Learning From Our Apartheid Past: Human rights challenges for health professionals in contemporary South Africa

Ethnicity & Health, 2000; 5(3/4): 227–241

Learning From Our Apartheid Past: human rightschallenges for health professionals in contemporary

South Africa

LAUREL BALDWIN-RAGAVEN,1* LESLIE LONDON3 AND

JEANELLE DE GRUCHY2

1Department of Primary Health Care and Family Medicine, University of CapeTown, Observatory; 2Specialist Registrar in Public Health at the Southern

Derbyshire Health Authority, UK and 3Department of Public Health, University ofCapetown, Observatory

ABSTRACT

Central to South Africa’s democratic transformation have been attempts to understandhow and why human rights abuses were common under apartheid. In testimony to theTruth and Reconciliation Commission evidence has emerged of a wide range of pastcomplicity in human rights abuses by health professionals and their organisations. Thishas presented a major challenge to the health sector to develop ways to operationalisea commitment to human rights in the future. This paper argues that only after a processof self-re� ection, both personal and institutional, which enables a thorough and accurateanalysis of why things went so wrong, can the health sector effectively move forward.The authors’ perspective draws on the submission to the TRC Health Sector Hearingsby the Health and Human Rights Project in 1997, which provides a systemic andcase-based analysis of the health sector’s role in human rights abuses under apartheid.However, human rights responses have to take account of a changing national andglobal terrain in which human rights issues are no longer as morally absolute aspreviously encountered, and in which seemingly insuperable resource constraints,inimical economic policies, and the demobilisation of civil society, are serious obstacles.Moreover, the politics of transformation has generated expediencies that threaten torewrite history in ways that fundamentally cheapen human rights. To address thiscontradiction, the authors propose a set of objectives that places accountability of healthprofessionals in a human rights framework. These objectives are intended to givesubstance to the main tasks facing the health sector—to develop and infuse the capacityto recognise and integrate both the ‘new’ and traditional human rights dilemmas, andto effect personal and institutional transformation. A matrix is presented, linking theseobjectives to key role players in the health sector and identifying activities speci� c foreach role player. As the health sector in South Africa grapples with the challengesframed in this model, key lessons for the international community may emerge thatfurther our understanding of the complex relationship between health and human rightsand how best to implement strategies for the attainment of human rights in health.

Keywords: accountability , professionalism , ethical standards , health professiona l practice, truth, justiceand reconciliation , ethnicity .

Address for correspondence : Laurel Baldwin-Ragaven , Human Rights Programme, Trinity College, 300Summit Street, Hartford, CT 06106-3100 , USA.*From January 2001 Laurel Baldwin-Ragaven will be the Henry R. Luce Professor in Health and HumanRights at Trinity College, Hartford, Connecticut , USA.

ISSN1355-7858 (print) ISSN 1465–3419 (online)/00/03/4227–15 Ó 2000 Taylor & Francis Ltd

DOI: 10.1080/13557850020000934 7

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L. BALDWIN-RAGAVEN ET AL.228

INTRODUCTION

Although the experience of illness, the becoming a ‘patient’, confers a degree ofvulnerability that is universal,1 there are aspects of that vulnerability which are uniquelySouth African. One such feature is the heightened susceptibility of those seeking healthcare to human rights violations on the basis of ‘race’.* The South African Truth andReconciliation Commission (TRC) convened Special Hearings in June 1997 to explorehow decades of systematic ‘racial’ discrimination had in� uenced South Africa’s healthservices and how the health sector contributed to the context for widespread abuses ofhuman rights under apartheid.2 In its � nal report, the Commission found that ‘the healthsector, through apathy, acceptance of the status quo and acts of omission, allowed thecreation of an environment in which the health of millions of South Africans wasneglected, even at times actively compromised, and in which violations of moral andethical codes of practice were frequent, facilitating violations of human rights’.3 It is thislegacy of colonisation and apartheid which now poses complex challenges as the SouthAfrican health sector begins to work toward preventing human rights abuses in thefuture. In the resolution of these dilemmas, key lessons for the international communitymay emerge that further our understanding of the complex relationship between healthand human rights4 and how best to implement strategies for the attainment of humanrights in health.

