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.
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
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
in Victims of Gross Human Rights Violations
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.
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
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
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
The Medical Practitioner’s
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
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.
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.
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
Truth & Reconciliation Commission (1998). Truth and Reconciliation
Commission of South Africa Report. Cape Town: CTP Book Printers.
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