JOURNAL ISSUE 6
2002/2003

THE LONG-TERM MEDICAL CARE OF VICTIMS OF GROSS HUMAN RIGHTS VIOLATIONS IN SOUTH AFRICA

Martin Connell, MBBCh (Wits), MFGP (SA)

 

Exodus Chapter 34; verse 7
He shows loving-kindness to the thousandth generation and forgives wickedness, rebellion and sin; yet he does not leave the guilty without punishment, even punishing the children and their children for the sins of the parents unto the third and fourth generation.


Introduction

 

This paper reflects my experience and insight from having provided medical care for victims of gross human rights violations. Many victims continue to have on-going health concerns that are rooted in the violations they experienced during the apartheid era of South Africa. In the following account I will briefly touch on the referrals to me of victims of gross human rights violations, their injuries and immediate and long-term management issues, the process of my consultation with them, and some observations regarding the health and coping skills of the medical practitioner in generel.


Referral of Victims of Gross Human Rights Violations

 

I have used the definition of ‘victims’ adopted by the South African Truth and Reconciliation Commission (1998). Victims are those who have experienced violations of their ‘bodily integrity rights’. These include the right: to life; to be free from torture, and from cruel, inhumane, degrading treatment or punishment; and to freedom and security of person including freedom from abduction and arbitrary and prolonged detention.

 

I provide medical care for people who were victims of agents from both sides of the liberation conflict. Some victims were exposed to police brutality in Johannesburg, where I work. Others were referred to me from various parts of the country and included victims of the homeland police forces (the homelands were self-governing semi-independent nation states within South Africa during the apartheid era). Cadres and officials of the African National Congress (ANC) assaulted and detained victims as well. Others were beaten up by Inkatha impis (impi is a word that means warrior). Ministers of religion and various health and allied professional workers referred victims to me, as well as lawyers requesting medico-legal reports. There were non-governmental structures available for delivering services to victims of violence. However, I was often selected because I was not affiliated to these structures. In fact, there were victims who came to me especially to avoid politically-related structures. Victims who had become patients of mine themselves made some referrals.

 

Injuries seen in Victims of Gross Human Rights Violations

 

Injuries seen in victims have varied from activists exhibiting gunshot wounds from every conceivable type of firearm, to the removal of an eye with a home-made spear, to bruises, lacerations, abrasions, bone fractures, burns, and ruptured ear drums of every imaginable type and combination. In some cases, I was asked to examine the corpses of activists with a view to re-opening inquests where the state pathologist’s findings were disputed by the families of the victims.

 

I came to realize that in the injured, however, there had been other, perhaps deeper wounds. It seems to me that it is insufficient to focus exclusively on where I was trained, on their physical well-being. Meaningful intervention demanded that I also try to address the psychological and spiritual issues raised by their trauma. Thus, my examination and approach has to detect and manage areas that are acutely uncomfortable for medical doctors to work with. Most of those injured have a deep feeling of depersonalization. They all have varying degrees of anxiety, which poisons many facets of their lives and limits their capacity to live and work. This anxiety may prevent them from taking the train or bus to work, or from concentrating on work or studies. The anxiety may be displaced or somatised into complaints such as burning eyes; strange weakness or numbness of fingers, hands or limbs; bowel upsets; headaches; and heart palpitations. They suffer from difficulty falling asleep, staying asleep, or waking up and getting out of bed. They are often unable to concentrate or lose their short-term memory.

 

I also came to realize that the permission I have as medical doctor to trespass into the private body-space of my patients gives me a unique opportunity to provide comfort and succour through touch. Thorough and respectful examination of the scarred and abused bodies of victims helps to return, in some small measure, lost self-respect and damaged self-image as well as trust in humanity. In the cases where I have been asked to examine and give a medical report on the injuries sustained by people killed, the care and detail I bring to the process reaffirms the dignity and worth of the deceased.

 

The Consultation Process

 

With each victim, I always take a very detailed history, noting the exact time and date of assault or assaults, the exact sequence of events, how injuries were inflicted and in what order, and the length of time over which they were assaulted. The reason for this is that the previous medical history may be of importance.