The principal focus of progressive theorisation and research in the health sector inSouth Africa during the current transformation has been on responding to health careneeds arising directly or indirectly from human rights abuses under apartheid, throughbetter understanding, diagnosis and treatment of various categories of clients/patients.These experiences, drawn from interventions with survivors and their families as well asfrom studies of perpetrators of human rights abuses, have made positive contributions tothe � eld of trauma psychology both in South Africa and internationally (for example,Dowdall, 1992; Skinner, 1998; Straker, 1992).5–7

However, with few exceptions, what has been largely absent from the debateshas been critical self-examination of the health sector’s own role in contributingto reproducing human rights abuses under apartheid. By con� ning the locus ofinquiry to the consumers of services and not addressing the policy-makers and providersof these services,8 the South African health sector runs the risk of failing to under-stand how it impeded, and may still continue to impede the realisation of ‘health forall’. Health professions eschew key lessons if they neglect to analyse their ownpositioning, personal and structural, in relation to human suffering9 during apart-heid, when violations of human rights in health care settings were routine and permiss-ible.10,11

It has been suggested that examining the past serves only to hinder moving forward,particularly given a democratically elected government, new legislation, as well as unityand transformation initiatives within health professional organisations and institutions inSouth Africa.12,13 In contrast, this paper argues that it is only after a thorough andaccurate analysis of why things went so wrong in South Africa that the health sector caneffectively determine where it chooses to locate itself now and for the future.3,14,15 Onlythrough understanding how and why the health sector colluded with the apartheid statecan there be redress of past inequalities and injustices, and the maximisation of themental health and well-being of all of South Africa’s inhabitants.

* Note regarding ‘racial’ terminology in this paper. The authors recognise that ‘race’ is a social constructionthat serves particular political purposes . In no way do we suggest that genetically distinct ‘races’ exist, withinherent biologica l differences , or that ‘races’ exist in essential groupings . The classi� cation of people into‘racial’ categories has had a profound effect on the pro� le of health and disease in South Africa, which stillpersists.

LEARNING FROM OUR APARTHEID PAST 229

This paper therefore examines the complicity of the South African health sector withhuman rights abuses during apartheid, with particular reference to mental health,re� ecting on how ethics were compromised and honour lost.14–16 It explores how thehealth professions can best respond to the challenges ahead, including the restoration ofthe public trust betrayed under apartheid. The � rst section summarises key themes ofhealth professional collusion, drawing on material presented by the Health and HumanRights Project (HHRP) to the TRC Health Sector Hearings.17 Secondly, examples ofcollusion with human rights abuses in mental health care are illustrated through two casestudies. Thirdly, the impact of South Africa’s transition to a democratic society isanalysed in relation to the changing landscape of health and human rights. Fourthly,some of the current challenges inherent in transformation in South Africa are articulated.The paper concludes by framing objectives for professional accountability in the healthsector, integrated into a matrix with proposals for speci� c activities and interventions tobe undertaken by the main role players in the health sector.

HHRP SUBMISSION TO THE TRC HEALTH SECTOR HEARINGS

As part of the negotiated settlement between the then-ruling National Party and leadersof the liberation movements, the Truth and Reconciliation Commission (TRC) wasestablished in South Africa to document gross human rights violations, grant amnesty toperpetrators of politically motivated violence and make recommendations about repara-tions for victims. From the start of public hearings in May 1996, there was mountingevidence that the health professions were complicit in a range of human rights abuses.In their statements, survivors and relatives of victims told the Commission about thehealth professionals with whom they came in contact, who participated in violations oftheir human rights, turning a ‘blind eye’ to the plight of patients under their care, or evendeliberately using their knowledge and position to aid the state in its � ght against theopponents of apartheid.*

This evidence, along with ongoing debates within the health professions as to how tounderstand and deal with past abrogations of professional ethics18–21 led the TRC toinstitute special hearings on the health sector held over two days in June 1997.† TheHealth Sector Hearings focused national and international attention on the healingprofessions’ involvement with the repressive apartheid state,2 and was the � rst time thata truth commission has held a hearing dedicated speci� cally to the activities of a nation’shealth sector.22 By doing so, the TRC sought to understand the context in which grosshuman rights violations under apartheid could have taken place. While many submis-sions focused on the role of particular organisations or institutions, the HHRP undertookto analyse not only individual case studies, but the broad systemic factors and dynamicsin the health sector as well.17 Key themes emerging from the HHRP submission arelisted below.

