Human Rights and Health: The Infectious Legacy of Apartheid

Leonard Rubenstein is Executive Director of Physicians for Human Rights.

Apartheid in South Africa was an ideology and a political system that not only disenfranchised the black majority but deeply infected every institution of society. So when the Truth and Reconciliation Commission set out to examine human rights violations under apartheid, it sought to probe human rights violations in the health sector, particularly the role white health professionals played, through active participation or complicity, in perpetuating oppression, discrimination, and abuse. It held two days of hearings on human rights violations in the health sector in June 1997.

The Commission sought assistance in this analysis from national and international organizations experienced in evaluating the human rights record of health institutions and health professionals. One request came to a group of US-based organizations experienced in investigating human rights violations in the health sector, which assembled a team of nine physicians, nurses, and public health and human rights experts, to provide analysis and make recommendations. The team was headed by representatives from the American Association for the Advancement of Science and Physicians for Human Rights and also included representatives from the American Nurses Association and the Committee for Health in Southern Africa. They interviewed health professionals, academic leaders, government officials, community leaders, anti-apartheid activities, leaders in the profession, and citizens, and submitted its report, Human Rights and Health: The Legacy of Apartheid, to the Truth and Reconciliation Commission.

The key finding of the report was that the racism of apartheid was built into every aspect of the health system and deprived black people of all human dignity. This racism was manifested in every aspect of health: rigid segregation of health facilities, grossly disproportionate spending on the health of whites as compared to blacks resulting in world-class white medical care while blacks were relegated to overcrowded and filthy facilities; public health policies that ignored diseases primarily affecting black people; and the denial of basic sanitation, clean water supply and other components of public health to homelands and townships.

Health services were deliberately fragmented to perpetuate discrimination. Race bias infected health research and even the keeping of health statistics. Even forensic evaluations were biased in favor of the police, controlled as they were by the very institutions who were responsible for human rights violations. Apartheid also exacerbated the denial of human rights of people with mental illness and mental retardation by locking them away in institutions, deprived of all semblance of human rights and due process of law, and denying them access to community-based programs that would enable them to recover. People with mental retardation were involuntarily sterilized.

The health consequences of apartheid extended beyond the practices within the health sector itself. Apartheid inflicted an enormous level of violence on blacks, including indiscriminate killing and torture. Forced relocations and family breakups inflicted additional trauma.

Blacks were largely excluded from the health professions. Those who were trained either attended black schools with inadequate resources or, when admitted to white institutions, were subjected to practices designed to humiliate and degrade them. For example, black medical students were not permitted to perform autopsies on white cadavers or wear white coats and stethoscopes in white hospitals. Black nurses were "supervised" by white nurses with fewer credentials.

A few white health professionals courageously spoke up for behavior in accordance with medical ethics. Some administrators desegregated hospitals and professional schools. But the majority either embraced the values of apartheid or found excuses to remain "apolitical" and silent. Some physicians were directly implicated in human rights abuses, especially in going along with interference by security forces with medical care and medical ethics. Some physicians working in detention facilities wrote false medical reports to cover up the existence of torture by the police; others testified falsely in support of security forces; others failed to provide adequate health care to detainees. Hospital personnel discharged to the police people shot in political demonstrations and in need of medical attention.

The conduct of the leadership of health professional organizations was in many respects the most troublesome of all. Given the positions they occupied, they could more safely speak out in support of medical ethics and human rights than many other professionals. Instead, the white leadership went out of its way to avoid challenging overt discrimination in health, forced relocations, and detention of children. When individual physicians committed violations, health leaders and regulatory bodies not only declined to intervene but also attacked the integrity of those who demanded accountability.

Apartheid has now ended, but its legacy in the health sector runs deep. The government is struggling to transform the health care system to one that serves the primary needs of the majority. Resources are limited and the country is faced with staggering public health problems, including an AIDS epidemic and a very high level of violence both inside the home and in society. Institutional reform has been slow. Organizations of health professionals have restructured so that black professionals have a greater role in governance. Academic institutions are moving toward greater black enrollment and greater equity. But a commitment to human rights as a governing ideal for health, with actions to carry out that commitment, remains tepid. Even human rights training for health professionals-a modest first step-has gained little support. Moreover some institutions, especially the powerful governing councils, remain unwilling to examine their own past and have resisted reform.

So the struggle for human rights in health in South Africa is far from over. It will take a strong voice from communities, a responsive government, and a profession willing to put aside deeply entrenched attitudes to bring the transformation the Truth and Reconciliation Commission recognized as necessary.

For information about Physicians for Human Rights or to order copies of Human Rights and Health: The Legacy of Apartheid ($15 plus $2 shipping and handling): PHR, 100 Boylston Street, Suite 702, Boston, MA, 02116; 617/695- 0041; phrusa@phrusa.org; Web: www.phrusa.org