I believe that a full examination must be done at every consultation as it is reassuring to have every organ and limb duly inspected and catalogued - blood pressure, pulse rate, eyes, ears, nose, teeth and throat. The chest and heart are auscultated with the stethoscope. It seems to me that the stethoscope has become an important emblem of the power to heal vested in the doctor and of the doctor’s commitment to protect and nurture. Using my stethoscope always has a reassuring effect. The abdomen must be carefully palpated. The urine is screened for any abnormality. I test all reflexes. This I do even if it is apparently unnecessary. All scars, bruises, lacerations and abrasion are minutely measured and catalogued and noted on a diagram of the body. This is very important at the first visit no matter how much time has elapsed since the date of the assault. It affirms the dignity of the victim and conveys the message that time has not lessened the sense of outrage that these things were permitted by society.

I probe for and generally find some evidence of the residual impact of these assaults on their current circumstances. This is generally a process of reviewing bodily ailments that persist. Often we simply have to tell each other that the problems are terrible and cannot be cured. The injuries still need to be acknowledged and not ignored. I feel this is part of the process of recognition of my shared humanity with the person I am treating. These may be pain on walking or running, pain with certain movements, or difficulty chewing. Problems commonly dealt with include loss of appetite, intermittent nausea, headaches, insomnia, sexual dysfunction, and difficulty with intimate relationships. Often the feeling that a malfunctioning organ has been thoroughly examined and pronounced free of organic disease starts the process of re-entering normal life. Much of the consultation involves listening both to what the patient says and what the patient does not say. The communication of compassion is vital.

I conclude my examination by arranging referrals where appropriate to specialists and counseling services, and occasionally for legal opinion. Often some form of medication, however minor, is convincing evidence both of my care and the fact that healing can and will take place.
For me, part of my role as a healer in this instance is to attempt to restore something of the victim's humanity - a humanity denied both by the treatment received at the hands of perpetrators of violence and the heartless unconcern of society. The care of a black eye or torn skin is often a route to heal more than physical injury.


Long-term Care of Victims of Gross Human Rights Violations

 

South Africa became a democracy in May 1994 when for the first time a general election was held for an electorate of all South Africans. It triumphantly delivered the African National Congress to power in a landslide victory. However, the problems of the country after three hundred years of colonialism did not just go away. New problems have emerged that were either never foreseen or inadequately projected. There are not the resources we hoped for, for the victims of abuse. Ironically, in very many cases, the youths, who sacrificed their education along with their mental and physical health for the democratic dispensation we now enjoy, have no access to the improved resources available for people of color in South Africa. They cannot hold the jobs they deserve because of lack of capacity and often they see that people who did not sacrifice anything are enjoying the fruits of their struggle.

 

Our society as a whole no longer wants to recognize and honor them. One particularly upsetting comment by the young bursar regarding the medical expenses of those seeking my care was: “For how long are they going to cry”. She was too young to have been affected by the liberation struggle and went to high school and university in a post-apartheid dispensation.

 

This has led to a change in the focus of my management. It has certainly become plain that it is a long-term endeavor. Care of these people must deal more with family issues, social issues, empowerment, and access to social security and legal help.

In the long-term management, what has emerged is the importance of getting a history regarding the families of the victims as well. I have needed to explore the impact of violations, and their physical and mental/psychological damage on their families, especially on their children. The impact of financial loss is often far reaching and is experienced on many levels. In many cases the victims of abuses, such as detention, were the breadwinners for the family. On their release from detention they have been too traumatized to work again and often have lost their employment because of their perceived political activity. In cases where families were driven from their homes they have returned to find their homes plundered and vandalized.

It is also very important to document and enlarge on their support systems and help them access whatever resources there are for obtaining an income. I have found that I can use my status as a medical doctor to fill in forms and approach state services in an advocacy role. In some cases, I have been able to stimulate a new energy in pursuing legal claims by writing to legal resources such as Legal Aid or the University of the Witwatersrand Law Clinic. Both of these institutions supply an overworked and understaffed free resource to the community. In some instances the official handling the case has moved on and no one is dealing with the victim’s problem any longer. Often my interest and input has kick-started claims that have become bogged down.