(1) ‘Apartheid permeated the entire health sector, distorting and corrupting healthprofessional training, research and service delivery’.2 Legislation, policies and

* The most egregious of these cases involved a Dr Wouter Basson, a cardiologis t recruited by the militaryto run their Chemical and Biological Warfare (CBW) Programme, a clandestine operation in which medicaland other scientists put their special scienti� c knowledge at the disposal of apartheid ’s security forces. Thespecial TRC Hearing on the CBW Programme found that the special laboratories were involved in themanufacture of weapons for use in assassination s and other illegal political activities .† This call to examine the accountabilit y of health professional s also resulted in the establishmen t of theHealth and Human Rights Project: Professiona l Accountability in South Africa (HHRP). The HHRP helpedto facilitate the TRC Health Sector Hearings as well as to document and analyse the involvement of healthprofessional s in human rights violations during apartheid .17


practices in health were determined primarily by ideological agendas, rather than bythe needs of those requiring care. This process violated the human rights of the vastmajority of South Africa’s population.

(2) Abuses occurred along a spectrum. They can be identi� ed most clearly in settingsof state custody, where access to health care was manipulated for political purposes,and where situations of con� icting loyalties—to police, to profession, to patient, toself—were commonplace. Less apparent was the banal day-to-day functioning insegregated health facilities. It is this latter ‘grey zone’, in which most violations ofhuman rights in health took place, that bears greater scrutiny.

(3) Instead of actively confronting the context that enabled immoral and unethicalprofessional behaviour to � ourish, apologists have framed these aberrations as dueto particular failings of certain individuals. Scapegoating a few health professionalsas ‘bad apples’, ‘mad scientists’ or crazed extremists has been far easier thanoverhauling an entire system. However, those responsible were not heinous villains,but rather ‘ordinary’ health care providers, doing their jobs within a system that hidits � aws beneath a veneer of professionalism.

(4) Apartheid health presented challenges, largely unmet, to professional codes of ethicsand organisational standards of conduct. The institutions of the professions failed toaddress the non-neutrality of health practice, research agendas, training and even thecodes of conduct or ‘ethics’ themselves. Rather, they actively perpetuated a myth ofobjectivity that served to bolster a system profoundly antithetical to human rights.23

(5) At best, there has been a systematic lack of support for individuals and organisationsthat resisted the repression of apartheid; at worst, people were victimised for theirstand against human rights abuses.

In the following sections, these themes are explored in more detail in the two casestudies drawn from the HHRP submission, which illustrate how various role playerswithin the health sector responded to the mental health effects of detention. They arepresented as examples both of health professional collusion with human rights abuses,as well as resistance to state repression.

Case 1: Neil Aggett—health professional complicity with state torture

Neil Aggett was a medical doctor who worked as a trade unionist with the African Foodand Canning Workers (AFCWU) and SA Allied Workers (SAAWU) unions. To supportthese activities, he held a part-time job in the casualty department at BaragwanathHospital, a large public facility serving Soweto township in Johannesburg. The nurseswho worked with Aggett at Baragwanath described him as different from other doctors,in part because they felt he recognised the relations between society and health, apartheidand illness, economic conditions and political power (Critical Health Editorial Collec-tive, 1982, p 7).24

Neil Aggett died in detention in 1982 at the age of 29. Held incommunicado underregulations which entitled the security police to hold a detainee in solitary con� nementinde� nitely, he spent a total of 72 days in detention until he died. At the inquest,Aggett’s own af� davit, signed an estimated 14 hours before his death, gave details of historture and noted that his request for medical attention had been denied. Althoughhomicidal hanging was considered, the inquest found that Neil Aggett had committedsuicide and that no one was culpable.

