- Email: [email protected]
South Africa
1000
caring for the indigent in exchange for guaranteed tax dollars remains to be seen. They will not provide services at a loss for very long. Humana claim a 17-33% cost advantage over competitors, but their charges are higher. PRESENT STATUS OF INDIGENTS
In the United States in 1983
more
than 35 million people
were
making less than what the federal government states is necessary to maintain a minimum standard of living ($10 178 for a family of four). The national average welfare payment per case in 1983 was $109 per month, barely enough to provide food alone. Current estimates of unemployed and homeless people are around 10 million. This poverty, accompanied by cutbacks and freezes in Medicare and Medicaid can be expected to increase the number of people without access to appropriate medical care. 50% of all children born since 1970 will spend some time in a single parent family, a condition noted for widespread poverty, before their 18th birthday. Even in 1980 more than 29 million Americans lacked health insurance cover. 1982 figures suggest that 160 million people (68% of the population) had major health insurance protection and that a further 26 million were covered by Medicare. This left 49 million unprotected. CONCLUSIONS
Government provision for the needy is inadequate and attempts to control costs have so far failed. Government policies of fiscal restraint and the encouragement of free competition appear doomed to failure. Public hospitals face extinction as the for-profit sector erodes their economic base. The trend is towards increasing numbers of people being without access to health care forming an unacceptable cost
Round the World From
South
our
Correspondents
Africa MEDICAL CARE OF DETAINEES
LAST August, Dr George Dall, dean of the Faculty of Medicine in the University of Cape Town, wrote to the South African Medical ,3‘ournal,on behalf of the Faculty, to express concern about press and Parliamentary reports that people injured when caught up in civil strife had difficulty in securing medical care. He declared that injured persons should be treated humanely in all circumstances, and he insisted that care should be given without distinction, other than by medical criteria. Medical personnel should not be compelled to give information about the wounded or sick in their care. This letter voiced anxiety felt by many doctors in South Africa and elsewhere about the care provided for the physical and mental health of those who oppose apartheid. Their concern has been exacerbated by past evidence of collusion between the State and some members of the medical profession. The role of the Medical Association of South Africa (MASA) is critical. It has come under increasing criticism for appearing to acquiesce in Government policies. Last month representatives from the MASA attended the 37th World Congress of the World Medical Association. Dr R. D. Le Roex, chairman of the MASA council, and Dr C. E. M. Viljoen, secretary-general, agreed to talk to me about some of these issues. Perhaps the one event which did most to draw attention to the involvement of doctors in State policies was the death of Mr Steve Biko in 1977. From the start the MASA decided not to take any action,against the three doctors who saw Mr Biko before his death. When the South African Medical and Dental Council exonerated the doctors, this conclusion drew a note of satisfaction from the MASA. But the matter did not rest there and various people, fearing that there had been a cover-up, continued to press for a full inquiry. Dr Le Roex insists that the MASA had no wish to see the matter 1. Dall G. Medical ethics and civil strife.
S Afr Med J 1985,
68: 133.
burden on the economy. It is clearly up to government, not the private sector, to respond constructively to these pressing
problems. The national network of public and teaching hospitals must remain the basis of a guaranteed quality health care system. In contrast to the current trend towards their "privatisation" these hospitals should be funded through payroll deductions, thus transferring private for-profit insurance premiums to non-profit public use. Funding should be organised on a state basis with the federal government providing guidance on minimum standards. Public hospitals would thus emerge as prepaid health maintenance organisations. There should be reciprocal arrangements between state systems. All efforts could be focused upon efficient health care rather than profitable sick care. Public hospitals (and ancillary services) funded in this way would have direct control over costs. Medicare and Medicaid would become obsolete and remaining funds could be distributed to the states. In such an environment, the private sector could be left to pursue the markets that the private sector does in education-serving the wants of those able and willing to buy something different. It would remain reassuring to the private sector’s patrons that the public service will provide for them in time of need. REFERENCES I Hunter DJ The privatisation of public provision Lancet 1983, i: 1264-69 2 Raffel W Comparative health systems University Park, Pennsylvania Pennsylvania State University Press, 1984 3 Iacocca L "Iacocca" New York Bantam Books, 1984. 4 Rubin J. Proposals for national solution the Administration perspective. Washington, DC Department of Health and Human Services, 1984. 5. Thurow LC Learning to say "no" N Engl J Med 1984; 311: 1569-72
