confidentiality. While it appears that district surgeons did not generally participate actively in torture they rarely spoke against inhumane practices. While there were a few bright spots, those few who did speak out against the abuses received little support from their colleagues as we have heard in testimony over the last day and a half, suggesting that the problem here was not restricted to a few bad apples, but in fact did represent a collective professional failure to responde appropriately.

Fundamentally then, district surgeons failed to honour the responsibilities that they had to their detainee patients under, not just international law to which South Africa was not then States party, but even under South African law.

This problem of complicity and torture, or the denial of treatment, the falsification of medical records, the violation of medical neutrality, as we've heard testified to yesterday in which patients were actually seized by security forces while under treatment, all point to this larger picture that we've heard in such graphic detail.

We would like to make three principle recommendations which we will then follow-up in our longer detailed submission later in September.

First, the category of regulation and enforcement. The discipline of physicians in South Africa under apartheid obviously was woefully inadequate and the Council failed to function in any meaningful way. Based on the testimony submitted yesterday I have to say that I have concern that there is in place the kind of reform at that self-regulatory system that would be necessary to protect against future abuses. I believe that there needs to be a complete restructuring and a recognition that self-regulation has not worked.

The SAMDC needs to be replaced by a pro-active group with representation by progressive community institutions such as women's organisations, labour unions and church groups. What we heard this morning about the changes underway with the Nursing Council, I think provides an example that the physicians group might well look to.

Second, accountability. There needs to be a human rights monitoring body that is both independent and yet empowered to investigate allegations of human rights abuses, including access to patient records.

It is difficult for us, as a group of Americans, to suggest exactly the form that this might take to accommodate to the values and the mores of South Africa, but we do believe that part of a strong, civil society that is now beginning to emerge in South Africa will create a supportive ground for the creation of such an independent monitoring body.

Third, education. Education and health and human rights should be provided at all levels. We've heard others testify to the same concern. Within the health profession schools it must be linked to the examination system in order to assure that human rights education will not be marginalised or trivialised by faculty and students alike.

Re-certification and re-licensure of graduates should include requirements for participation in human rights education and training.

While we applaud the efforts described by MASA to work with the seven South African Medical Schools to develop ethics curricula, we do not believe that this goes far enough. Given the apartheid past and its legacy we believe that education in the areas of social, cultural and economic rights, as well as civil and political rights go above and beyond bio-ethics in the context of the diadic doctor/patient relationship or nurse/patient relationship. It is necessary, in order to understand fully the social determinants of health and disease in South Africa, to appreciate the nature and extent of psychological barriers that might prevent the full disclosure of symptoms and history by patients still wary of the system; to sensitise health professionals to the origins of the distrust which many patients will continue to feel in months and years to come, and to identify residual, structural impediments to the full guarantee of human rights to the citizens of South Africa, whether patient or health professional.

Thank you.

DR WENDY ORR: Thank you very much, and thank you for being such remarkable timekeepers for yourselves. I think district surgeons demonstrate par excellence the dilemma of the doctor with dual obligations, but obviously they are not the only doctors who have dual obligations. They have obligations towards their patients which you and I believe should be paramount, but they also have obligations to the person or body or institution which is employing them. We see that in the military, we see that in the Police, we see that in the Prison Services. Do you have any thoughts as to how this tension can be addressed, this dual obligation tension?

PROF R LAWRENCE: I believe in the United States we have in our teaching of health professionals focused on the question of values clarification as a way of approaching ethical conflict when somebody confronts a dual loyalty situation. One of the healthy things that I believe would be useful here would be to create regular fora in which people could come, almost like a clinical pathological conference and say in the last week I was faced with the choice to do this or that, I am not sure I made the right choice but this is what I did.

Michael Balant(?), the late British psychiatrist in his classic work, The doctor, the patient, the illness", talked about the value of confidential small groups of health workers getting together on a regular basis to share the problems confronting them in practice, ethical, moral, legal problems. A seductive patient, a problem where confidentiality breaches some other kind of family relationship problem, I think here, given the 45 years that you have just been through, that it would not be at all inappropriate to designate a regular opportunity for health workers to come together and to recognise that these are difficult tasks to sort out. People haven't had a lot of experience in dealing with them and then to work that in to the curriculum for health and human rights.

DR WENDY ORR: Thank you. I certainly find that a very useful suggestion. I have no further questions. I certainly look forward to working with you and your organisation in the months to come as we pool our final report and recommendations together, and want to thank you again for coming here today.

MS MKHIZE: I would also like to thank you for being part of this important step in the history of our country where professionals are re-looking at where they are coming from, re-defining their roles as Dr Orr has said. We see you as our allies and hope that you will continue assisting in as much as you can. Thank you very much for coming.

PROF R LAWRENCE: Thank you for having us.

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DeNOSA SUBMISSION

MS MKHIZE: We will now be listening to DeNOSA. While they are coming forward I would just like to make a comment which will apply to DeNOSA, NAMDA, OASSA and HHRP, that we will really appreciate it if they try not to repeat what other people have said, especially the work which has been referred to many times, but to highlight those aspects which are unique to their organisations. Thank you very much.

I will ask the two of you to stand up, read out your names so that you can take an oath.

MARY MOLEKO: (sworn states)

SHEILA CLOW: (sworn states)

MS MKHIZE: Thank you. Miss Wildschut will assist you in presenting your submission.

MISS WILDSCHUT: Welcome, may I add my welcome to that of the Chair. I am not quite sure, I am quiet because I am not quite sure what is happening in front of me, so I don't know if this is going to be part of the presentation or - okay alright. Please go ahead and present your submission to us.

MS S CLOW: Thank you, and thank you to the Truth and Reconciliation Commission for the opportunity for us to present.

DeNOSA, the Democratic Nursing Organisation of South Africa was constituted in 1995. At present our top leadership and top management are attending the International Council of Nurses Quadrennial Congress in Vancouver where DeNOSA will be admitted to the ICN and the Commonwealth Nurses Federation, as the organisation representing South African nurses.

It is unfortunate that they cannot be here to make this presentation but this prior commitment was made known to the Health Sector Task Group as soon as the dates were set for these hearings.

Professor Feldun Zimande, Chair of the Joint National Board of DeNOSA and President elect will make introductory comments via a pre-recorded video tape, and thereafter Mrs Mary Moleko and I, members of the Executive Committee of the Joint National Board, will continue the submission on Nursing.

MISS WILDSCHUT: Thank you. I always knew nurses were innovative.

VIDEO SHOWN AND PROFESSOR ZIMANDE ADDRESSES

PROF ZIMANDE: The submission made to the TRC today is a preliminary submission by the Democratic Nursing Organisation of South Africa, DeNOSA, which represents plus/minus 100,000 nurses in South Africa of all categories.

This submission aims to provide background information about the organisation; to provide overall context within which the submissions occur; to outline the parameters of our relations identified at this preliminary stage.

(...indistinct) reflects the personnel and the experiences and perceptions of the (...indistinct). (...indistinct) made today will only provide broad categories and areas whereby (...indistinct) to the rights of nurses were entered.

DeNOSA is a professional and a labour organisation representing more than 100,000 nurses. Organisations that form DeNOSA are TRANA, PNINA(?), SINA, BONA, KNO, (...indistinct), SANA and CONSA.

In November 1996 all these organisations unified thus forming one very strong organisation in South Africa. They thus shared their assets and their membership. The organisation has just gone through the first democratic elections in the country of the nursing profession and the boards that have come out as a result of these elections, that's the national and provincial board, we start operating in July.

For the nurses of South Africa the process of unification and transformation is a major step. It is therefore of great concern that these submissions that have been made today will not harm and destroy the unity that is being developed.

DeNOSA submits that the input of apartheid legislation constituted gross violations to the rights of nurses and nursing in South Africa. In all our submissions that are being made today we cover areas like violations of human rights of nurses and the nursing profession as a whole; of nurses as women, nurses as men; nurses as health care givers and nurses within the nursing education.

The intention of DeNOSA is to develop and initiate, with assistance of the support from the TRC a reconciliation and a re-correction process that would meaningfully explore and expose past injustices within the nursing profession. Having made these introductory remarks a full submission will be presented shortly.

VIDEO ADDRESS ENDS

MISS WILDSCHUT: Sheila could we ask you to just highlight the aspects of your preliminary presentation because we do know that you are going to give a much fuller presentation later on in writing.

MS S CLOW: At leadership level DeNOSA is committed to engaging with the TRC process as the consequences of the period in question have left severe divisions within the nursing profession that perpetuate distrust, resentment and bitterness.

Nurses have welcomed the opportunity to be heard and want to participate in the process. They are committed to and support a larger participatory and inclusive process that results in individual and group submissions as part of our final report.

To protect the respondents and to encourage participation DeNOSA has secured an undertaking from the South African Interim Nursing Council that nurses making voluntary submissions to the TRC will not be subjected to professional conduct review.

As we have mentioned DeNOSA came into being in 1995. It was the first professional group within the health sector to do so and this was as a result of three years of wide and inclusive negotiations with all groupings of nurses within South Africa. After a further 19 months, in October 1996, unification was achieved with the dissolution or merger of all pre-existing nursing organisations.

The process of negotiation has been a difficult one and in some cases very painful. The current challenge to build unity amongst members, who represent great diversity, is huge. In understanding these dynamics the TRC will appreciate that the energies of the organisation have been largely directed towards issues of transformation, both within the profession and the health sector, as well as holding the first democratic elections of the organisation.

For this reason the submission that has been presented in writing to the TRC, and the oral submission today, is very much a preliminary submission. The Joint National Board expressed a deep concern that the TRC process should not erode the unity that is being developed. The Board therefore decided that separate submissions from the leaders of the former organisations would be counter-productive to the process of building unity, and so at this stage this submission aims to offer a broad perspective on nursing during the period under review.

We recognise the limitations of the preliminary submission. One of these is that there are many perceptions of the truth in relation to specific issues. But rather than support one perception only we recognise that our history has shaped us in different ways and that we experience and interpret events differently. For that reason we will accommodate these tensions in our submission in an attempt to illuminate our past.

In the final submission that will be made in writing in October greater detail, with careful corroboration of evidence and verification will be included. For example, the roles of the various nursing organisations, and nurses in often side-lined sectors like the mining sector, prisons etc.

As nursing is the one profession which most closely resembles the demographic realities in South Africa in terms of race, socio-economic status and the rural/urban mix, and is the health profession closest to the population, the experiences of nurses in South Africa are a useful indicator of the experiences of the population.

In terms of violation of human rights in nursing DeNOSA submits that the impact of apartheid legislation effected during the period in question constituted gross violations to the rights of nurses and nursing in South Africa. Enacted by officials of the day whose political imperatives resulted in establishing a culture of segregation, discrimination, inequity articulated through acts, emissions and offences, an environment was created and reinforced at all levels of society where severe strife, conflict, untold suffering and injustices were meted to nurses and their patients.

DeNOSA believes that there are many experiences relevant to nurses and nursing that constitute gross violations to the rights of nurses. Further, they have resulted in severe consequences for nurses, nursing and patients at the receiving end of care.

Based on the oral submissions of a number of nurses, violations to their rights as nurses have had serious implications for them in a variety of circumstances, including the right of affiliation as members of a professional body. These violations permeate all levels of human existence, resonating consequences of a social, political, economic, psychological and in particular, spiritual nature.

The violation of the very essence of human experience, within the context of the spiritual relates to the meaning and purpose nurses attribute to their lives, their sense of worth and dignity and their ability to forgive and apologise.