Testimony at the inquest illustrated the ways in which health professionals supportedthe interests of the security forces. Johannesburg’s Chief District Surgeon* exonerated

* District surgeons were state-appointe d doctors charged with forensic responsibilities , including medicalcare for detainees and prisoners .


the district surgeons for not having visited Neil Aggett. Further, in response to a questionfrom the Aggett family lawyer about what he would have done had he visited an injuredNeil Aggett, the District Surgeon replied ‘I would have told them they were overdoingthings’.25 This doctor’s statement appears to be an implicit acceptance of torture as amethod of interrogation, as long as it was not too excessive.

Another expert witness for the State, a psychiatrist, submitted forensic psychiatrictestimony on Dr Aggett’s death that began with the premise that Dr Aggett had infact committed suicide. By not questioning how Aggett actually died, he uncriticallysupported the police version of events. The psychiatrist’s report went on to layout certain generic predisposing factors, citing as pertinent Dr Aggett’s ‘adheren[ce]to Marxism’ and his ‘loss of religious conviction’ (quoted in the Health and HumanRights Project, 1997).17 Although the psychiatrist mentioned the detention, hemade no reference to Dr Aggett’s af� davit of torture. Supporting the district sur-geons, he noted that visits from them would not necessarily have changed the courseof events, as no one could have been expected to predict Aggett’s suicide. None ofthe medical practitioners identi� ed the role of solitary con� nement as torture, norreferred to medical ethical codes that speci� cally oppose any form of complicity intorture.

The response of the medical community at large is also telling. The South AfricanMedical and Dental Council (SAMDC), the statutory body responsible for maintainingthe highest professional standards, remained silent about Dr Aggett’s death, even thougha doctor had died in detention and other doctors registered with the Council appeared tohave assisted the state in a possible cover-up. Similarly, the Executive of the MedicalAssociation of South Africa (MASA), the voluntary professional body for doctors, ratherthan condemning the circumstances of Dr Aggett’s death, chose to leave comment ‘in thehands of people who are more quali� ed to express an opinion’ (Minutes of the ExecutiveCommittee of the Federal Council of MASA, 19 February 1982, cited in HHRP, 1997,p 180).17

In contrast, organisations such as the National Medical and Dental Association(NAMDA), which had broken away from MASA following its lack of censure of thedoctors involved in the death in detention of Black Consciousness leader Steve Biko in1977, and the Detainees’ Parents Support Committee (DPSC), a lobbying group ofdetainees’ family members, uncategorically condemned Aggett’s death and called for therelease of political detainees and investigations into the conditions under which detaineeswere held. Progressive health activists published a special edition of Critical Health asa tribute following his death.24

Case 2: Simphiwe Manzana:* the ‘treatment’ of mental torture

Mr Simphiwe Manzana was detained without trial in 1986 under emergency regulations,when civil liberties, such as they existed, had been completely suspended. Held in StAlban’s Prison in Port Elizabeth for nearly one year, Manzana was never questioned norcharged with an offence. On three occasions, however, he was admitted to a civilianhospital for treatment of depression; one such incident followed a suicide attempt. In all,he spent six months as an in-patient at Livingstone Hospital, a public general hospitalwith psychiatric facilities, as well as receiving treatment as an out-patient.

Certain aspects of the care provided by the health professionals looking after Manzanaare noteworthy. The professional behaviour of the Senior Psychiatrist with the Depart-ment of Health and Welfare demonstrates a particular understanding of the limitsof professional responsibility. This psychiatrist diagnosed and began treatment of

* A pseudonym has been used to shield the identity of the individua l involved.


Manzana’s mood disorder within two weeks of Manzana being detained. He wrote toMr Manzana’s lawyers that the detainee ‘� nds it dif� cult to adapt to detention … hereacts by becoming Depressed and Anxious’ (quoted in the Health and Human RightsProject, 1997).17 Yet, despite this diagnosis of a reactive disorder, along with anacknowledgement that the symptoms ‘will probably be relieved completely when hisdetention is terminated’, the psychiatrist made no attempt to eliminate the precipitatingcause of his patient’s symptoms. Instead, the psychiatrist recommended medication tomake the condition more bearable. He also asserted that there was no danger ofpermanent mental harm being caused. Ironically, his belief was to be contradicted evenby the conservative Society of Psychiatrists who, in 1987, issued a tame and never-op-erationalised public statement which cited ‘detention in isolation, solitary con� nementand immoderate interrogation’ as having the potential to cause damage to mentalhealth.26