covered up, and that critics who said that the MASA never raised its voice and was never in favour of a full inquiry were wrong. He pointed out that Guy de Klerk, former chairman of the MASA council and a member of the SAMDC, called for such an inquiry during a council meeting-but in vain. The MASA then sought advice from a "very senior counsel" on the advisability of taking legal action to force the SAMDC to call a full inquiry. Their adviser, a judge in the Supreme Court, recommended against this course, which was abandoned in favour of an ad-hoc committee to investigate the medical care of detainees in general, under the chairmanship of Prof S. A. Strauss, professor of law in the University of South Africa. Seven doctors then achieved what the MASA had apparently been advised not to attempt. They successfully obtained a ruling from the Pretoria Supreme Court in November, 1984, that the case be reopened, with the ultimate result that two of the doctors who attended Mr Biko, Dr Benjamin Tucker and Dr Ivor Lang, were found guilty in July, 1985, of improper conduct by the disciplinary committee of the SAMDC 2 Drfiucker was also found guilty of disgraceful conduct on ten counts and was suspended for three months. A recent report from Pretoria indicates that this decision has been overruled by the full SAMDC, and that Dr Tucker has been struck off the medical register permanently. Faced with this outcome, Dr Viljoen could only suggest that the seven doctors who brought the case had received better legal advice, possibly because they had’more support than the MASA, which "did not have the financial power". The representatives of the MASA acknowledge that the Biko case has done irreparable harm to South Africa. Professor de Klerk said in 1981 at a WMA congress in Lisbon that it was a cross that the medical profession in South Africa would have to carry for a very long time. The MASA chose not to confront the Government on this particular case, but rather to set up a committee to look at the issue in general terms. Dr Viljoen made it plain that the MASA does not believe in confrontation with the Government, and that it has little time for "media tactics" which may be used to stir up public opinion. Instead the MASA believes that it can achieve far more 2. Editorial Feebleness
in
South Africa Lancet
1985,
ii:
136
1001 that this strategy has produced a major in the treatment of detainees. The committee which the MASA set up under Professor Strauss included Dr John Gluckman, the pathologist who acted on behalf of the Biko family, and later for a number of other detainees. The problem the committee identified was that detainees were automatically treated by district surgeons, who were part of the system. Detainees have no right of access to medical opinion of their own choice. One solution was for detainees to have access to their own doctor, subject to security clearance, but this was rejected by the committee on the grounds that no Government would accept it. The alternative was for detainees to have access to a panel of doctors appointed jointly by the MASA and the Government Department of Health. Any doctor on the panel should have security clearance to ensure that "subversive elements or communists" would not be included. Negotiations with the Government were protracted, but they were aided by the intervention of Dr Lionel Wilson, a former president of the WMA. Finally, this month, agreement was reached and a press release stated: "The MASA is delighted to be able to announce that after more than two years of negotiation the relevant government department has now agreed to the appointment of a panel of medical practitioners from which detainees will be able to select a practitioner of their own choice if for some reason or other they were to request a medical opinion other than that of the district surgeon. This is regarded as a major breakthrough and should materially assist in ensuring that an incident like that involving the late Steve Biko should not occur again. It also demonstrates the importance and value of negotiation in a responsible and dignified manner instead of resorting to confrontation and media pubicity". Representatives of the MASA welcome the outcome of these negotiations, partly because they seem to vindicate their carefully cultivated relations with the Government and partly because of the benefit to detainees. What difference will this development make for detainees? Panels will be carefully vetted and the Government "partner" in the scheme may exclude not only "known subversives" but anyone likely to criticse any aspect of the security system in South Africa. Under the Internal Security Act, detainees can be denied access to a lawyer. How can access to a doctor be enforced? Dr Viljoen did not think enforcement would be a difficulty, although he acknowledged that no South African Government would ever allow detainees to see the doctor of their choice-only someone on the panel. The National Medical and Dental Association (NAMDA), which represents nearly 500 doctors and health workers in South Africa, described by Dr Viljoen as "political activists", has protestedat the medical treatment of those injured during the riots in Uitenhage on March 21. Some doctors were said to have colluded with the authorities. The NAMDA also questioned whether the South African medical profession had learned anything from the Biko affair. Dr Viljoen replied that the allegations had not been substantiated by the judicial inquiry which investigated the riots, but he suggested that, in disturbances where the police exceeded their powers, doctors had to deal with the situation behind the scenes and not indulge in confrontation. Dr Le Roex pointed out that there was no way that the law could force a doctor to report a patient with a bullet wound, unless he was convinced that high treason had been committed. Similarly when police had tried to remove patients from a doctor’s care, and even, it had been alleged, from operating tables, he maintained that doctors had a right to protest and if necessary to obstruct the police physically.