Unlike the medical profession there have not been high profile cases as we have heard in the last day or so, but as nurses are the backbone of the health sector, as we keep on hearing, it is very unlikely that nurses are not going to be implicated in some of these human rights violations. To this end we have informally requested the Health and Human Rights Project to furnish us with any evidence that relates to nurses so that we can have as full a picture as possible in our final submission.

In the interests of time we do not intend to read our preliminary submission but to highlight certain aspects that have led us to present under specific headings.

MS M MOLEKO: Madam Chair allow me a few minutes to indicate these areas of violation of the rights of nurses.

MISS WILDSCHUT: Sheila you have two minutes.

MS S CLOW: The last violation relates to nursing as a profession, and just some of the things where there's been incongruence between legislation and the type of caring and ethical base that one could expect in nursing.

Some of these incongruencies in terms of having to implement legislation has resulted in the formation of Homeland structures; the failure of professional associations and regulatory bodies to investigate inconsistencies in health care provision; the failure of these bodies to represent and defend the interests of Black nurses; the failure of these bodies to provide leadership, guidance and protection for nurses in response to political violence. And then the withdrawal of the South African Nursing Association from the International Council of Nurses in 1973.

In conclusion. We request assistance from the TRC for research support to enable us to complete the final phase of this submission on nursing in South Africa during the period under review. We recognise the need to reflect on the past in order to proceed with planning for the future, and in particular to inform strategies aimed at preventing the recurrence of past irregularities, inconsistencies and injustices.

However, it would be premature to make recommendations for future action and reparation before this particular process is complete, but these recommendations will be forthcoming in the final submission in October.

What is clear is that a fundamental shift in attitude is required, both within nursing and the health sector in general which respects the worth and rights of those both seeking care and those giving care. DeNOSA is committed to being part of that process.

MISS WILDSCHUT: Thank you very much to both of you. I do have quite a few questions which I won't ask now because you have pledged to give us a more complete submission later on this year when you have done some more research and you can give a more complete version of what the status of the Nursing Association was before and how you've moved towards unity.

I cannot resist the temptation to comment about the conversions of events in that the South African Nursing Association, as it was known then, had walked out of ICN, that's one version of the story, and that DeNOSA is now being admitted to ICN. I think that the story of SANA not being in the ICN for such a long time is a story that has to be told and many people do need to know and hear that story, and hopefully that will come into the submission later on.

MS S CLOW: Madam Chair, certainly that will be in our submission. However, Mrs Moleko was at Mexico City when South Africa withdrew from the ICN, perhaps you would like her to comment briefly at this point.

MISS WILDSCHUT: I would have to ask the Chair if we would have that indulgence.

MS MKHIZE: No. I just would like to thank you very much for your presentation, and also to say, as a newly-born organisation, I hope it won't be a change in name, but in terms of policies and practices. Thank you very much for coming.

MS S CLOW: I am sorry there isn't an opportunity to flesh those out now, but they will be in the final submission.

MS M MOLEKO: Our constitution bears witness to our commitment.

MS MKHIZE: Thank you.

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NAMDA SUBMISSION

MS MKHIZE: I would like to ask the NAMDA representative to come forward please. Welcome. As I indicated when I invited DeNOSA, I should think this will apply to your organisation as well, we will try to channel you to talk to those areas which haven't been documented. First of all I would like you to stand to take the oath.

MALCOLM BARRY KISTNASAMY: (sworn states)

MS MKHIZE: Can you say your name, your position and where you are located please.

DR B KISTNASAMY: I am Malcom Barry Kistnasamy. I am currently Deputy Director General, Environmental Affairs, Health and Welfare, Northern Cape Provincial Administration. I speak in my personal capacity on behalf of a group of progressive doctors who were part of the executive of NAMDA between the years 1982 and 1992.

MS MKHIZE: Thank you very much Dr Kistnasamy. What I would like to do is to raise three questions for you so that as you are talking through your document you will have in mind areas which, based on what you have submitted, we felt needed further clarification.

The first question is; how did NAMDA's objectives differ from those of MASA? Where is NAMDA today?

The second question is; looking at the state of health services today are there any strategies learnt from NAMDA, activities which you think would be more effective in ensuring health for all today?

The third question is to request you to spend some time sharing your thoughts on the way forward, especially in view of the fact that up to today survivors of human rights violations are the poorest of our society, and they are from communities where health services are still either non-existent or inappropriate.

Thank you.

DR B KISTNASAMY: Thanks Madam Chair. The National Medical and Dental Association came into being on the 5th of December 1982 at a conference in Durban after more than two years of consultation amongst all progressive doctors, dentists and other health workers nationally and internationally.

In the preamble to its constitution NAMDA proclaimed its acceptance of the World Health Organisation's definition of health as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. And perhaps I think that these are things that colleagues within other organisations, both represented here today and over the last two days, probably need to examine in terms of their own submissions in terms of this WHO definition of health.

It reiterated the belief that health is a basic human right which should be available to all the people, irrespective of race, colour, political belief, economic or social condition. It further committed itself to creating the conditions for optimum health which can only exist in a free and democratic society. And I think that's where the variance came in with many of the organisations that saw itself, at that stage, as part of the apartheid State machine, or sharing the world view of White South Africans, and that was earlier alluded to in various things. Whereas NAMDA felt that you cannot have optimum health for people if you did not have the conditions, the structural changes that needed in society to bring about optimum health, and NAMDA committed itself to creating those conditions as well.

Its aims and objectives were as follows:

Health professionals in South Africa have long been aware of the damaging effects on the health of the population imposed by a system of racial and economic exploitation.

The social consequences of apartheid were so gross, so thoroughly destructible and so widely acknowledged and abhorred by the international community that there could be no avoiding the intrusion into the professional lives of medical men and women in this country. The idiocy of the pencil test for babies, abandoned babies; of floor beds on one side of the hospital while the other half remains empty; Black medical students in ward rounds that ended in the tea room with the porters while the White students continued with the White professors to the White side of the hospital; Black nurses that could not have White nurses looking after them, and you heard from DeNOSA and maybe their submission later on will point more to that.

The issues about conferences upon conferences where government policy was acclaimed in terms of the Transkei Medical Association, the Homelands, the League of Nursing Associations of South Africa where SANA and the Transkei Nursing Association, KwaZulu Nursing Organisation came together, where these conferences were to acclaim and loud-hailing the government policy of the day were seen as being part and parcel of delivering health care to the majority.

Now the effects of apartheid and its devastating consequence on the majority of our citizens are well-documented. Suffice to say that it combined class and race to give White South Africans their health care system better than some of the Scandinavian countries, and for Blacks worse than Botswana, a country just north of us.

We need to note that the health planners and the medical superintendents and the heads of departments of health at that stage, we need to note what positions do they occupy today in South African society. These issues of separate casualties, separate waiting rooms, do these health planners still have a role in South African society today.

Thirdly, the formation of NAMDA. With popular resistance rising in the seventies through the eighties the apartheid regime increased repression, even health facilities were not safe, and you've heard of instances of that over the last two days.

There were instances of active collusion by health authorities as with the District Surgeon in Colesberg handing over a patient to the police, to possible participation in biological and chemical warfare. Indeed the doctrine of low intensity warfare had become one of high intensity with deaths, disappearances and detentions being the order of the day leaving us a society deeply traumatised and hopefully this process will bring about healing.

Bishop Tutu himself spoke about Johnny on a submission to a conference in the Frontline States late in the eighties.

Lastly, in terms of NAMDA's coming into being, was the programme to train health workers for Black, mainly rural areas, by the South African Medical Services, the so-called COMOPS, designed to win the hearts and minds, gather military intelligence or a genuine commitment to the poor? What of the biological and chemical weapons experimentation? Was it merely defensive? The Reverend Frank Chikane's poisoning, organophosphates, the death of Sipo Mtimkulu. It must be noted that the forensic laboratory's services up to now still reside with the South African Police Services.

The TRC needs to note that health professionals, not just doctors, but biological scientists, psychologists and others would have had to be part of a wider group providing inputs for the destruction of our people, using their knowledge of human physiology and a psyche. Earlier reports of torture to this Committee and others allude to the use of truth sera(?) being injected to detainees.

Historical perspectives are such that it's well-documented about the social conditions and the determinants on health and I'm going to leave that out.

Let me go onto, "did we know"? Given what has been documented previously and what the TRC has heard to date, it is amazing that there are not more health professionals coming forward to testify, similar to Sean, and we would hope that the TRC would continue so that more health professionals could come forward.

Ergonomics is a scientific discipline and in its simplest definition looks at designing the work place to suit the worker. Since the earliest days of our mining industry, the backbone of our economy, heated climatisation chambers were set up to design the worker to the workplace. We need to document what the Chamber of Mines and Wits Physiology Department had done in the early days of designing workers to the workplace.

Recently there has been widespread news coverage of a public health service study in the United States which began in 1932 and continued until 1972 involving 399 Black men who were left untreated for syphilis to let doctors track the course the disease. Madam Chair, our own (...indistinct) continue today. Pneumoconiosis research with volumes of slides of lungs of dead miners in Johannesburg documenting advancing stages of disease, and as yet no interventions. The various drug trials, the people in Lebodi, the rural doctor who spoke about rural health problems, the ex-miners in Prieska, what are we going to do about them and the destruction of family life in terms of migrant labour?

Let me move on, NAMDA's structures. NAMDA was active in all parts of South Africa and enjoyed international support. It grew from 52 members at inception to well over a 1,000 by 1990. I must pay tribute at this meeting to the international aid organisations and governments which provided funding for the organisation's activities aimed at redressing the effects of the apartheid state.

On the other hand the organisations' members were harassed by the State and its structures in various ways. Firstly, inability to get jobs in the public sector. Secondly, harassment by the Security Police.

Thirdly, mysterious break-ins in our offices in Durban and Port Elizabeth and elsewhere with theft of computers and various documents of the organisation including detainee care records, which led us then to devise substantive ways of disguising names of ex-political prisoners and detainees.

Second lastly, detention of members, and lastly bombings and death threats against members. We would like to know who bombed Professor Jerry Kouvadia's house, and that we would ask of the TRC to find that out.

It was unable for us to hold meetings at some of the medical schools, example, Stellenbosch University campus where the students invited us but we could not go onto that campus. The meeting was banned by the Rector, the NAMDA meeting at that stage.

Lastly, we could not get scholarships or research grants, whereas the Medical Research Council continues to contribute to the brain drain of scientists from South Africa by granting scholarships internationally.

The South African Medical Journal, a reputable health science journal, at one stage devoted an entire supplement, I have a copy of it here, attacking Dr Emjee(?), a former president of the organisation. A similar article attacking NAMDA dental colleagues appeared in the Dental Association South Africa's journal. We heard of earlier submissions where the journal refused to tackle what they call "academic valued articles", and peer review (...indistinct) articles, and we would like to know what is the peer review of this article in terms of it being there in the supplement of the SAMJ, 18th of July 1987.

At a branch meeting of the Medical Association of South Africa in the Western Cape in 1987 an Army Intelligence officer addressed that meeting about NAMDA.

Where is the organisation today? Unfortunately the Association finally merged with other progressive organisations in 1992 to form SAHSO, South African Health and Social Services Organisation. Since 1995 a core group of ex-NAMDA doctors have rallied around the umbrella of the Progressive Doctors Group to begin discussions about a united medical association for South Africa that will espouse the true values of health and human rights.

Very briefly NAMDA's programmes, and this might have an impact in terms of the future function of the TRC and the health sector in general. There were major health policy initiatives by NAMDA that are now coming to bear within the Department of Health's formulation of health policy and we are glad to say that NAMDA's earliest contributions have contributed in more ways than one to a national health system for South Africa, a new system of medical education and training for the health sciences, and lastly debates on health financing. Those policy options are now firmly entrenched within the South African Government's programme of action.