In contrast to this psychiatrist, the psychologist at Livingstone Hospital advocated MrManzana’s immediate release to relieve his symptoms, noting that the South AfricanInstitute for Clinical Psychologists had that same year condemned detention without trialas ‘a threat to the mental health of the people of South Africa’.17

Five months later when Manzana’s condition continued to worsen, the State Psy-chiatrist wrote to the Chief District Surgeon that the ‘detainee’s personality does appearto be deteriorating and there is a danger of a suicide attempt’. Instead of requestingimmediate release however, the psychiatrist recommended that ‘the process of interroga-tion be speeded up if possible with a view to earlier discharge if there is no seriouscharge against him’.17 That this request concerning the nature of the interrogationprocess was given not to the relevant security authority, but to another doctor, raisesquestions about the closeness of the relationship between district surgeons and thesecurity forces.

District surgeons had considerable power over detainee-patients who were beingtreated in civilian centres. When the Chief District Surgeon* was made aware of thiscase, particularly about the difference in opinion between the state psychiatrist andhospital psychologist, he wrote a letter to the Medical Superintendent of LivingstoneHospital. All Heads of Clinical Departments subsequently received a memorandum thatonly the State Psychiatrist should have access to detainees, in particular to Mr Manzana.For any detainee-patient to see a psychologist, the following criteria had to be met: (1)there had to be a request from the detainee; (2) the police had to grant permission; and(3) the State Psychiatrist also had to be present during the interview (Memorandum citedin HHRP, 1997).17

Apart from the hospital psychologist, other clinicians resisted the interference by thedistrict surgeon and security police in the management of Mr Manzana’s depression.Refusing to tolerate ‘the gross violation of [his] rights as attending physician’ whileattempting to practise ‘the highest calibre of medicine that [he] was capable of’, Dr PatNaidoo, Head of the Department of Medicine, refused to discharge his patient,17 and MrManzana had to be forcibly removed from Livingstone Hospital by a group of securitypolicemen.

Dr Naidoo suffered repercussions for his stance against the hospital superintendent,district surgeon and regional director of health. He was called to face disciplinary actionby the SAMDC and received no support from MASA.

These two cases capture the broad spectrum of complicity by health professionals inhuman rights abuses that existed under apartheid, as well as the diverse and nuancedways in which resistance to human rights violations could be effected, even if at somecost to the individual health professional.

* This district surgeon was one of the two doctors found in the inquest to be complicit in the death of SteveBiko in 1978, but who had subsequentl y been promoted to Chief District Surgeon in the 1980s.


A CHANGING HEALTH AND HUMAN RIGHTS LANDSCAPE IN SOUTHAFRICA?

On the surface, there are many changes in South Africa since 1994 that seem to promotethe attainment of human rights. Major legal reforms, such as the new Constitution andBill of Rights, are considered amongst the most progressive in the world (Blake, 1998,p 13).27 Statutory bodies are now established to protect human rights in civil society,notably the South African Human Rights Commission, the Commission on GenderEquality and the Of� ce of the Public Protector, which serves an ombudsman role,investigating complaints of unfair treatment or prejudice by the state. The IndependentComplaints Directorate examines breaches in police codes of conduct. With regard tohealth care, legislation has been enacted to extend universal access to primary careservices, to enable choice on termination of pregnancy, to mandate inclusivity in medicalaid schemes, and to require community representation on licensing councils andcommittees of public sector facilities.28,29 Organisations of health professionals inmedicine, nursing, psychology and other professions, are undergoing processes of‘unity’30 to bring together a once ‘racially’ and politically divided membership.

At the same time, however, it is clear that many changes may be less thanfundamental, manifesting a complex and contradictory nature that perhaps limits theimpact of major structural transformation. For example, some of the laws, althoughimplemented, are as yet untested. Others remain theoretical, offering rights on paper, butwithout attainable plans for implementation, while others still remain draft white papersfor discussion. To be meaningful, legislative reforms must be able to protect the mostvulnerable citizens in balancing priorities between competing rights.