through dialogue and success
Wendy Orr These guidelines are important for doctors whose reponsibilities to their patients may be hampered by police and security services, but how much support will individual doctors receive when they do come into conflict with the State? Dr Wendy Orr, who had been working as a district surgeon in the Port Elizabeth area, saw injuries suggesting torture and maltreatment of detainees. She applied to the Supreme Court for an injunction to prevent the torture of detainees. The injunction was granted but a hearing has yet to take place. The The Case of Dr
3 Bloem H. Medical
treatment in
South Africa Br Med J 1985; 291: 1052.
evidence from both sides has still to be presented. The view of Dr John Gluckman, chairman of the Southern Transvaal branch of the MASA, is that "faced with large numbers of what she regarded as intolerable injuries allegedly inflicted by the security and police forces, she felt morally and ethically obliged to protest in whatever
way she could. Her courage in doing so has earned her the admiration of all her colleagues". At the time of the court hearing, Dr Orr was not a member of the MASA, although she has since joined. Dr Le Roex and Dr Viljoen attached importance to the fact that she had not been through the proper channels in her protest. Having spoken to her immediate superior, who apparently was Dr Ivor Lang, one of the doctors who examined Mr Biko, she could have contacted directly the Director-General of Health, but instead she went straight to the Supreme Court. This action was seen as evidence of her lack of understanding of the proper procedures. Although Dr Viljoen pointed out that the MASA always gives moral support to a colleague who acts according to the dictates of his or her conscience, he discussed what might happen to Dr Orr if she were to be found guilty of perjury, and he made no reference to her future if her evidence were accepted as true. Dr Orr has been removed from her job while the court case is pending. Although Dr Viljoen has been assured that Dr Orr is in no danger of losing her job, he seems to accept without question the argument that she has been taken away from her previous job for her own safety because the prison authorities will "not be very friendly towards her". In challenging through the courts the policies of the South African Government, Dr Orr has taken on a hard task. It remains to be seen how far the MASA will be able and willing to offer her practical support. MASA and the World Medical Association In 1976 the MASA left the WMA and the Secretary-General of the WMA, Dr Andre Wynen (Belgium), took on the task of getting the MASA back into the world body. During a visit to South Africa in February, 1980, he stated that "South Africa’s medical service is 4 amongst the best and we would like to have her back in the family".4 In a recent comment he insisted that South Africa’s health record was good compared with other black African countries, and that many countries also had inequalities of health care. The MASA was readmitted to the WMA in October, 1981, and a large number of other members left in protest. Nevertheless, plans went ahead to hold this year’s WMA congress in Cape Town, but intense international pressure and for reasons of "security" the WMA council decided last May to switch the venue to Brussels. At the same time the council also decided to send an investigative team, independent of the MASA and the South African Government, to see for themselves "what the conditions in medicine truly are in that country", and to report to the Brussels assembly. But no delegation was ever sent and Dr Wynen said the trip had been postponed until next year because of shortage of time. Perhaps the decision had more to do with the unstable political situation in South Africa at the moment.
The WMA clearly want to support the MASA and to play down the differences in health care associated with apartheid. As the troubles in South Africa deepen, however, the rest of the world have their attention drawn inevitably to the inequalities which disfigure life in that country. PETER KANDELA
West
Germany THE BATTLE OVER PHYSICIANS’ SAMPLES
GERMAN
physicians are vigorously defending their "right" to get
drug samples. Since there is no financial gain (except in rare swaps with a pharmacist), what is their motive? It may date back to the
spend
post-war years, when a Sick Fund physician was allowed to only a fixed amount on drugs prescribed. The excess was withheld from his fee. Today only physicians exceeding their colleagues’ average by 20% or more are summoned for peer review. If they 4. S Afr
Dig Feb 2,
1980.