Secondly, care of ex-political prisoners and ex-detainees and their families. You heard yesterday testimony from one of our colleagues in Livingstone Hospital, of NAMDA's inputs that were made together with other progressive organisations. We had made submissions to structures such as the Department of Health at that stage, the Medical and Dental Council, from example, the Fort Glamorgan issues in the East London area, the Eastern Cape, however to no avail. We would like to know where those documents are today and whether there would be a re-opening of some of that evidence.

In addition the State very soon after NAMDA safeguarding hospitals in the eighties began to move ex-detainees to No.1 Military Hospital. What was different from public sector doctors, so-called NAMDA doctors treating people in public hospitals than military doctors in no.1 Military Hospital? There were quite a few ex-detainees, the detainees that were moved to the Military Hospital.

Lastly there were psychiatrists as you heard today that began to justify detention and justify torture and I think those issues need to be examined further. To the extent that NAMDA began to say that we were treating not post-traumatic stress syndrome, that we were treating continuous traumatic stress syndrome.

First aid training. This programme began as a direct result of the violence in the townships and the many mass rallies that were being held. Many wounded people were arrested in hospitals and thus were afraid to go into health facilities. Examples abound where security forces surrounded health facilities or set up mobile police stations outside health facilities. In addition health facilities were at times closed during periods of unrest.

At that stage Madam Chair, organisations such as St Johns, the South African Red Cross and Noordekulplike were, according to our perspectives, not responding adequately to the needs of the victims of security force action. They were still continuing with life-saving activities and old age homes. Content of the training which NAMDA developed was aimed at community based organisations and trade unions and focused on first aid, emergency medical supplies, counselling skills and organisational skills to meet urgent health needs.

NAMDA members and other progressive health workers were asked to ensure the safety of all patients at health facilities and provide care for the victims of violence, and yesterday was quite an emotional outbreak in terms of Dr Pat Naidoo and other colleagues like Betty at Livingstone Hospital.

Of special note was an attempt by NAMDA during the latter half of 1985 and early 1986 to get information on the nature of the compound used in teargas. We needed to know what was in teargas and how to treat it because there were instances coming through of media reports attributing deaths and severe ill health to the indiscriminate use of teargas. This information was denied to the organisation.

The next programme was a progressive primary health care network which was launched in 1987 and still remains to today in terms of a highly major grouping of community based organisations and health workers contextualising the political, economic and social conditions which give rise to ill health, and that structure continues to this day.

It emphasised community accountability, comprehensive health care and ensure that health workers use their knowledge and skills to service the needs of the disadvantaged.

We further went on to have a national campaign on apartheid in health de facto in 1987 this was launched. The campaign had four objectives, to publicise the fact that hospitals were segregated by race; to enable Black patients to be seen at White hospitals; to de facto integrate hospital inpatient facilities and to force government to publicly declare that all facilities are open to all races. International campaigns that NAMDA engaged in was against torture, detention and racial segregation of facilities for the isolation of health professionals in South Africa, especially the Medical Association, the Dental Association, SANA and such structures, government functionaries and academics. And particularly when it came to academics who held a fairly liberal view of individual rights versus group rights, and they felt that this was curbing their international linkages. And unfortunately there are many of them present here today in the audience who still feel that this was a major impact in terms of their own growth, whereas the needs of the majority of the South Africa's citizens were being denied at the same time.

Lastly, NAMDA campaigned for the release of political prisoners who had health problems.

We did publish articles that were not covered in this SAMJ but were covered in prestigious journals like the BMJ, The Lancet and such international journals.

The very special programmes that we worked with, there were local programmes like "Free the Children Rights" campaigns, etc, and I must say, in conclusion, that all the other programmes while initiated by NAMDA had close collaboration with the Health Workers Association, which later became the South African Health Workers Congress, the Detainees Parents Support Committee; the Organisation for appropriate Social Services in South Africa; the South African Council of Churches and various doctor and dental guilds.

Some thoughts on the way forward. Human rights as a discipline becomes part of the curricula in our education system, and the patient's charter of rights needs to be emphasised. However, we should be wary that the custodians of this human rights culture are not the very perpetrators who benefited from a system in the past. I find it almost impossible where we find chairs of human rights or whatever ethics that are still held by people from the old establishment. We need to see about people who were actually denied fundamental human rights taking up those chairs and those professorial posts.

The annual NAMDA human rights lecture, we had a human rights lecture series be resuscitated in conjunction with the Human Rights Commission and we feel this would be a token to NAMDA and the work that it did in those dark years in terms of the human rights lecture series being resuscitated, where we would then work with local people, the African experience and further experiences in South America where I think those things need to be probed as well, the links in terms of South America and various countries like Uruguay, Argentina etc, and the South African Government and its agencies in those dark ages of the seventies and the eighties.

Thirdly, very important to the future function of the TRC and its recommendations. Many of the survivors of the high intensity conflict need health care, especially counselling services, and it's nice to know that Project Curamus is there for ex-servicemen and servicewomen, what about a Project Curamus for the victims and the survivors of apartheid's human rights violations? One of our own workers who over 20 years worked in the human rights field has currently had major psychological problems and he doesn't have an Operation Curamus to help him. Can we get the SANDF to assist us further in this field, together with the Department of Health. Let's extend their services.

Fourthly, we need a much closer examination of the role of the district surgeons. They are still present today. And the delivery of health care to prisoners and victims of State-sponsored violence. Perhaps we should note that many part-time district surgeons also have those separate segregated facilities. How many of them are members of current organisations such as MASA? Should we not be taking them to court, Constitutional and other ways, but apart from the fact of saying part of the conditions of service with Government as district surgeons that you cannot have separate entrances and separate facilities?

Fifthly, as with the landmines campaign which we applaud the South African Government for taking the lead on, we should begin a campaign against biological and chemical weapons, in fact campaign for peace and promote a war against poverty. That's the biggest threat to this country, poverty.

The TRC further needs to explore the relationship, if any, between military regimes, especially in South America and the brutal methods of torture and violation of human rights that took place in our country all these years, in line with biological and chemical weapons offensive.

Six, seven and eight, in terms of its recommendations the various organisations, Medical and Dental Council, Pharmacy Board etc needs to examine their own rules and that they have started to do. The professional organisations MASA, DASA, the Optometry Society, the Occupational Therapy Society, there's a whole range of these bodies across the range in South Africa and I don't think the TRC hearings have concentrated enough in terms of beyond doctors and nurses and psychologists. Many other health professionals helped in some ways or the other to uphold the apartheid state. They need to examine their roles.

The voluntary organisations, the Red Cross, St Johns, Noordekulplike, consider their role in terms of the international charters that they were part of, and what were they doing and what are they going to do.

Lastly, I am part of the Department of Health, and I spoke in my personal capacity, I hope that through my own involvement in the Department of Health we will continue to make changes, with government involvement, with political inputs, to make changes that satisfy the aspirations in terms of the health needs of all South Africans.

In conclusion the wounds and the scars remain, memories of a continuing past which will not disappear. We are only beginning to set the economic and social foundations for a health system that meets the needs of all South Africa. Medical ethics in times of armed conflict are identical to medical ethics in times of peace. The World Medical Association quotes that the supreme guide of the doctor is his conscience. How many of us have been true to our conscience?

I thank the TRC on behalf of NAMDA and its colleagues for allowing us to make this submission and we will continue to work with yourselves in whatever forms to actually take this process forward in terms of the reparation process thereafter. Thank you very much.

MS MKHIZE: Dr Kistnasamy thank you very much for representing what I will say, all the survivors of human rights violations as well. Dr Ratemane shared about what he was exposed to as a student in the South African universities, so I see you certainly as one of the survivors who remain a strong voice for many people of South Africa who have suffered under the previous socio-political order.

You have made a commitment to work with us in finalising some of these ideas and we will continue to pose questions to you, especially as we finalise our report. Thank you very much for coming forward.

MS GOBODO-MADIKIZELA: Excuse me. While you are on your way out, can you tell us about this organisation that supports ex-servicemen?

DR B KISTNASAMY: That was part of the SAMS submission.

MS GOBODO-MADIKIZELA: Oh okay.

DR B KISTNASAMY: And what we are saying is to extend that to all South Africans.

MS GOBODO-MADIKIZELA: Okay, thank you.

MS MKHIZE: Maybe just while you are leaving I would like to mention one thing, that we have received submissions from the Physiotherapy Board, Occupational Therapy Board, South African Pharmacy Council, Medical Research Council, HSRC, so we are working with all these other bodies.

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OASSSA SUBMISSION

I will then invite a representative of OASSSA, Miss Ann Harper to come forward please. Thank you very much for coming forward, Dr Orr will assist you to take your oath.

DR WENDY ORR: Ann welcome. I know you've travelled all the way from Durban to be with us and we are very happy to have you here.

ANN HARPER: (sworn states)

MS MKHIZE: Welcome again. I will try to do the same. I will pose three questions to you and ask to talk to those aspects of your submission which will address the three questions.

Your organisation operated during a difficult period of extreme political oppression and I am almost certain that you experienced difficulties related to the type of work you were doing. A specific question,

The second question is,

MS A HARPER: Thank you very much, and thanks for the opportunity to present something in a more structured form than the previous submission we made to the TRC. It was certainly at their nudging that we were encouraged to try and put down some of our thoughts into a more structured format.

I perhaps need to explain that I am certainly not speaking here as OASSSA, the organisation, in case some of my colleagues in the audience think I have forgotten organisational discipline, I actually am speaking as the Durban Branch of OASSSA, and more specifically the Detainee and Repression Counselling group.

So if I could preface my input to say that this was drawn together by the remnants of that group who have spent time together trying to reflect on the experiences we've been through which in fact we discovered had pre-dated OASSSA days.

And perhaps if I could just try and follow the order of your questions and structure my input by saying that there are two specific events, although obviously all the issues that have been raised over the two days informed the response of the organisation and of this particular group. I think two in particular are linked to the roots of this particular group of counsellors. The one was the mass detentions in the 1980's, and as a result of that, and one of the many responses was the formation of the Descoms, the Detainee Parent Support Committees, and those committees, very quickly, as their work increased, started to pull in legal, medical, psychological, welfare sub-groupings into the Descom structures, and a number of the people who were part of this counselling group had their origins there. So it goes right back to those days.

What happened after that was the need to organise perhaps more coherently the work of the psychologists, the social workers, the people who were coming at the detainee work from a mental health or health perspective, and the Natal health group was formed in support of the Descom work. As that developed more and more we found we were drawing in physiotherapists and doctors, students, and I need to give enormous recognition of the role that students played in the work that we did, they certainly nudged the professionals into moving faster.

As this was going on in the Durban region OASSSA was

forming itself in the Transvaal, and that was in the 1984/85, so that in the Durban region there wasn't really a need, it wasn't perceived to be a need for us to, at that stage, form an OASSSA branch.

The next major event I think that shifted the focus of what we were doing to some extent, and also deepened the work was the state of emergency. That the health care systems and the social service systems of that time were inaccessible as it was were fragmented, were certainly not near to where the need most was. And what became apparent to us is that we had to have a response to that lack of accessibility.

So from the Natal Health Group a new group formed called the Emergency Services Group which worked together with the NAMDA people and a number of organisations that my previous colleague articulated. So we had a history, if you like, of development, the two main political events that happened, one was the mass detentions and the need to have a response to that from the mental health sector, and finally the state of emergency which really made accessibility to any kind of care and support almost impossible for the people who most needed it.

