A hermeneutical analysis of the impact of socio-political and legislative developments on South African institutional mental healthcare from 1904 to 2004

Submitted in fulfilment of the degree of Doctor of Philosophy (PhD) in Bioethics and Health Law, Steve Biko Centre for Bioethics, University of the Witwatersrand. Johannesburg, 2015The use of diagnosis and treatment of mental illness to manage and manipulate the shape of the social and political world is not a new concept. It has been documented in the USA, the USSR, Indo-China and other countries internationally. There were a number of accusations of rights abuses made against South African (SA) mental health institutional practices by international bodies in the heyday of apartheid in the late 1970s and 1980s. The South African government vehemently denied politically directed rights abuses against patients in long term psychiatric institutions that were used to further the aims of the then apartheid government. International health bodies travelled to the country to investigate the claims made by the Citizens’ Commission for Human Rights (this group mainly represented the interests of the Church of Scientology) and the findings that that there were abuses occurring were rejected by the SA Government. In spite of the rejections, legislation was put in place to prevent further incidents of investigation and to protect practitioners who were employed to work in these facilities. The abuse of human rights was not to be found in general clinical practice of South African facilities or practitioner practice of psychiatry. It was imbedded in the system of sending people, who were guilty of apartheid social offences (for example not carrying pass books, public drunkenness or simply for not speaking English or Afrikaans), to homeland ‘retraining’ facilities or South African ‘rehabilitation’ facilities. It was also entrenched in a system of institutional care that was both differently funded and provided across the colour bar. These people were left isolated and neglected in circumstances, which over time degraded their dignity and humanity to the point of institutional stasis. Homeland facilities, while ostensibly not linked to South African practices or government, were paid for by the South African Department of Health to house Black persons who had proved not to have the social skills or the desirable qualities of a suitable worker in the South African system. They were simply returned to their cultural region, away from White areas, where they did not fit in. South African mental health professionals, who had been concealed behind the justification that they were pawns in the political process and could not change the status quo, were guilty of a greater crime than actively using their profession to commit politically motivated acts of direct abuse against individual patients. Being not only aware of the political issues in psychiatry and being pressurized by their international peers to do something to demonstrate their rejection of the system maintaining the abuse, the majority of practitioners chose the option of distancing themselves from the areas of mental healthcare under scrutiny. This action - considering that many were an intrinsic part of the both the private and public service delivered to government - had no effect whatsoever on changing the status quo. A number of practitioners continued to attend the patients in these facilities under the auspices of government and some continue in their personal capacity to the present day. Practitioners continued to refer patients to these private facilities from provincial hospitals. They knew what these facilities were because they had publicly rejected them as a professional body, and they knew that these patients would not be given appropriate care because this was the reason they had given for their rejection. They turned their backs on a situation which they were very aware would leave vulnerable certified patients at the mercy of a system of private mental healthcare, providing paid incarceration and relocation services to the South African government, under the guise of ‘rehabilitation’. They effectively omitted these people from their clinical practice scope by rejecting the facilities in which they were held in the name of conscientious objection. This denialism was part of the deep and pervasive abuse perpetrated by the law and political structures that underpinned all of South African life. The process of sending ‘patients’ to these facilities lay at the door of psychiatrists and mental health professionals in South African provincial mental health facilities. They continued this practice well into the 1990s. This research identifies the processes, players and specific historical incidents that drove the promulgation of various acts, social principles and legislation into a place where such abuses could occur. The rise of private for-profit institutions and the human rights abuses that occurred are testament to how professional, personal and profit agendas can sublimate the mores on which ethical clinical care is based. The concepts of beneficence and non-maleficence, as examples, are lost in the business concepts of providing a service for a customer, who perhaps does not see the provision of ethical and quality care as an operational mandate of importance, and the customer being right. The set of interconnecting contexts and circumstances, during this period, opened the door for abuse of the process of care by a series of national agendas and power plays in international politics, the expansion and self-promotion of medical practitioners’ own agendas and the accumulation of personal wealth. Critique of the conditions and practices in South African mental and social institutions continues to the present. As the people who were placed in these facilities begin to die of old age, many having spent 30 years upward of their lives incarcerated for social and political agendas, time is simply running out because they have been forgotten by the very people who should have been there to protect them. They are unwitting detritus on the road of history and are now a complication which both the Department of Health and those same practitioners, now in positions of authority, are loath to acknowledge still exists. The new Mental Health ‘Action Plan’ - to which the South African Government and the WHO are signatories - is hailed as the new era of mental health care in the country, yet, these patients are still missing from the numbers of the research and statistics which the government is presently using for service planning going forward