caring for the indigent in exchange for guaranteed tax dollars remains to be seen. They will not provide services at a loss for very long. Humana claim a 17-33% cost advantage over competitors, but their charges are higher. PRESENT STATUS OF INDIGENTS
In the United States in 1983
more
than 35 million people
were
making less than what the federal government states is necessary to maintain a minimum standard of living ($10 178 for a family of four). The national average welfare payment per case in 1983 was $109 per month, barely enough to provide food alone. Current estimates of unemployed and homeless people are around 10 million. This poverty, accompanied by cutbacks and freezes in Medicare and Medicaid can be expected to increase the number of people without access to appropriate medical care. 50% of all children born since 1970 will spend some time in a single parent family, a condition noted for widespread poverty, before their 18th birthday. Even in 1980 more than 29 million Americans lacked health insurance cover. 1982 figures suggest that 160 million people (68% of the population) had major health insurance protection and that a further 26 million were covered by Medicare. This left 49 million unprotected. CONCLUSIONS
Government provision for the needy is inadequate and attempts to control costs have so far failed. Government policies of fiscal restraint and the encouragement of free competition appear doomed to failure. Public hospitals face extinction as the for-profit sector erodes their economic base. The trend is towards increasing numbers of people being without access to health care forming an unacceptable cost
Round the World From
South
our
Correspondents
Africa MEDICAL CARE OF DETAINEES
LAST August, Dr George Dall, dean of the Faculty of Medicine in the University of Cape Town, wrote to the South African Medical ,3‘ournal,on behalf of the Faculty, to express concern about press and Parliamentary reports that people injured when caught up in civil strife had difficulty in securing medical care. He declared that injured persons should be treated humanely in all circumstances, and he insisted that care should be given without distinction, other than by medical criteria. Medical personnel should not be compelled to give information about the wounded or sick in their care. This letter voiced anxiety felt by many doctors in South Africa and elsewhere about the care provided for the physical and mental health of those who oppose apartheid. Their concern has been exacerbated by past evidence of collusion between the State and some members of the medical profession. The role of the Medical Association of South Africa (MASA) is critical. It has come under increasing criticism for appearing to acquiesce in Government policies. Last month representatives from the MASA attended the 37th World Congress of the World Medical Association. Dr R. D. Le Roex, chairman of the MASA council, and Dr C. E. M. Viljoen, secretary-general, agreed to talk to me about some of these issues. Perhaps the one event which did most to draw attention to the involvement of doctors in State policies was the death of Mr Steve Biko in 1977. From the start the MASA decided not to take any action,against the three doctors who saw Mr Biko before his death. When the South African Medical and Dental Council exonerated the doctors, this conclusion drew a note of satisfaction from the MASA. But the matter did not rest there and various people, fearing that there had been a cover-up, continued to press for a full inquiry. Dr Le Roex insists that the MASA had no wish to see the matter 1. Dall G. Medical ethics and civil strife.
S Afr Med J 1985,
68: 133.
burden on the economy. It is clearly up to government, not the private sector, to respond constructively to these pressing
problems. The national network of public and teaching hospitals must remain the basis of a guaranteed quality health care system. In contrast to the current trend towards their "privatisation" these hospitals should be funded through payroll deductions, thus transferring private for-profit insurance premiums to non-profit public use. Funding should be organised on a state basis with the federal government providing guidance on minimum standards. Public hospitals would thus emerge as prepaid health maintenance organisations. There should be reciprocal arrangements between state systems. All efforts could be focused upon efficient health care rather than profitable sick care. Public hospitals (and ancillary services) funded in this way would have direct control over costs. Medicare and Medicaid would become obsolete and remaining funds could be distributed to the states. In such an environment, the private sector could be left to pursue the markets that the private sector does in education-serving the wants of those able and willing to buy something different. It would remain reassuring to the private sector’s patrons that the public service will provide for them in time of need. REFERENCES I Hunter DJ The privatisation of public provision Lancet 1983, i: 1264-69 2 Raffel W Comparative health systems University Park, Pennsylvania Pennsylvania State University Press, 1984 3 Iacocca L "Iacocca" New York Bantam Books, 1984. 4 Rubin J. Proposals for national solution the Administration perspective. Washington, DC Department of Health and Human Services, 1984. 5. Thurow LC Learning to say "no" N Engl J Med 1984; 311: 1569-72
