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The South African government has apologized to APA for disparaging and then dismissing a 1978 report written by an APA delegation that identified abusive practices, substandard care, and violations of medical ethics in that country’s psychiatric system.
The apology is part of a self-examination by South Africa’s Department of Health conducted for the country’s Truth and Reconciliation Commission. The controversial commission is forcing various segments of South African society to confront their complicity with the abusive, sometimes lethal, racial policies of the long-entrenched, government-sanctioned apartheid system.
In its unvarnished mea culpa, the Department of Health admits that during the decades when apartheid was the law of the land, it routinely functioned as "an important arm of the State. . .acting in ways which contributed to making Apartheid the system of inequity and oppression which it was. . . leading to much ill health and unnecessary deaths." It also acknowledged that it regularly made decisions that "put political considerations above health and health care."
In 1978 APA was invited by the Smith-Mitchell Corporation, which had a contract with the South African government to run its private mental health services, and by the country’s health secretary to observe a number of treatment facilities, both private and public. The South Africans hoped that the 17 days of site visits by American psychiatrists would dispel allegations by a United Nations committee, the World Health Organization, and sources within South Africa that the government was using the psychiatric system to punish political dissidents, much as the Soviet Union was doing at the same time.
Once they arrived in South Africa, however, the American psychiatrists learned that they were to be denied access to the public facilities.
The results of the visit were not at all what the South African health officials had expected. The American delegation found substantial evidence to confirm reports that black South Africans were the victims of a pervasive pattern of abuse by employees and officials of the country’s mental health system.
In a report that pulled no punches, the APA representatives wrote, "There is good reason for international concern about black psychiatric patients in South Africa. We found unacceptable medical practices that resulted in needless deaths of South Africans. Medical and psychiatric care for blacks was grossly inferior to that for whites."
Most of the patients they interviewed said they had never received a medical examination while hospitalized, a claim borne out by patients’ medical records. Other examples of substandard care included psychiatrists routinely assigned to black patients who did not speak the patients’ language, part-time psychiatrists who were unfamiliar with tardive dyskinesia, results of mental status examinations that were incompatible with the recorded diagnoses, the absence of toilet paper and washbasins in bathrooms, and a policy to not provide sheets for beds in which black patients slept. Only two hospitals the APA delegation visited had full-time physicians on staff, and the Americans concluded that the part-time medical staff was "grossly inadequate to provide decent rehabilitation or treatment."
Contrary to reports received prior to their visit, the Americans saw no evidence of inappropriate use of drugs or electroconvulsive therapy or confinement of political dissidents in the facilities they were allowed to visit.
On receiving the report, the Department of Health wasted no time in labeling it "completely unacceptable" and characterized it as "prejudiced, biased, and a masterpiece of malicious misrepresentation of facts."
In the department’s recent report to the Truth and Reconciliation Commission, however, it admits that upon reexamining the observations and recommendations in the APA report, "most of the contents of this investigation were, in all likelihood, correct."
Jeanne Spurlock, M.D., a former deputy medical director of APA and head of its Office of Minority and National Affairs, was one of the American psychiatrists on the 1978 visit. "I can’t help but wonder what took them so long," she told Psychiatric News. "I question, however, how much things have really changed when it comes to health services in South Africa. The amount of money the government is now spending on health care hasn’t increased much at all over the years since we visited."
In addition to admitting that the American psychiatrists had accurately described the serious deficiencies in the provision of mental health services to South Africans, the authors of the recent report state that "APA deserves an apology from the Health Department for, in essence, calling them liars."
During a visit to APA headquarters in Washington, D.C., on July 29, Professor Melvyn Freeman, the director of the South African government’s mental health and substance abuse agency, said that APA soon would be receiving a written apology for his government’s unjustified response to the 1978 report, according to Ellen Mercer, director of APA’s Office of International Affairs, who was present at the July meeting. By late October, APA had not yet received that apology.
Spurlock added that if the South African government had taken APA’s report to heart when it was delivered, an apology would not have been necessary, and the country would by now be experiencing some significant improvement in the state of health care delivered to its huge majority of nonwhite citizens.
In the health department’s report, the officials charged with examining the department’s past practices also conclude that it is time for South Africa to do away with laws that "prohibit the public and the international community from knowing what is happening in our [psychiatric] institutions. While the confidentiality of the patients should be protected, this can be done without prohibition on the reporting on institutions."
In his meeting at APA in July, Freeman indicated that the Department of Health has instituted a multifaceted plan to improve conditions in South Africa’s psychiatric hospitals. Among its goals are to move patients from institutional to community care, pass legislation guarding the rights of psychiatric patients, improve hospital management, conduct research on quality of hospital care, and develop standards for treating patients with severe psychiatric disorders.