I had included here some background on OASSSA, but perhaps if I could throw it out as a challenge to executive members of OASSSA, the need to really write their history and to put together in fact the origins of that organisation as a whole because I cannot hope to do justice to all the areas of work which were included in that organisation's brief.

If I could just touch on the headings of what OASSSA was attempting to do at that time. By 1989 there was a branch in the Transvaal which had started in '83, Cape Town '85, Durban '87 and 'Maritzburg '87 and Grahamstown in 1989, so by that time OASSSA was well launched. It's general brief and terms of reference, because one has to, and I think, I don't want to belabour the point it's been made very well in the last two days, that the mental health services, the practice, the training, the professions, the professional bodies in particular were very closely reflective of the wider society, the divisions, the fabric of the apartheid society certainly was reflected within everything that - all those areas of psychological life. What OASSSA then tried to do, and I'll talk a bit about, I think the origin in the Transvaal as quite a symbolic beginning for the kind of people who were drawn to OASSSA was, the group of ad hoc students who got together in about 1984 to protest the location of an Institute of Family Therapy conference on the family to be held in Sun City, and I think that that was quite a significant turning point for many people because the total obscenity of holding a conference that was going to be focusing on family life in a homeland where, and in the context of a system which is actually destroying families, did not seem to perturb the organisers of the conference, but it certainly motivated a group of students of the time to say there is something terribly wrong with this type of process. So I think that was the kind of - then there were moments like that in psychologists lives I think where suddenly having seen South Africa a different it was impossible to say you did not know or you had not thought about it.

So what OASSSA tried to do really was look at how the Mental Health and Social Service workers were organised and to try, I suppose, in many ways provide an alternate home for the psychologists and social workers. We had a number -we were quite open membership who just did not feel that they fitted into the traditional professional bodies. So it did have an organisational aspect to it.

It also attempted to research and expose the social, economic and political conditions which we believed undermined the wellbeing of all the people of South Africa, and I don't want to go into that because I think it's very well covered. We certainly are willing to put a more detailed report together to list those.

Also to develop and try and offer more appropriate social service which was much more responsive to the real needs of the society as we saw them and based more in the realities of the people who were most disadvantaged in terms of access to the few and fragmented services that were available. So we also wanted to challenge the way we went about our work. In fact it was reinforced today, the training of psychologists was happening in this extraordinary vacuum, it certainly wasn't happening in South Africa and you learnt nothing in that training about the realities of the difficulties that the majority of our citizens were facing and the threats to their actual wellbeing. So we felt it was necessary for us to start examining what we were doing to try and find different models of doing our work.

Another part of that was to try and share our skills. The South African psychologists were very elite, maybe, I am not sure about past tense, but there is very much a sense of "expertise" and you do not work with non-professionals. You do not share your case notes with social workers at one stage. So we were trying very hard to share our skills as much as we could wherever there were people who were already identified as care-givers in the community.

So the counselling group in particular, perhaps I need to focus for the rest of the time very quickly on them, the counselling group, the detainee counselling group then which was a subsect of the OASSSA were specifically counselling ex-detainees, their families and their friends. I think the point has been made that the State was certainly not just targeting individuals, they were targeting the whole social network and support system of people who were detained.

And as our work developed we found ourselves more and more working with victims of various forms of oppression and repression and violence as well. I will go into that in a bit more detail. Police and vigilante harassment especially in KwaZulu, compulsory conscription, we found more and more that as we became identified as a resource within the community this very small group of health care professionals and workers were being called upon to intervene or become involved in the care of a number of different people, although as I said we did start out as a detainee family and friends group. The work with the detainees, as Barry has mentioned, was carried out very much with NAMDA under the auspices of the emergency services group.

The other work that we felt it was important to get involved with was just presenting workshops and seminars and talks on detention and the effects of detention, because at that stage we felt it was really necessary to try and counter the denial of State officials that in fact torture and abuse of detainees was really taking place. And if you remember the state of emergencies there is no way that you could get that information published. You remember the Weekly Mail where they eventually published just one blank page because everything was banned and censored at that time. So we felt it was really necessary to keep running workshops, keep trying to tell people about what was going on. And again we need to give credit to the overseas supporters who enabled us to publicise some of that work.

It also arose the need for workshops to try and broaden the net of support in the townships because it became impossible for us to hope to get our services into the townships. If there were services in the first place people just did not - were not able to enter or leave the townships and the people who were in there we found were enormously resourceful, the ministers, the teachers, the grandmothers in particular, the mothers, were very much seen as the support system within the townships, and we felt it was much more worthwhile for us to train other people who might be able to offer the support at source, if you like.

We were also involved in a number of other activities which I will elaborate in a more detailed submission. But perhaps if I could go on because I think it is a slightly different stance that I would like to present here about the way in which being a professional psychologist, or a group of professional psychologists who were trying to do things differently, or work with people who were seen to be enemies of the State, the way in which that actually was made more difficult by our professional organisations, the lack of support from colleagues, also the way in which it compromised the kind of service we could offer to people. So I'd like to spend a bit of time on that and avoid the repetition of the other inputs.

The most frequent groups we saw, as I had mentioned earlier, apart from the ex-detainees, were people, activists who anticipated being detained or becoming victims of violence, and in KwaZulu that was quite a significant group. That created a very particular challenge for the psychologists, because when you were working with people on the run the assumption that you would be seeing people for a number of sessions, or you would see them in a location which was clearly identified was totally thrown out the window. You had to become a person who would go to where people were in hiding, and that usually involved a whole network of moving around. At that time that was not an exercise without its own dangers.

Another group that started coming to us much more were the conscripts, so they were people who were attempting to avoid the call-up, people who are AWOL and on the run, or those who had completed their military service and were totally traumatised by their experience. I found that group escalated, especially during the state of emergency, in terms of the students on the campuses.

The other groups which, and in our more detailed submission we will go into the kind of issues that we were forced with, were ex-political prisoners, returning exiles and I think it's a group that still needs some thought. And in KwaZulu in particular, displaced children, children who were trying to escape the violence, particularly of the Midlands and Pietermaritzburg and we found this huge wave of street children who suddenly entered the city of Durban.

From a counselling - another obstacle was just the profession itself, I don't want to go into that too much because I think Lionel captured it very well this morning, but basically the PASA - although we had made attempts to try and get them to take a public stand against apartheid and to actually come out in recognition of a link between apartheid and the enormous damage that it was doing to the people in the country, both PASA and the Society for Student Counselling refused to do that. Eventually, I think after two years, they came out with very watered-down versions.

So we were operating without a base, if you like, without the support of our professional body. I think it was mentioned this morning, they hid behind the professional neutrality or objectivity, and in fact their silence and inaction of the majority of the health professionals possibly, became a way of colluding with what the State was trying to impose at that time.

It is more than possible that collusion took more of an active form and I think a lot of people have alluded to that, and one encourages the TRC to try and investigate that. We will certainly cooperate in whichever way we can.

You also asked me about our role as professional counsellors, and I'll try very quickly to cover what we thought as the ways in which our own professionalism had been compromised. And even started questioning the quality of the care that we were able to give to people. It became an issue of your political credibility actually outweighing your credibility as a good psychologist or a good counsellor because of the way in which we were having to offer our services. We were often seeing people in inadequate facilities because you couldn't see people in the clinics because the State services or a lot of the places where you might have been able to operate were viewed with suspicion, especially by the people on the run, and there were certain buildings which were being watched. So where we ended up seeing people were often odd ad hoc rooms with no sound proofing, not conducive to counselling at all.

The whole issue of confidentiality and record-keeping I think Barry covered it very well, became an enormous issue where it was important for the people we were seeing that nothing was written down and we had to go through all sorts of manoeuvres to try and disguise what we were having to record, but certainly in terms of professional behaviour and ethics, the fact that we didn't keep records and we did not make those available to anyone could have become an issue. The lack of continuity, you could not assume that you would be able to see people in a follow-up or referral situation. The referrals were impossible. You had to rely on the network of people who you were working with and the network organisations to do those referrals. So again as a professional you were compromised, you were seeing people quite often one off, and you had to try and do what you could within that time.

Another moral and ethical dilemma and I won't cover the other points that we did raise, was that you needed to maintain your credibility as a profession so that your word was treated with seriousness, but at the same time in doing that you were put into a moral dilemma. I'll give you an example of having to assess the mental status of conscripts knowing full well that if they were not sick enough they would be forced into a situation which they found totally abhorrent, so you were all the time - your own professional standards were being challenged by the moral consequences of what you were being faced with at the time.

Also just to mention that it was a very, very small group of people, so the pool of people you could draw on, because you were not getting the support of your professional bodies, it was a very small group of people who were engaged in this work and that put enormous strain on a very small group who were having to face quite seriously traumatised people, be they detainees, torture victims, be they conscripts.

So I think if I can in a very rushed way, knowing your time constraints, if I can just move on to some of the recommendations we had in mind and make a commitment to put this into some sort-of form, a report that would stand more substantially on its own.

Our recommendations for the TRC I think really just underline and reinforce recommendations that have been coming from some of the submissions today, that adequate allocation of resources for the provisional of mental health and community care to those still traumatised by the violence, oppression and human rights abuses of the past, and I think it's been emphasised by others as well, and those who are experiencing ongoing violence, I think there is an assumption that all is well. Certainly in KwaZulu this is an ongoing need and certainly the facilities are not there. It's the same people quite often who didn't provide facilities and services before who are still the people in charge of the services if they are there.

That, in our opinion needs to include ongoing and systematic support for those people who have been encouraged to tell their stories at the TRC. There is a worry from our side, I think coming from our experience of working with people who you are encouraging to talk about their traumatic experiences, that that trauma is a very ongoing, has very ongoing consequences, and although there's a feeling of relief at having spoken about things I guess it's a plea to the TRC to ensure that their support is an ongoing and structured one for those people who might be telling their stories for the first time.

A group, as we were talking, our little detainee counselling group, a group that we never thought we would want to focus on as much as it's becoming more apparent to us, that young boys of 18, 19 were forced into compulsory brutal military training. They were deployed inside and outside the borders, often forced to commit the most dreadful acts, and for them only to discover, in the light of the new political dispensation and public revelations that the rationale for their behaviour and the framing of their experiences was being manipulated by politicians and securocrats and I think we are not even touching what is going on with that group of young people. I am not talking about permanent force people, or people who made a choice, I am actually talking about those people who were forced at a very young age to commit some of the most vile acts.

I think the plea to the TRC would be to recommend that all avenues be explored to enable these young people to tell their stories be given a sympathetic hearing and obtain professional assistance.

The final suggestion, if you like, because we battled to know quite what it was that you were asking, was to have some sort of public - we couldn't decide if it should be a protector or ombudsperson or a monitor for human rights as they pertain to the health sector. I think a couple of presentations today have underlined that as well. And they need to include in their brief and monitoring of the consequences of human rights abuses from the perspective of the health sector, and especially the mental health, because quite often mental health is put very low on the list of needs, mental health and community care actually, to monitor whether the professional bodies do actually fulfil their commitment to change, their model and their training, their models, the behaviour, if you like, of their members. We would take a guess, without hoping to be too cynical about it, that self-regulation of the profession and the health sector just hasn't worked in the past.

So it feels like there needs to be an outside agency that is monitoring that, and we have got a number of examples of the kind of things we feel would need ongoing monitoring, even in a society which is perceived to be a democratic one.