Scarce resources restrict the broad-scale implementation of new public policies.28 Forexample, access to abortion services remains uneven across the country; rural sites sufferhuman and material shortages; mental health services remain predominantly psychiatricand curative, and the spread of HIV is unabated. Cut-backs, together with a growingnational debt and calls for � scal responsibility, have led to the demise of the govern-ment’s Reconstruction and Development Programme (RDP).31 The RDP was designed asa comprehensive strategic plan for national economic and social development through amix of people-oriented policies. Instead, the RDP has been replaced by the Growth,Economic and Redistribution (GEAR) policy,32 underpinned by extremely conservativemonetarist economic policies, focused on markets as the key instruments for develop-ment, and dependent on international investment and reduction in budget de� cit to fueleconomic growth. This has been manifested in cuts in social expenditure, which, inhealth care, has translated into hospital closures, the lay-off of skilled personnel andadoption of targeted, as opposed to comprehensive and multisectoral interventions.

Con� icts of political and personal values have also been obstacles to change. Manycivil servants from the old administration remain in their former positions, actively orpassively resistant to transformation. Former political activists, now in the business ofrunning the country, are faced with the vicissitudes of real politick where they mustbalance ideology with pragmatic considerations. The absorption of this critical voice intogovernment or into ‘reformed’ professional organisations has resulted in the fragmen-tation of an activist lobby. Non-governmental organisations have become severelyweakened and civil society demobilised in the transformation process leaving govern-ment and formal institutions without concomitant counter-balances and external monitor-ing.

Global trends also pose additional challenges to achieving human rights in SouthAfrica. As an emerging market, South Africa has shown itself to be extremely vulnerableto economic chaos on international markets, with profound impacts on the local economyand, as a result, on the delicate progress in attempts to build human rights in atransforming country. Even with the best of intentions and clearest of understandings,


economic fragility of this nature destroys institutional capacity to implement theinfrastructural developments needed to sustain human rights. At the same time, globalinterest in the privatisation of health care and the introduction of the markets in health,has seen the growth of managed health care initiatives in South Africa,33,34 whichthemselves create serious ethical and human rights dilemmas for health care delivery.35

As a result of the changing national and international terrain, human rights struggleshave come to involve issues which are less morally absolute than previously encoun-tered, for example, with the egregious excesses of apartheid. Since many of these currenthuman rights dilemmas are not inherently attractive or have easy solutions, there is noguarantee that they will � nd their appropriate place on the political agenda.

For example, speci� c to the mental health sector are the linked issues of de-institution-alising chronic mentally ill patients and the response to the escalating crime epidemic inSouth Africa. The former has largely stemmed from the growing pressure for costcontainment in the health sector,36 while the latter has found expression in the introduc-tion of extreme forms of maximum security prison operations that legitimate solitarycon� nement, called C-max prisons.37 Both developments pander to popular prejudice,which clamours for a hard-hitting approach to crime and violence, and which regardsmental illness as deviance. However, without resources to support the de-institutionalisa-tion of the chronic mentally ill, the discharge of such patients into already disintegratingcommunities will no doubt exacerbate crime and violence. Data from the United Statesshow that of the inmates of maximum security prisons, a high percentage suffer from amajor psychiatric disorder (personal communication, A. Berkman, Cape Town, 1998).South Africa’s de-institutionalised may well � nd themselves criminalised and sent to thecountry’s own legal torture prisons. Con� uence of these two developments in SouthAfrica presents the horri� c prospect of the sacri� ce of human rights for populistadvancement, and reminds us how dif� cult human rights advocacy will be when tacklingnon-traditional human rights concerns.

THE POLITICS OF TRANSFORMATION—CAN WE RECOGNISE TRANSFORM-ATION WHEN WE SEE IT?

Amidst the dif� culties of implementing change under resource constraints, is a numberof other key phenomena that pose challenges to transformation.

On the one hand, while conditions, social, political and ideological, have changed,methods of engaging with those who hold political power in order to defend humanrights have not kept pace. Old methods of popular struggle may have contradictoryimpacts and may not work as effectively as new strategies for which human rightsactivists are poorly prepared. A human rights agenda now demands different skills suchas lobbying, or rather a hybrid of methods that introduces more sophisticated approachesto change management and advocacy.