Trauma experienced by victims

 

1. Depression and anxiety. This often requires ongoing long-term treatment with anti-depressant drugs. This has obvious cost implications.
2. Cognitive impairment. Many victims are unable to perform at the intellectual level they had attained prior to the incidents of abuse. Many have lost desirable jobs as teachers or clerks and have no hope of managing the same level of work for a considerable time to come.
3. Consequences of gunshot wounds, and physical damage from torture. These include loss of function of a limb or hand; persistent diarrhoea and malabsorption after abdominal gunshot wounds; and neurological damage which has caused atrophy or deformity of a limb or has caused erectile dysfunction. This has obvious effects on the capacity to command a job and function in a relationship.
4. Loss of capacity to nurture, emotional blunting or hardness in the survivor. This has frequently been a major factor in the breakdown of family and community relationships. It renders the sufferer yet more isolated and lacking in hope.

 

The vast majority of those seen in this context are unemployed. Their education has been abandoned or has otherwise been curtailed due to the process of detention. The state’s abrogation of its promises to provide reparations means that the former soldiers of liberation have often forfeited their own and their children’s future in favor of those who avoided confrontation with the Apartheid system and instead went for their own goals and who have consequently attained qualifications and skills.


The future, the children and the children’s children

 

1. Education for both the victims and for their children has suffered. The children of these victims are trapped in a downward spiral of hopelessness and poverty. A poorer educational foundation means that there is a reduced or absent capacity for self-support in the families of the victims. Even where there are community or family structures to provide support, their plight is a drain on resources of future family structures and networks.
2. The trauma experienced by parents who are victims has made them less able to provide a sense of security for their children. These children sometimes have a reduced capacity to love and form lasting bonds with people.
3. Depression and anxiety. Both of these emotional states are commoner in the children of victims.
4. Drug dependency, truantism, delinquency and crime.


The Medical Practitioner’s Health and Coping with the Effects

 

The Medical Practitioner’s Health
No one can sit and listen to and catalogue horrors without being affected by them. My feelings have ranged from horror to nausea to personal guilt and impotence. I have felt contaminated by both the brutality and viciousness of the assailants and the degradation and despair of the victims. Their fear and anxiety tends to linger in my mind, causing nightmares and paranoid fears. The sense that we all bear moral responsibility for these events can be crushing. At times I have become burnt out and felt unable to see more victims for a time. A balance must be maintained between objectivity and over-identification with the victim.

 

Coping with the Effects
The most effective coping mechanism I have found is talking out the anguish of these events with family, close friends, and people who share political and human perspectives. One has to be careful not to become a constant purveyor of horrors and ghoulish details to the same people or one risks being avoided by them!

 

Time-out is very important. The care-giver must give himself or herself permission to do enjoyable, restful, curative things - enjoy a glass of wine, a game or a sport or a hobby. I wrap myself in the physical labor of tending a garden or playing music. I take weekends off far away from a telephone. Learning stress management techniques such as meditation and regular exercise is important.

 

Maintenance of boundaries is vital. Accessibility by phone may need to be limited during time off work, even if it means disconnecting the telephone. Nobody can maintain single-handed 24-hour care and I believe one should not attempt to. One must be clear on what kind of service one is competent or prepared to offer. I often have to resist being cast in the role of lover or favorite son or rescuer. Feelings of impotence or frustration may sometimes be resolvable by consultation with or referral to a colleague or community resource.


Conclusion

 

In South Africa we have lived through a nightmare. The consequences of apartheid will still haunt our country for generations. Those of us in the helping professions have often felt helpless in the face of powerful state repression and guilty that we do not speak out more and risk detention ourselves. I believe that it has been possible to make some contribution to alleviating the suffering and the damage by using my legitimate professional skills and standing to provide a witness to the human rights violations in the courts and to provide some physical and emotional healing.


REFERENCES

Truth & Reconciliation Commission (1998). Truth and Reconciliation Commission of South Africa Report. Cape Town: CTP Book Printers.




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