I think then, just in conclusion and I am sorry that I've gone over, is that I think an awareness that came to us as we talked about our experiences that changing the distribution of the political and economic power will not automatically change the nature, accessibility, training models availability if you like of mental and community health services. It actually has to have a push, something needs to push that to make it happen, and I think we are hoping that the TRC sees itself as having an on-going responsibility in giving further impetus to the kind of commitments we have been hearing today. Thank you.

MS MKHIZE: And thank you very much for coming forward. We are hoping to get that submission from you as soon as it is ready. We thank you very much for agreeing to participate in this process. Thank you.

While HHRP representatives are coming forward, Dr Orr has got one announcement to make.

DR WENDY ORR: We announced this morning that copies of submissions were available from the Quick Copy Centre in St George's Mall, unfortunately, I don't know if this is sabotage or mere coincidence, every single machine in the Quick Copy centre has broken down, so that arrangement no longer pertains. We are trying to come up with some sort-of alternative. For those of you who are leaving today if you can give us your names and address we will undertake to get the submissions to you, otherwise if you are going to be around for the next few days we will try and find another copy centre where the machines are working. So please don't go to Quick Copy looking for submissions. Thank you.

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HHRP SUBMISSION

MS MKHIZE: Dr London in welcoming you I would like to make the same plea, that we will really appreciate it if you can limit your presentations to those aspects which haven't been heard, and Ms Wildschut will assist you to take an oath and then Ms Gobodo-Madikizela will assist you with your submission.

LESLIE LONDON: (affirms)

MS GOBODO-MADIKIZELA: Thank you Chairperson and welcome again Leslie. You have submitted a 200 page document and it's very succinct and I just don't know what to say to ask you to - whether to ask you to speak on certain parts, but I really leave that up to yourself to decide which parts you think we should hear in public today. Over to you Leslie.

DR L LONDON: Thank you Pumla, thank you Commissioners. The document is now down to about 10 pages so I am sure we will fit into the time allocation.

This submission is on behalf of the Health and Human Rights Project, which is a joint initiative of the Trauma Centre for Victims of Violence and Torture, and the Department of Community Health at the University of Cape Town. In developing this submission the Project has drawn on the experiences of a wide range of human rights activists who have been active in the field of detainee work and support for victims of repression over the past years, both in Cape Town and nationally and we want to acknowledge their contribution.

One of the Project's key aims is to facilitate the process of documenting past involvement of health professionals and their organisations in human rights abuses so as to prevent recurrence in the future and to develop guidelines for how to operationalise that.

The Project operates with the premise that the health professions and society cannot afford to ignore the past, and that the cost of this selective amnesia which we see so much of with regard to past human rights abuses are enormous. It is very difficult to see how any trust, within the health sector and also between the health professionals and the broader community can be achieved until the truth is disclosed.

We believe that only by fully acknowledging and understanding what took place in the professions under apartheid is it possible to achieve reconciliation in the health sector. Any apologies that are made without this understanding will fail to achieve meaningful progress in moving the health sector to a human rights culture.

And while the TRC has played an important role in stimulating this process the real challenge that faces the health sector is for health professions to accept human rights as a fundamental responsibility. Real truth and reconciliation can only come from below, from within our institutions and should be seen as part of a larger project to rehabilitate the health sector and build a culture of human rights within it.

After those comments I just want to digress a little bit and particularly for the benefit of the lawyers who've trooped into this hearing, I think we, as the Project, want to register our concern for this whole process which has led to a situation where many of the cases that we have brought to the attention of the Truth Commission we cannot actually name the particular health professionals involved. We are not going to name those health professionals but we feel it is really a travesty of the process of truth to arrive at a situation where we cannot speak openly. We fought for many years for a situation where people will be free to speak the truth and it seems that legal mechanisms have been invoked to limit the extent to which the truth could be disclosed. We would like the TRC to take note of that, particularly the fact that as far as the Project was concerned we were able to supply the TRC with the names of the doctors as far as we understand within the required time.

Just in that regard we can talk about the kinds of cases we would have discussed. These cases would have included, for instance, the poisoning of political activists, the development of chemical warfare capacities for the SADF; the failure to adequately explain the death in detention of Mr Sipo Mutsi, who police claim suffered an epileptic fit and fell backward in a chair resulting in his death; the cooperation of a health professional in the torture of an ANC cadre captured in Messina in 1987 by ensuring that the detainee could survive further interrogation and assaults; a case where there was a failure to report injuries sustained by the detainee Jonas Cheshum Moataung in Johannesburg in 1980, and a host of other cases. We won't name those.

What we do cover in our submission is issues of looking at complicity of health professionals in prison and police cells and that's been extensively covered.

We also raise issues around military health personnel and we particularly want to challenge the SAMS whose presentation yesterday did not touch on any of the issues that we've raised and I think Commissioner Ramashala has certainly posed the question to them, but we have presented evidence regarding programmes which involved the re-programming, the use of aversion therapy for gay men in the military and we believe that these cases require further investigation, and the TRC, we would hope, would follow up in that regard.

Forensic services have been covered in some detail. We want to add to the list of cases raised the question of organ harvesting and the way in which practices in which organs were harvested appear to have been substantially racist in the past and has violated the rights of Black families in the way in which shortcuts were taken towards achieving consent for the harvesting of organs.

In terms of hospitals we've heard quite extensively from the Eastern Cape, and from Mark Bletcher and from others about the way in which hospitals were turned into arms of the security establishment. I won't go into that in detail, but just to say what is of real concern is that even though the environment has changed and we don't have detainees or injured people arriving at hospitals we do believe the mindset of the hospital administrations has not changed, and I'd like to hand this in to the Commission. It's a memorandum which was released by the Groote Schuur Hospital region as a hospital notice 12.97 dated 14 May 1997. This memorandum deals with admission and treatment of foreign patients and it's really about questions of how the hospital should deal with patients who are foreign. And point 2 under "Policy", he talks about
"......refugees and illegal immigrants, i.e. people with no temporary residence document. They may not be accepted as patients unless as in an emergency and their presence should immediately be reported to the nearest South African Police Service office or the Immigration Department by admin reception staff".
What this means to us is that the thinking in the health services has not changed. Ten years ago it was detainees, it was people injured in gunshot injuries, today it is another form of social deviant, it's the illegal immigrant without papers.

We make these points because we believe that even though the health sector at a micro level was complicit in abuses, these were not isolated, these were not events involving a few bad apples, as the term has already been used, rather these abuses arose in a context in which the entire fabric of the health sector was permeated by apartheid and in which human rights were profoundly devalued.

We have heard much about the training institutions, and we would support the notion that by the internalisation of apartheid policies and the way they treated Black students and Black patients the health training institutions created the environment where professionals would qualify and be more amenable to the bending of professional ethics to suit the exigencies of security force priorities.

We want to also state that the lack of attention to ethics in human rights in undergraduate and postgraduate curricula, notwithstanding all the words said today, has changed very little since apartheid days. And particularly that there is a substantial difference between human rights and ethics and the institutions need to consider this in their developments.

Underpinning this also was a form of medical science that was devoid of considerations of the implications of human rights for the health professions. Under apartheid we saw a scientific discourse that justified the use of racist terminology and that promoted a research agenda that harmonised with the needs of apartheid. Scientific data were misused or neglected to support apartheid policy objectives and we give various examples of that.

Where research findings did present a different view of reality the authorities and hallowed research institutions, such as the Medical Research Council, in medical journals in State departments wasted little time in suppressing this research. And in particular there's an extensive and very well researched documentation included in our submission of the work by George Ellison and Theo de Wet on material published in the South African Medical Journal over the period 1950 to 1990 which reflected how scientific papers, how editorial policies' letters reflected and reinforced discriminatory policies in the country at the time.

We've also examined the impact of State policies and we won't go into that in much detail.

We also want to make the point that health administrators and civil servants under apartheid had considerable leeway as to how vigorously they operationalised the grand plan of apartheid and at what cost to individuals. I'd like to quote, this is correspondence from the Minister, it's quoted in Federal Council Minutes in the South African Medical Journal and is in relation to correspondence where the Medical Association wrote to the Minister in connection with the question of Black doctors in hospitals. At that time Black doctors were effectively being precluded from working in hospitals because they were not allowed to give orders to White nurses. The Minister's response to the MASA is the following, and the translation from Afrikaans is mine so you must bear with me.

We also want to make the point that the private sector, which has enjoyed relative freedom from the constraints of public bureaucracy was also complicity in applying apartheid. Even to this day, less than three years from the turn of the century, we are still aware of racist discrimination in private practices. We've heard it today. We see it documented in the papers.

I think perhaps for time we would like to go on to probably the most important issues in the health sector, and that's the issue, the failures of the organisations representing the health professions to distance themselves from the policies of the apartheid government. The neglect of Black health professionals was a common theme to all the disciplines and is symptomatic of the profound inability of the professions under apartheid to come to terms with their role as advocates for human rights. And as we have heard today these organisations covered up abuse, they acted as apologists for government policies, they actively vilified colleagues who were prepared to stand up for justice and human rights.

For example the language and concerns of the Medical Association, as they acknowledge, reflected a world view that believed in maintaining the security of the State above human rights considerations. But we also want to say that it was not only that, there were also issues of placing international esteem and status above the recognition that much was not well with the health of South Africans.

Notwithstanding the failure of MASA to take action against the doctors who treated Steve Biko; the MASA's failure to condemn apartheid and detention without trial; the abuse of the South African Medical Journal for its own political agenda, perhaps the most fundamental criticism of MASA is that it definitely was an organisation that was permeated with an anti-human rights culture.

In the 1980's, as Barry earlier pointed out, it sought and received advice from military officers. In our submission we also point to the fact that the 1977 MASA annual congress which was held in Bloemfontein in that year, ironically a city from which Indians would be forbidden to be present in for more than 24 hours without a permit, had a session focusing exclusively on military medicine, and this was hailed as a great innovation. We want to ask why in the year following the Soweto uprisings, with the bloodbath that swept the country, there was not a mention of the costs to human health and human rights of this uprising, and yet the Medical Association chose to make military medicine a feature of its congress in that year.

We think it's not only in the formal links with SAMS that an association with security concerns can be built, but it was very much within the culture of the organisation.

To this point we also want to refer MASA to the book, the Super Afrikaners, in which it is fairly easy to identify members who were Broederbonders. In fact the general secretary of the - the former general secretary at the time was a Broederbonder and as far as we could tell at least three of the publications committee members in the eighties were members of this organisation. We have no idea to what extent the Broederbond membership permeated other leadership structures of the organisation.

Now we do acknowledge that the MASA of the nineties has clearly undergone major changes, but it's not apparent whether these changes involve a change in the fundamental culture of the organisation. It appears, and certainly from the submission made today, that an assumption that increasing Black membership of the MASA is going to solve the problem, but it's not clear to us whether MASA is really able to appreciate and operationalise a commitment to human rights.

For example the comment made earlier that MASA's commitment to self-examination was only possible because of the TRC process is profoundly disturbing to us. We cannot see why a professional organisation that would seek to maintain the standards of the profession could not have embarked on this process long ago through mechanisms and structures that it could have developed entirely independent of the TRC.

Secondly, we are not quite clear why the organisation has to wait for a complaint about members who practice apartheid medicine. One simply has to go, drive to De Doorns in the Boland and see the farm workers standing outside the garage in the rain while the paying patients, most of whom are White, but some of whom are Black, are inside in a comfortable waiting room.

And many of the MASA leadership live in Cape Town and would have had the benefit of a Cape Times supplement examining the state of the Nation in which an advice office worker in Coligny in the Free State says very explicitly the local general practice is racially segregated. There is no reason why one has to wait for a complaint to reach the organisation before one acts on that.