covered up, and that critics who said that the MASA never raised its voice and was never in favour of a full inquiry were wrong. He pointed out that Guy de Klerk, former chairman of the MASA council and a member of the SAMDC, called for such an inquiry during a council meeting-but in vain. The MASA then sought advice from a "very senior counsel" on the advisability of taking legal action to force the SAMDC to call a full inquiry. Their adviser, a judge in the Supreme Court, recommended against this course, which was abandoned in favour of an ad-hoc committee to investigate the medical care of detainees in general, under the chairmanship of Prof S. A. Strauss, professor of law in the University of South Africa. Seven doctors then achieved what the MASA had apparently been advised not to attempt. They successfully obtained a ruling from the Pretoria Supreme Court in November, 1984, that the case be reopened, with the ultimate result that two of the doctors who attended Mr Biko, Dr Benjamin Tucker and Dr Ivor Lang, were found guilty in July, 1985, of improper conduct by the disciplinary committee of the SAMDC 2 Drfiucker was also found guilty of disgraceful conduct on ten counts and was suspended for three months. A recent report from Pretoria indicates that this decision has been overruled by the full SAMDC, and that Dr Tucker has been struck off the medical register permanently. Faced with this outcome, Dr Viljoen could only suggest that the seven doctors who brought the case had received better legal advice, possibly because they had’more support than the MASA, which "did not have the financial power". The representatives of the MASA acknowledge that the Biko case has done irreparable harm to South Africa. Professor de Klerk said in 1981 at a WMA congress in Lisbon that it was a cross that the medical profession in South Africa would have to carry for a very long time. The MASA chose not to confront the Government on this particular case, but rather to set up a committee to look at the issue in general terms. Dr Viljoen made it plain that the MASA does not believe in confrontation with the Government, and that it has little time for "media tactics" which may be used to stir up public opinion. Instead the MASA believes that it can achieve far more 2. Editorial Feebleness
in
South Africa Lancet
1985,
ii:
136
1001 that this strategy has produced a major in the treatment of detainees. The committee which the MASA set up under Professor Strauss included Dr John Gluckman, the pathologist who acted on behalf of the Biko family, and later for a number of other detainees. The problem the committee identified was that detainees were automatically treated by district surgeons, who were part of the system. Detainees have no right of access to medical opinion of their own choice. One solution was for detainees to have access to their own doctor, subject to security clearance, but this was rejected by the committee on the grounds that no Government would accept it. The alternative was for detainees to have access to a panel of doctors appointed jointly by the MASA and the Government Department of Health. Any doctor on the panel should have security clearance to ensure that "subversive elements or communists" would not be included. Negotiations with the Government were protracted, but they were aided by the intervention of Dr Lionel Wilson, a former president of the WMA. Finally, this month, agreement was reached and a press release stated: "The MASA is delighted to be able to announce that after more than two years of negotiation the relevant government department has now agreed to the appointment of a panel of medical practitioners from which detainees will be able to select a practitioner of their own choice if for some reason or other they were to request a medical opinion other than that of the district surgeon. This is regarded as a major breakthrough and should materially assist in ensuring that an incident like that involving the late Steve Biko should not occur again. It also demonstrates the importance and value of negotiation in a responsible and dignified manner instead of resorting to confrontation and media pubicity". Representatives of the MASA welcome the outcome of these negotiations, partly because they seem to vindicate their carefully cultivated relations with the Government and partly because of the benefit to detainees. What difference will this development make for detainees? Panels will be carefully vetted and the Government "partner" in the scheme may exclude not only "known subversives" but anyone likely to criticse any aspect of the security system in South Africa. Under the Internal Security Act, detainees can be denied access to a lawyer. How can access to a doctor be enforced? Dr Viljoen did not think enforcement would be a difficulty, although he acknowledged that no South African Government would ever allow detainees to see the doctor of their choice-only someone on the panel. The National Medical and Dental Association (NAMDA), which represents nearly 500 doctors and health workers in South Africa, described by Dr Viljoen as "political activists", has protestedat the medical treatment of those injured during the riots in Uitenhage on March 21. Some doctors were said to have colluded with the authorities. The NAMDA also questioned whether the South African medical profession had learned anything from the Biko affair. Dr Viljoen replied that the allegations had not been substantiated by the judicial inquiry which investigated the riots, but he suggested that, in disturbances where the police exceeded their powers, doctors had to deal with the situation behind the scenes and not indulge in confrontation. Dr Le Roex pointed out that there was no way that the law could force a doctor to report a patient with a bullet wound, unless he was convinced that high treason had been committed. Similarly when police had tried to remove patients from a doctor’s care, and even, it had been alleged, from operating tables, he maintained that doctors had a right to protest and if necessary to obstruct the police physically.