Secondly, part of the contradictions of transformation is the confusion generated inrevisionist rewriting of the ‘truth’ about events and individuals. For example, the Councilof the British Medical Association recently awarded its highest honour, the Gold Medalfor Distinguished Merit, to Dr Bernard Mandell, citing Dr Mandell’s ‘distinguishedcontribution to the understanding of the relationship of medicine and human rights in thenational and international spheres’38. Dr Mandell is currently � rst president of the newlyunited South African Medical Association (SAMA). However, he was also formerly amember and later chairman of the MASA Federal Council, and was party to thecomplicity of MASA leadership in the Biko affair39. Unlike health professionals cited inthe HHRP submission, Dr Mandell was conspicuously absent from participation in thehuman rights movement within South Africa in the 1980s, when leadership commitmentto human rights advances would have been critical.

In the headlong rush therefore to achieve reconciliation, a contradictory reality is


created in which it is dif� cult to be sure that change has actually taken place, leadingto a tension that those seeking to promote human rights are as yet unaccustomed.Whereas in the past under apartheid, it was relatively easy to de� ne right and wrong,good and evil, such simplistic analyses of who was ‘for’ human rights and who was notare no longer appropriate or perhaps useful. Assessing the nature of transformation isthus particularly problematic in a new social order that attempts to accommodateeveryone in the ambit of legitimate and good.

If then the goalposts for human rights are shifted, how does one measure accountabil-ity for the protection for human rights? Without a clear and shared understanding ofexactly what is meant by ‘human rights’, human rights run the risk of being cheapenedby political expediency.40 Most importantly, it places two tasks at the centre of humanrights transformation in South Africa: (1) the ability to recognise and integrate both the‘new’ and traditional generation violations of human rights; and (2) personal andinstitutional transformation—learning from the past in order to change the future. Weexpand on these tasks in the following section.

IMPROVING HUMAN RIGHTS ACCOUNTABILITY THROUGHOUT THEHEALTH SECTOR

If human rights are to be integrated into an agenda for transformation, and meet thecomplex challenges described above, health professional accountability becomes a keyand non-negotiable objective.15,41 Accountability in the context of a human rightsframework is the only effective and coherent way to move beyond lip-service to effectsystemic transformation and to ensure that struggles to attain socio-economic rights canintegrate health and human rights in a common paradigm.4

As a means of gauging such transformation in the health sector, this paper suggestsclear reference points, and � ve core objectives for professional accountability inprotecting human rights.

(1) To enunciate/prioritise accountability to patient, to selves (honour in the ‘pro-fession’), and to society. An environment of accountability, operating proactivelyand with repercussions for consequences must frame professional practice. Byprioritising a more holistic view of health and health care, health professionals candevelop a shared culture of respect for autonomy and social rights.

(2) To be able to identify abuses and operationalise human rights tenets. The capacityto recognise a human rights abuse when it happens, or is about to occur, is critical.To do so, health professionals need to be able to identify what allies and resourcesexist to protect human rights, and how these facilitate the operationalisation ofexisting codes of conduct/ethics.

(3) To treat patients with dignity and respect; recognise and empower vulnerablegroups. The voiceless, particularly important in mental health, cannot be expected toadvocate for themselves unless given the tools and the power (individual orcollective) to do so. Health professionals need to be sensitive to the needs not onlyof vulnerable patients but also vulnerable groups. Who are the vulnerable groups inour society, historically and at present? What is the social positioning of certaingroups of people, culturally, socio-economically, marginalised and at risk of beingviolated? To avoid becoming paternalistic in our response, health professionals needto understand the power of professionalism and the tendency to exercise that powerin negative ways. For example, medicalising ‘social’ or political problems occurscommonly, where deviance is rede� ned to suit ideology. This is particularlyimportant in mental health, where abuses of psychiatry for political reasons havebeen well documented.42–44

(4) To re-orient practice toward a larger social and political context. The work of


health professionals has traditionally been restricted to corridors of hospitals andsometimes community clinics, i.e. within the boundaries of institutions and in areactive paradigm. Limits to health are essentially political and not professional. ThePrimary Health Care (PHC) approach has changed that somewhat, but the challengesremain substantial.45

(5) To clarify values; to de� ne and be aware of con� icting loyalties. Health profession-als need to be aware of their own positioning in society and how their values andloyalties may put them in inconsistent or con� icting situations.43,44,46 Particularly intoday’s complex and changing society, pitfalls may be extremely dif� cult to identify,yet it is incumbent on health professionals to seek to confront these limitations asopenly as possible.