I do believe that the MASA is genuinely committed to addressing these issues but it needs to demonstrate that in practice. I think many of these issues apply to other professional organisations as well.

Further, we need to examine the role of the Councils, and that's been touched onto some extent. I think yesterday's presentation by the Council confirmed our greatest concern that we don't understand why the Council cannot be pro-active about defending human rights in this country. We want to know what part of legislation actually precludes the Council from establishing a commission or from doing an investigation, or from commissioning a university or an NGO from doing some work to defend human rights, or to establish human rights in the health professions. I don't think that has been adequately answered and it points to a critical issue in the need for fundamental reform to the Councils.

We do want to make the point that not all health professionals chose to comply with abusive practices. There were many health professionals who actively defended human rights under apartheid repression and many who paid dearly for their actions. The point we wish to make is that notwithstanding the context, the overwhelming plethora of security legislation and power, individual doctors and other health professionals could and did make choices. And when we consider the history of the health sector we need to be clear that there were choices that could be made.

In terms of common themes the one issue that emerges all the time is clinical independence of health professionals being compromised, either by a plethora of legal and institutional frameworks or by the active complicity of health professionals. There obviously were cases where health professionals may have unwittingly participated in human rights violations, but there were also cases where health professionals have been more than active in taking steps which have led to the violations of individual human rights.

We also want to make the point that even though there was a plethora of health legislation, a plethora of security legislation, there were a whole stratum of regulations and administrative practices in hospitals in the district surgeonancy that emerged out of dark offices that were simply borne out of the culture of the health services service to the apartheid security forces. So hospitals would gag their own staff, district surgeons would be subject to certain internal directives which prevented them from taking steps to protect their patient's health. These institutions reproduced the apartheid states' intentions at local level to ensure that health professionals were compliant.

However, when we highlight the power of the contextual constraints we do not argue that individual health professionals can be absolved of responsibilities. To do so would be to introduce the degree of de-construction that is not grounded. Quite simply one cannot say, for example, that district surgeons can be absolved of any responsibility for complicity in detention or the death penalty, or corporal punishment; military doctors who received orders to assist in torture by applying medical skills were not devoid of choices. Psychologists who were drawn into devising better ways of interrogation cannot simply rationalise their contributions as technical. The toxicologists whose skills were put to use in covert operations cannot argue as the Nazi doctors did that they were simply doing their job.

I think Wendy, as a Commissioner, in her case, it's a clear example where action could have been taken, but we need to ask why there were not more district surgeons like Wendy who refused to comply with these practices.

The evidence presented in our submission supports the notion that many health professionals acted more freely in abuses. They never attempted to offer assistance to tortured and injured, they effectively really covered up the footprints of the torturers.

And one way of looking at this is in terms of parallels with other countries. In his reinterpretation of the Nazi holocaust Daniel Golhargen(?) suggests in his book that the traditional theories for explaining the complicity of ordinary Germans in the Jewish genocide cannot be entirely plausible any longer. He argues it is difficult to attribute participation in mass killings to the fact that Germans lacked a voice or options or that they were responding to social psychology of group dynamics that compelled them to commit atrocities against their will. To the contrary he argues that the Germans participated willingly in the abuse, torture and killing of Jews because of the annihilationist anti-Semitism that permeated German society.

We believe that similar arguments could be made for the complicity of health professionals in human rights violations in South Africa. The implication of this is that we must reject the bad apple notion of complicity. It is insufficient and indeed misleading to argue that it was only a few deviant professionals who led the whole profession into disrepute, and rather than identifying a convenient number of scapegoats we need to look at the profession as a whole and understand what made the profession so inherently amenable to cooption by an ideology that denied human rights.

It's particularly in the area of the lack of professional accountability that this emerges. The statutory institutions, professional organisations abdicated their responsibilities and in particular they failed the profession and the South African people by refusing to hold individuals accountable for human rights abuses. We have little doubt that if the organised health professions had sent a stronger message to doctors, namely that unethical conduct would not be tolerated and would result in severe disciplinary action, the history of complicity by health professionals in human rights violations would have been very different.

In closing this off we also want to remind the Commission about the private sector. Our contention is that health care providers and corporate interests in the private sector have roles and responsibilities that require examination and redress. We believe this is a big gap in the current approaches to achieving reconciliation through the TRC and we would like to believe that the TRC shares our concerns related to the need for redress of violations of socio-economic rights.

As part of the reconciliation process and of reestablishing trust in the profession we argue that, for instance the environmental and occupational health impacts of activities in the private sector, should be subjected to the same process of scrutiny as initiated by the TRC. In the long term reconciliation can only be achieved by disclosure of what went on in the private sector as well and a genuine commitment to facilitating redress.

In conclusion, the challenge is for the health sector, and that is the whole health sector, the institutions, those of training, of research, of professional regulation, for the organisations of the profession and for the State health services and the private sector to embark on some process of serious self-examination. What could have been done differently? Why could it have not been achieved? Did we know enough as to why it wasn't achieved? Where were the role models? Has enough been made public to understand what went wrong?

There are many other questions that arise in this process, to answer them effectively, honestly and openly is the challenge facing us. Abuses continue to occur in the health sector. The process is then not only about digging up the past but about creating an ethical framework to guide health professions in the future.

We have made extensive recommendations, I am just going to mention some of them, perhaps the most important ones. We believe a legally binding code of conduct for all health professionals that specifically prohibits participation in human rights violations should be adopted. There should be a special commission on health and human rights established to implement the recommendations that arise from these hearings and others. The commission should be comprised of, but not limited to, members of health professions, should include human rights experts, legal advisors and community input. The commission should have the confidence and support of key stakeholders in the health professions.

There is a great deal of archival material which we believe is still available if it hasn't been shredded. The TRC should use its legal powers to obtain this material in relation to human rights violations in health, in particular copies of district surgeon reports, reports from the International Committee of the Red Cross, Health Department memoranda and security force records.

There should also be ongoing documentation of past and current health and human rights abuses. Cases of abuse should be fully investigated, and we are particularly calling for the reopening of past cases where evidence of complicity exists.

We also put a challenge to the institutions responsible for training of health professionals to look seriously at the question of human rights education and to make it a fundamental component of curricula. That institutions are to be transformed to create a culture that respects and promotes human rights and produces graduates who are capable of seeing advocacy for human rights, advocacy for their patients as being part of their responsibilities.

We believe this hearing will begin a process that will help all of us reach a common understanding to establish a culture of accountability, of respect for human rights and a re-adoption of the notion of health professionals being advocates for the vulnerable. This we believe is part of the healing calling of the health professions and should be reasserted as an indisputable and inseparable element of the profession's ethos. Thank you.

MS GOBODO-MADIKIZELA: Thank you Leslie. The Health and Human Rights documents it's really quite extensive and it's a pity that we haven't been able to deal with many of the specific issues that you have researched in the documents. But I want to engage you just for a moment on one of the arguments that you make because I think it is important if you are going to be thinking about reconciliation and the redress of some of the pertinent issues in the abuse of human rights in the practice of medicine and in other sectors in general. You say that you give the example of people like Wendy and other individuals who stood up for the rights of their patients and you made the point that if people like Wendy could do it, why couldn't the number of people in the health sector who could also speak out, why couldn't they do it. What worries me, I think it is a concern, but this is true in many sectors of our society in the past, of our history, these questions could be raised in relation to education, to military service where some people left the country or some objected and so forth, but the majority, always it is the majority who do not speak out. And I wonder what your views are about why it is that only a few people always speak out and the majority of people don't speak out against the abuse of human rights.

DR L LONDON: In a sense the issues have been touched on by various people. I think at an individual level there are questions of fear, of political alignment world view, but I think in the context the professions failed to support or failed to provide role models for people to say we will support you if you speak out, or we think this is the norm, the problem was that the training institutions, the professional organisations were reproducing a norm which was entirely devoid of any social conscience. We believe that had that been done differently it would have been less easy for doctors and other health professionals just to ride on what was happening.

MS GOBODO-MADIKIZELA: Yes, Madam Chair, sorry, I think that you are right, but the concern is that these kinds of modalities have been reproduced throughout the world. There have been, I mean you referred yourself to the holocaust and to the book, The Willing executioners of Germany, the reality is that people live in an environment that propagates a particular kind of culture which starts from the education of the young, the teaching of certain modes of behaviour, the exclusion of certain individuals, the abuse of certain groups in the population and people learn about this from a very early age. And I think we should be looking at a different way as a form of social engineering which could address these problems rather than look - yes we could look at individuals as well, but I think largely we should perhaps be looking at different forms of social engineering that could re-teach or teach new moral behaviour in this country, and that is my view even as far as it relates to medical ethics. We need a re-teaching of moral behaviour of new ethics in a different way that will start people at a very early age of their education and I think that way we might be able to have some kind of achievement in the area of the learning of human rights. That is my last comment and I will welcome a comment from you and we will end up the conversation.

MS MKHIZE: Maybe if I might just come to your protection I should think the comment that you have just raised let's take it as food for thought. Thank you very much for giving us what is like a synthesis of the debates that have gone over these two days, and also for setting a tone and a challenge for people who will be picking up these issues. Thank you very much. Other people will have an opportunity of debating these issues later on during the plenary meeting.

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DEPARTMENT OF HEALTH SUBMISSION

MS MKHIZE: At this point in time I would like to invite representatives of the Department of Health to take a seat please. While they are coming forward I would like to read two messages of support.

The first one is from the African Christian Democratic Party. I am reading this without implying that you are under the string of Cabinet. It says,

OL ER PRETORIUS: I am Oliver Pretorius, Deputy Director of Department of Health.

MELVYN FREEMAN: I am Melvyn Freeman, Director Mental Health and Substance Abuse.

TIM WILSON: I am Tim Wilson, one of the Chief Directors in the Department.

DR OLIVER PRETORIUS: (sworn states)

MELVYN FREEMAN: (sworn states)

TIM WILSON: (sworn states)

MS MKHIZE: Thank you. Dr Ramashala will then assist you in talking to your submission.

DR RAMASHALA: Good afternoon gentlemen. You know Dr Pretorius it would not be true to my nature if I didn't comment about the gender representation - (General laughter), yes, and colour. Before I proceed may I say thanks for your patience. I know you have been sitting here for two days and there is a method to this madness, it was by design to actually assign you to the last submission. It was very important for us that you listened to the two days testimony because ultimately it is the Department of Health that is held accountable as the national health accounting structure, and I hope that you were able to benefit from the presentations for these two days, and that the presentations will help you in terms of joining us to move forward to address the very serious problems that are facing the South African health care system.

May I make a comment and say that, is it correct that this is just a preliminary submission, am I correct? Okay. And you don't intend to read it in its entirety are you? Okay. May I ask you to proceed and then I'll come back to prevailing questions.

DR PRETORIUS: Madam Chairperson, Commissioners, Ladies and Gentlemen. True to my personality I would not comment on the fact that we are addressing a Commission only consisting of women. (General laughter)

It is for the Department of Health and for me, as a public servant who served in those dispensations, an historic and important opportunity to make this submission today. This presentation is a short overview of the full submission already submitted to the TRC. And in the light of what has been said today I am pretty sure that we will have to make a subsequent submission dealing with the issues that have not been dealt with sufficiently in the initial one so that we can provide a comprehensive response.