through dialogue and success
Wendy Orr These guidelines are important for doctors whose reponsibilities to their patients may be hampered by police and security services, but how much support will individual doctors receive when they do come into conflict with the State? Dr Wendy Orr, who had been working as a district surgeon in the Port Elizabeth area, saw injuries suggesting torture and maltreatment of detainees. She applied to the Supreme Court for an injunction to prevent the torture of detainees. The injunction was granted but a hearing has yet to take place. The The Case of Dr
3 Bloem H. Medical
treatment in
South Africa Br Med J 1985; 291: 1052.
evidence from both sides has still to be presented. The view of Dr John Gluckman, chairman of the Southern Transvaal branch of the MASA, is that "faced with large numbers of what she regarded as intolerable injuries allegedly inflicted by the security and police forces, she felt morally and ethically obliged to protest in whatever
way she could. Her courage in doing so has earned her the admiration of all her colleagues". At the time of the court hearing, Dr Orr was not a member of the MASA, although she has since joined. Dr Le Roex and Dr Viljoen attached importance to the fact that she had not been through the proper channels in her protest. Having spoken to her immediate superior, who apparently was Dr Ivor Lang, one of the doctors who examined Mr Biko, she could have contacted directly the Director-General of Health, but instead she went straight to the Supreme Court. This action was seen as evidence of her lack of understanding of the proper procedures. Although Dr Viljoen pointed out that the MASA always gives moral support to a colleague who acts according to the dictates of his or her conscience, he discussed what might happen to Dr Orr if she were to be found guilty of perjury, and he made no reference to her future if her evidence were accepted as true. Dr Orr has been removed from her job while the court case is pending. Although Dr Viljoen has been assured that Dr Orr is in no danger of losing her job, he seems to accept without question the argument that she has been taken away from her previous job for her own safety because the prison authorities will "not be very friendly towards her". In challenging through the courts the policies of the South African Government, Dr Orr has taken on a hard task. It remains to be seen how far the MASA will be able and willing to offer her practical support. MASA and the World Medical Association In 1976 the MASA left the WMA and the Secretary-General of the WMA, Dr Andre Wynen (Belgium), took on the task of getting the MASA back into the world body. During a visit to South Africa in February, 1980, he stated that "South Africa’s medical service is 4 amongst the best and we would like to have her back in the family".4 In a recent comment he insisted that South Africa’s health record was good compared with other black African countries, and that many countries also had inequalities of health care. The MASA was readmitted to the WMA in October, 1981, and a large number of other members left in protest. Nevertheless, plans went ahead to hold this year’s WMA congress in Cape Town, but intense international pressure and for reasons of "security" the WMA council decided last May to switch the venue to Brussels. At the same time the council also decided to send an investigative team, independent of the MASA and the South African Government, to see for themselves "what the conditions in medicine truly are in that country", and to report to the Brussels assembly. But no delegation was ever sent and Dr Wynen said the trip had been postponed until next year because of shortage of time. Perhaps the decision had more to do with the unstable political situation in South Africa at the moment.
The WMA clearly want to support the MASA and to play down the differences in health care associated with apartheid. As the troubles in South Africa deepen, however, the rest of the world have their attention drawn inevitably to the inequalities which disfigure life in that country. PETER KANDELA
West
Germany THE BATTLE OVER PHYSICIANS’ SAMPLES
GERMAN
physicians are vigorously defending their "right" to get
drug samples. Since there is no financial gain (except in rare swaps with a pharmacist), what is their motive? It may date back to the
spend
post-war years, when a Sick Fund physician was allowed to only a fixed amount on drugs prescribed. The excess was withheld from his fee. Today only physicians exceeding their colleagues’ average by 20% or more are summoned for peer review. If they 4. S Afr
Dig Feb 2,
1980.