How then do we move to implementing these objectives in the health sector? Table 1*presents a framework for integrating these objectives in a matrix with a range ofactivities and interventions to be undertaken by the role players. The role playersidenti� ed in the model range from individual health professionals to organisations andinstitutions in the state, in the professions and civil society. Whereas the private sectoris often omitted from discussions of accountability, this model explicitly includes theprivate sector since it has as great a responsibility for, and role to play in preventinghuman rights abuses.

The model offers one way of conceptualising the multilayered approaches needed tooperationalise commitments to developing a human rights culture in health. For example,the role of training for health professionals is a core element, located across a numberof objectives, and identi� ed with a number of different role players. Not surprisingly,education and training has formed one of the key recommendations for the health sector.3

The role of codes of conduct, � agged by the TRC report which recommended thedevelopment of a single legally binding ethical code for all health professionals,3 can besupplemented in terms of this model by additional strategies for human rights promotion(publishing cases studies and trends, proactive monitoring, etc.). Most importantly, therole of self-study emerges as key to all role players and for all objectives.

The discussion on this model is necessarily brief for reasons of space. None the less,further exploration of this model’s strengths and weaknesses may usefully contribute toclarity on how the health sector can more effectively promote, and be infused withhuman rights. Developments in South Africa may therefore offer important insights forother countries47–49 and international institutions45,50,51 grappling with similar challenges.

CONCLUSION

Can the South African health sector at this stage move from being an international pariahto positioning itself on the cutting edge of ‘professional accountability’? The unfoldingexperience of transformation in South Africa provides a multiplicity of rich opportunitiesfor learning. Most importantly, the TRC Health Sector Hearings have provided a focusaround which a rich tradition of past human rights struggles in health5,44,52 could bebrought together, to inform nascent and ongoing human rights activities both within andoutside of the health sector. Indeed, much of the documentation assembled for thehearings emerged from a long tradition of civil society mobilisation around human rightsthat saw primary documentation and analysis as part of resistance to apartheid.

It is in this forward trajectory that the value of re� ecting on how and why healthprofessionals came to be complicit in the apartheid project will emerge. When the role

* This table was previously published in Baldwin-Ragaven L, de Gruchy, J & London, L (eds.) AnAmbulance of the Wrong Colour: Health Professionals , Human Rights and Ethics in South Africa, CapeTown: UCT Press, 1999.


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players in the health sector take responsibility for their past actions and practices, linkinghuman rights to professional accountability, it becomes possible to shape future be-haviours aimed at promoting and protecting human rights in the health sector.

Such challenges are not easy, particularly the task of individual or collectiveself-study, and demands a level of honesty, self-criticism and stamina not normallyassociated with the notion of professionalism. Moreover, this is clearly a long-termprocess requiring constant vigilance on the part of all stakeholders, collectively andindividually. However, the evidence from South Africa is that it is possible to begin sucha process. The Universities of Cape Town and Witwatersrand, largely in response to theTRC Health Sector Hearings, have committed themselves to processes of institutionaltruth and reconciliation.53 If such initiatives are located in a framework that linksaccountability (both individual and collective) to human rights, it may well be possibleto anticipate fundamental shifts in the future in the way in which health professionalsview and practice human rights in health.

ACKNOWLEDGEMENTS

The authors wish to acknowledge the contributions of members of the Health andHuman Rights Project Support Group to the ideas contained in this paper, and theSwedish NGO Foundation for Human Rights for � nancial support of the project. Theauthors also take inspiration from the struggles of many millions of South Africans forfreedom, democracy and human rights over the past decades.

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Documents

Learning From Our Apartheid Past: Human rights challenges for health professionals in contemporary South Africa