Before I start I would like to clarify my terminology that I will be using. When I use the term "Department of Health", unless I specific otherwise, I refer to all health departments during the previous 30 to 40 years at the national and provincial level. This will also include the health departments of the then independent and self-governing states and thus also by implication the various departments responsible for the budgeting and governance of the various homeland structures, such as the Department of Foreign Affairs and the Department of Development, Cooperation or whatever name was used during the various phases of its history. And the departments of health of the Tricameral system. I am, however, not speaking on behalf of the political functionaries who were the final decision and policy-makers.

The Department of Health was not a passive functionary only carrying out political orders. It was responsible for drafting and the practical implementation of the policies of the State, and that fragmented system of the past with provinces being quite autonomous and the various homeland governments being also autonomous this created the formula which allowed different interpretations of present policy in various areas.

This period was marked by legislated racial discrimination, segregation and oppression, which not only affected the organisation of health services, but also the health of the people.

Although the full consequences of the policy of apartheid were never anticipated nor acknowledged during the time when it was developed it is well researched and well documented. In this submission I will briefly outline how the department acted as part of the apartheid apparatus leading to ill-health of millions and the unnecessary death of many South Africans.

It is the responsibility of every person working in the health department today to ensure that never again will we allow practices and policies to be developed and implemented that will ignore or abuse the health and human rights of our people as it was in the case in the period under review.

The health status of the population is a measure of more than just health services, poverty, employment, access to water, sanitation facilities and other socio-economic conditions are major determinants of health status in the country. However, it is worth looking at the health status during the period under review as it reflects important patterns of health and health care which can be considered as violations of human rights. Quite a number of speakers during the past two days have referred to various aspects of it.

Through the period 1960 to 1994 the health situation in South Africa reveals two distinct patterns of disease and health status for Blacks and for Whites respectively. Differences between the mainly Black rural areas and the urban areas are also stark. White South Africans have had the infant mortality and life expectancy rate similar to countries in the developed world. The figures for Blacks were similar to the underdeveloped world. For the period 1965 to 1970 the life expectancy for African males was 51 and for females 60 years. For Whites during that period the figures were 65 and 72 years respectively. During 1985 the figures for African males was 55 and 61 compared to the 68 and 76 years respectively for Whites. The life expectancy of the Indian and Coloured people fell between the White and the African figures.

The following figures of estimates of infant mortality rate by population group and in rural areas in South Africa speaks for itself. The IMF for South Africa during 1981 to 1985, excluding the TBVC countries was 94 to 124 for Africans, 51,9 for Coloureds, 17,9 for Indians and 12,3 for Whites. In the urban areas the situation was that the IMF for Africans was 38,6; for Coloureds 25,9; for Indians 17,1 and Whites 12,3. While in the rural areas the figures for the African population was 100 to 135; for Coloureds 66; Indians 19,8 and for Whites 12,3.

High incidence of kwashiorkor and marasmus have been extensively documented and clearly link the policies of the day to such - such as the Homeland system and the migrant labour system. It was estimated in 1989 that there were 2,3 million people in South Africa, including the TBVC countries, who could be considered to be in need of nutritional assistance. Of these 87% were African and 2% were White. Active nutrition support programmes, however, only started in the latter part of 1992.

The disease patterns reflected major differences between the White and Black South Africans during that period. Amongst Africans and Coloureds diseases such as tuberculosis, pneumonia, enteritis ...(intervention)

MS MKHIZE: Dr Pretorius can I just ask you to put a mike close to your mouth, some people can't hear. Thank you.

DR PRETORIUS: Amongst Africans and Coloureds diseases such as tuberculosis, pneumonia, enteritis and other diarrhoeal diseases were the major causes of death. In 1978 typhoid fever was 48 times more common amongst Blacks than Whites. In 1971 deaths from diarrhoea were 100 times more common among Black children than White children in the Cape Town area.

In 1987 African women had 3,5 times higher rates of cervical cancer than Whites. The health system was, however, geared for disease patterns of the Whites who, for example, had higher levels of ischemic heart disease and diseases common in the western world. On neither quality nor quantity of service can be completely correlated with the financial input. It is certainly clear that without financial resources to provide adequate services health care will suffer.

The allocation of inequitable resources is probably the single most important factor for which the department can be held responsible, for that resulted in the inequities between the different areas in the country. The per capital expenditure on health care ranged from, during 1985, for Africans, R115,00; for Coloureds R245,00; Indians R249,00 and for Whites R451,00. During 1987 the figures were as follows. For Africans R137,00; for Coloureds R340,00; for Indians R356,00 and for Whites R597,00.

According to the Brown Commission in 1984/85 only 12% of the public health expenditure went to the Homelands where perhaps 40% of the population lived.

I would like to refer now to the issues related to the health care of detainees. Much has been said yesterday and today about the problems experienced by detainees, and rather than to repeat what was said I will confess that the way in which some of the staff of the Department of Health treated detainees and disposed of their roles as the watchdog of the health of the detainees was questionable to say the least. And that as a result of that the health and human rights of many people were violated.

It was the duty of the district surgeon to record physical and mental signs of torture and abuse and to report these for the necessary action. It appears from the evidence presented at this meeting that medical negligence was a factor in the deaths of a number of people in detention. Many district surgeons were put in the invidious position of having to comply with the Prison Act and the Emergency Regulations and cooperate with the law enforcement authorities on the one hand, and the principles of their own medical ethics on the other hand. Most district surgeons appear to have opted for the former, either out of commitment to a political ideal or out of fear for not doing this.

We have no evidence that doctors actively participated in torture, except one case that was mentioned yesterday, but nor did they expose torture when it was evident that it had occurred. As the employer of district surgeons it is incumbent on the Department of Health to bear some responsibility for the fact that it created the mindset for the district surgeons to become accomplices to actions resulting in unnecessary illness and death. However, it is important too, for the Department of Health to accept blame for not having taken sufficient action to enable district surgeons who wished to report on malpractices that became evident through their medical examination to do so without fear of victimisation.

In the one case where a district surgeon did attempt to protect the rights of patients who were being tortured authorities in the Department of Health did not give their support and in fact even obstructed her.

Often youngsters and children were injured in clashes with the police. When they went to the health services for care many were duly arrested either before or after initial treatment. As result of this many people refused to go to the health services for treatment. This resulted in the creation of community initiatives to care for the injured in clandestinely set up surgeries. By not acting against such practices the Department of Health was in fact collaborating with the police services against the health interests of their patients.

The Department of Health had little to protect the professional confidentiality and in fact collaborated with the police in producing information. There are numerous reported incidents in which doctors, nurses and administrative staff were forced to give information, often with threats against the health worker or their family.

Like in other forms of medical care psychiatrists and psychologists were faced with the dilemma of fixing a person up to be returned for further abuse. In such situations the practitioner cannot withhold treatment in order to avoid being an accomplice to further interrogation or torture. With patients needing psychiatric care the chance of a fairly rapid decline was probably higher than with most other illnesses. The onus was on the practitioner to recommend that the person be discharged, or at least put into a slightly more normal situation than, for example, solitary confinement or isolation.

When a number of patients were referred to a hospital to be treated for various conditions, some of which may have related directly to the detention and some of which were unrelated illnesses they were handcuffed to the bed to ensure that they did not escape. This included patients sent for psychiatric care as well. The now Premier of the North West, Pope Molefi is reported to have been kept in leg irons while being treated for a lung infection.

The Security Police took action against many people who opposed the apartheid system and a list of health personnel who were detained and harassed during that time is available.

The proposed new policy on medico-legal services in South Africa has been accepted by the PHRC and will now be submitted to the MINMEC meeting for consideration, and I think that this is a major breakthrough to move away from the kind of problems that have been discussed over the two days.

Much of the family planning services of the department were directed at controlling the size of the Black population. In 1981 the director general of this department warned that sterilisation and abortion might have to be made compulsory unless certain ethnic groups accepted family planning measures. Fortunately this was not enforced. This reflected the underlying motivation of government for the Department to allocate higher priority to family planning than to its primary health care services.

The allegations of human rights abuses in South African psychiatric institutions came to a head around the mid-1970's following a number of newspaper articles which documented violations in the mainly State subsidised institution, the Smith-Mitchell Company. There was also major concern internationally that South Africa, like the USSR was committing political dissenters to psychiatric institutions.

During 1978 the American Psychiatric Association visited South Africa to investigate all the Smith-Mitchell Hospitals. They were, however, not given the same access to State institutions.

The following findings were recorded:
An unduly high death rate;

Substandard care;

Some instances of abuse practices;

Grossly inadequate professional staff;

Possible exploitation of patient labour; and

Apartheid had destructive implications on the mental health of Black South Africans.
The APA also found that treatment of Black patients were substantially worse than those of White patients. They also made findings, such as, that patients were provided neither with toilet paper nor washbasins adjacent to toilet facilities. Black patients, by policy, are not provided with sheets, and that the majority of Black patients answered in the affirmative to the question of whether they had been beaten or assaulted by staff.

The then Department of Health found the APA report to be completely unacceptable and is rejected as prejudiced, biased and a masterpiece of malicious misinterpretation of facts. We have no reason to believe that the APA had reason to misinterpret the facts. This together with similar allegations contained in a 1996 investigation into psychiatric institutions led us to assert that most of the contents of this investigation were in fact true. The APA deserves an apology from the Department for, in essence, calling them liars.

As with all health services emergency services, including ambulance services were separated by race. Inevitably patients died because they were not given timeous treatment which they could have received had they not been of a different race group. Because admission to hospitals was racially based patients were forced to go to hospitals which were not necessarily the nearest or the most accessible. In terms of ambulances they were despatched to emergency situations based on race. As a result if an ambulance serving the Black population group was in use a patient would have to wait rather than an ambulance reserved for Whites being despatched.

The task team responsible for the development of a new emergency health care service policy has advanced fairly well and will be on - the coming Friday, will discuss the final policy document which will then, if accepted then, be submitted to the PHRC and the MINMEC for consideration.

Personnel abuses: Many hundreds of South Africans can justifiably blame the Department of Health for the fact that they were not given the opportunity to advance into a medical or related career. While much of the blame for this must be borne by the Department of Education, for example, the Bantu Education and University Extension Act which essentially barred most Blacks from being educated as medical and related practitioners the Health Department must also carry some responsibility.

Under the Extension of University Education Act of 1995(?) non-White students were accepted into universities only with Ministerial permission. During 1978 83% of Indian and 95% of Coloured applicants were granted permission while only 29% of African applicants were accepted, or were given permission. Between 1986 and 1977 88% of all new doctors who were White and 3% were African. The indignity of having to ask permission from a Minister to study was heartfelt by students.

The issue of discriminatory rules with regard to the training of Black students in White institutions were mentioned by a number of speakers and therefore I will not refer to it in any further detail.

Other professional groups were similarly prejudiced in terms of admission and training. The opening of the Medical University of South Africa was part of the grand apartheid plan which was aimed at having fewer Black doctors trained at White universities.

Despite equitable qualifications between White and Black personnel for most of the period under review discriminatory salaries were paid to Blacks. This includes nurses and other professionals. In addition facilities and conditions were separate and unequal. Personnel working in the same facility and with the same qualification had separate toilets, separate tea rooms and separate accommodation.

Despite Black health personnel sometimes having better qualifications and experience White personnel were promoted above them. It was seen as unacceptable to have Blacks in position of authority over Whites. Within the Department of Health no Black person had been appointed at director level or above until the new democratic dispensation.

With minor exceptions women were also not appointed to senior management level. The new human resource policy that deals effectively with these concerns is in its final stages of development.

In accurate representations by the Department of Health: We believe now that the Department of Health and other government departments were responsible for giving inaccurate and distorted perceptions of health and health care in South Africa. These were often done deliberately to promote South Africa's standing in the world and for other propagandistic reasons.

Conclusions: Apartheid could not have existed without the apparatus which constituted it. The Department of Health was one such apparatus. In this historical overview of the health services over the past years it became quite clear that the Department of Health played a significant role in creating and maintaining apartheid. In terms of human suffering this Department has much to answer for and much to apologise for.

Rather than allowing health to be the driving force of its policy this Department concentrated most of its efforts and resources on only part of the population in line with the political objectives of the apartheid state.

The Department also became part of the oppressive apparatus of State by not taking stands and intervening when medical ethics were being violated even by their own employees.

At a number of points in this submission we have suggested how the Department may have acted differently. We make apologies to those discriminated against in terms of the poor or no health services resulting from the inequitable and racist allocation of resources.

We make apologies to those detainees and their families who did not receive adequate health care, or who were abused by employees of this Department by commission or omission.

We apologise as the Department of Health for not taking the actions necessary to ensure that such abuses did not occur and for not supporting those who did object to torture and other abuses of medical ethics.

We apologise to those activists who were not protected by the Health Department and may have died or have permanent injury as a result.

We apologise to the patients who have been violated at psychiatric institutions.

People who have suffered as a result of emergency services' practice along racial grounds.

We apologise to people who would have wished to become part of the health personnel but were not allowed due to race.

To practitioners who were discriminated against in terms of training, salaries, facilities and for acting against apartheid. Those who suffered as a result of this Department's policies.

But before I conclude, I would also like to use this opportunity to thank the large numbers of dedicated health workers who have, on many occasions, worked long hours under sub-optimal conditions to fulfil the professional mission of a caring health service.

As the Department of Health we will be doing all within our knowledge and power to ensure that the wrongs of the past are not repeated. However, we would welcome any input from the Truth and Reconciliation Commission to assist and guide us in creating a quality health care system.

I thank you.

DR RAMASHALA: Thank you Dr Pretorius. I am going to approach this in somewhat the same way that I approached the SAMS. The numerous questions that I have, and if I have to go through the questions we'll be here until tomorrow. What I would like to recommend is that I go through the questions for the public record, where you want to comment very, very briefly, like one second, you may, but what I would like to do is to have you respond to these in writing, in fact some of these questions will require that you do some research.

Thanks to the AAAS in reinforcing the way I've categorised the questions we somewhat agree about the broader range of issues, I've approached it from the perspective that as a national health service your primary responsibility is policy and accountability. So there are four broad categories that I want to outline and then I'll go into the questions.

The first one, which is exactly the same as the AAAS recommendation, is the issue of regulation and enforcement. And under regulation fall the issue of financing of services, organisation of services and even management of services.

The second one is accountability which is a part of enforcement. Under that comes monitoring. How do you know in fact that the health services that are provided are of quality, they are accessible, all of those things? And corrective measures under accountability, and that relates to the issue of the code of conduct of health professionals.

The third one is capacity development which you allude to in your document very briefly. I would like to know if the Department in fact has a grand plan, and we are talking here not only about the issue of redress but accessibility of services with the difficult populations like the elderly and in rural areas. What is the Department's grand plan in capacity development.

And the last one is the issue of education, and I've divided it into two. The first one is education including skills development, that is the training of medical professionals. The second one is re-education and rehabilitation, and that speaks to the issue of abuses beginning with district surgeons all the way through the system.

Let me go through the questions and I think you have a preliminary copy of that. I may have variations.

The first one is,

I think it is wonderful to apologise but I think until we know the basis for these decisions it will be difficult for us to move forward.

Thank you. Do you have any comments or lack of clarity on this?

DR PRETORIUS: Yes Madam Chair I would gladly deal with the questions asked by the Commission and supply the information as is available, although one realises it might be difficult to get it out of the fragmented system and a lot of that has disappeared, but nevertheless we will try and provide what is available and put it into the necessary context.

I think it's also in the report that I have given was during the period prior to our elections, but if we do not get an opportunity to unpack what has been done subsequently in terms of the restructuring of the entire system, the development of new policies and pieces of legislation, that comes out of the considerations and the experience from the people whom we have heard were part of those that were disadvantaged and affected by the system. So that we have a lot already that we can be proud of, but we are not complacent about that. But the picture is a bit distorted and even the composition of our panel that the structure of the Department, the changes that took place there is well known in terms of gender issues as well as the issue, racial representation.

And that presently we are operating in the Department getting the input and the benefit and contribution and the value added from all of the people present in the Department. And that I must say it is nice working in a Department where there is so much openness and honesty as well as criticism. A lot of what's been done comes out of the bottom drawers of people working in the system but it was put on the table and what was good was accepted and what was not good was taken away. So it's a process of contribution and if you've got something to add and you can justify and you've got the facts to prove it it's accepted. If it's not accepted it's thrown out. Melvyn!

DR M FREEMAN: I think my comments are very similar. A white paper has just come out from the Health Department in which the whole restructuring of the Department is contained. There are also a number of policies which have either been accepted or are in the process of being accepted through various structures for the transformation of the health sector and I think that they need to be read to see the kind of movement that is happening in the Health Department and yes, as Dr Pretorius said, we were reflecting on a specific period which we were asked to comment on.

The second thing that I wanted to say is that we can develop some of these guidelines and frameworks for what to do with district surgeons or whether we should go back to the past or just look to the future, but I think our intention has always been that we would like to do it together with the Truth Commission so that it shouldn't be us going back, doing it, coming to you and then comparing notes. I think that we would rather like to look at the issues together and see where we should be going, and I think that's why the next session is so important for us. I think this is a bit overwhelming for us to have all these questions bombarded at us, and I think that I personally take some exception to being equated with the submission from the Medical Services last night because I think that we really have attempted to examine that past and to look at what has gone wrong and to apologise where we have seen that things have gone wrong. So that's just a personal view of the facts.

DR RAMASHALA: You need to listen very carefully, you were not equated to SAMS. I said I will approach my questions somewhat the same way that I approached it. I hope you understand that.

Let me say that the Truth Commission, particularly the Committee on Reparation and Rehabilitation is making a commitment to work with you, but remember that in December we are gone, and so we have a very, very short shelf life, and whatever needs to be done in consultation with the Truth Commission is short-lived, however, we hope that out of this conference will come out some kind of task force that will be a continuation of the issues that are raised through the Truth Commission process to work with the Department on a long term basis. Thank you.

MS MKHIZE: In thanking you I would just like to reiterate some of the issues that have been raised by Dr Ramashala. For us these questions are serious, especially when dealing with the public structures like ministries. Some of the questions, we live with this contradiction all the time. When we meet with representatives of ministries we get this message that we have done so well, we have these grand plans on our table, but at the same time, at this point in time we have got about 10,000 statements, people who have come forward who really we have nowhere to refer. A significant number of people have died who have come before the Commission who couldn't get help because they are living in areas where the quality of health care is still disgusting. When it comes to mental health care it's difficult to describe what we are faced with on a daily basis. We have met with MEC's, we run around looking at the percentage of the crippled nation that is living with us up to today. So much as we accept that ministries have come up with grand plans, but the reality that we are confronted with on a daily basis it talks to the opposite.

So in thanking you I will really appreciate and thank you for making a commitment, and we will appreciate to get the responses to the questions that have been raised and to continue a dialogue. Thank you very much.

DR PRETORIUS: Thank you to the Commission, thank you very much again from our side, for the opportunity and we are also serious about this. But it's important that one needs a proper plan before you can start implementing it, so that we are in that phase where we are developing the plans to make sure that when we operationalise it, it will be proper and it will be in line with the thinking of the government of the day. Thank you.

MS MKHIZE: Thank you. At this point in time I would like to thank my colleagues. Glenda will read out a few messages first and then Dr Orr will thank all the relevant people who have facilitated this, but before I hand over the Chair I would like to personally thank Dr Orr for working tirelessly on this project and making the process to be where it is today. To you I would like to really say thank you very much on behalf of the Commission. Thank you.

And then after Glenda has read out the letters of support Dr Orr will then thank everybody. Thank you.

MISS WILDSCHUT: Thank you Hlengiwe. We have received, as Wendy said yesterday, many letters of support. I am not going to read verbatim what these letters of support are, except to tell you where they are from and then also just to tell you the gist of what is contained in these letters of support.

We have a letter of support from the Human Sciences Research Council. From the South African Institute for Medical Research. From the TRC and Gender Group that is coordinated by Beth Goldblatt. From the South African Pharmacy Council and from the University of Zululand. All of them say something similar to this.

Thank you very much.

DR WENDY ORR: To add to Glenda's list and it goes on and on, we have one, a letter of support from the Department of Community Dentistry at the University of the Western Cape; the Human Rights Center at the University of California at Berkeley; SINTROS which is a health and human rights organisation in Chile; the Medic Alert Foundation; the Inter-American Institute of Human Rights; the Dental Association of South Africa; the Gauteng Provincial Government Department of Health and a health and human rights organisation in India whose name I am afraid I can't pronounce. But I think this all just demonstrates that the issue of health and human rights is not only a national one, it's an international one and the process which we are going through together is one of immense importance.

Before I move on to thank all the people who have made this hearing possible I want to underline the importance of the meeting which is going to follow which is going to be chaired by Dr London.

We have to acknowledge that there are certain things which the Truth Commission is authorised and mandated to do and other things which it cannot do, and I think the time has now come for us to say that the health profession must decide what needs to be done about the issue of health and human rights. The Truth and Reconciliation Commission is certainly prepared to assist and facilitate and give whatever input we can, but as Mapule said our shelf-life ends on the 15th of December 1997, health and human rights issues will remain a concern for decades to come.

So I do ask that as many of you as possible do stay for the plenary meeting which is going to follow immediately after I have done the wedding reception thing of saying thank you to everybody. I always feel that everyone switches off at this stage, but it's really very important because these people have all made a tremendous contribution towards these hearings.

At the workshop in November last year we elected a task team whose primary task was to ensure that these hearings occurred and they have worked tirelessly for the last however many months, seven months, meeting regularly, spurring people on to make submissions, making submissions themselves and I would just like to name them. The membership has been a bit of a moving goalpost but the hard core group, as it were, consists of David Green, Leslie London, Donald Skinner, Rachel Prinsloo, Gavin Dampster, Sheila Clow, we had a representative from the Progressive Primary Health Care Network who tended to change from meeting to meeting, and latterly three researchers joined us, Laurel Baldwin from the Health and Human Rights Project; Sheila Roquitte, who is a research intern here at the TRC and Lionel Nicholas, who was asked by PsySSA to help them with their submission and who actually presented their submission. This group, without a doubt, has made the last two days possible and I personally want to thank them for the practical and the emotional and spiritual support that they gave me as I worked towards these hearings.

I want to thank the TRC staff who have worked, Thulani and Wilhelm who have been here, but who aren't here now, for the past two days, who are going to help us in pulling the proceedings together and documenting them; our logistics officers Gayle and Elizabeth; Linda van Demen my secretary who has dealt with mountains of correspondence and faxes and submissions and Martila Naidoo who is our support services manager in this office.

Thanks to the South African Police Services who provided security. I think they have been quite unobtrusive but I can assure you they were here every morning at 7:30 with their sniffer dogs making sure that these premises were safe.

The translators who have a very difficult job. I think simultaneous translation is one of the most difficult things to do and they always somehow need to manage.

And then to my fellow panellists who have also worked very hard in going through the submissions allocated to them and in compiling questions. Thank you very much.

Today is the end of one process and the beginning of another, and I look forward to seeing that process through with very many of the people who are in this room and many who aren't in this room as well. Thank you very much.

HEARING ADJOURNS

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