PRISON HEAL TH CARE IN SOUTH AFRICA: a study of prison conditions, health care and medical accountability for the care of prisoners University of Cape Town Judith van Heerden, MBChB July 1996 The copyright of this thesis vests in the author. No quotation from it or information derived from it is to be published without full acknowledgement of the source. The thesis is to be used for private study or non- commercial research purposes only. Published by the University of Cape Town (UCT) in terms of the non-exclusive license granted to UCT by the author. University of Cape Town DECLARATION I. Judith Antoinettevan Heerden, hereby declare that the work on which this thesis is based is original (except where acknowledgements indicate otherwise) and that neither the whole work nor any part of it has been, is being, or is to be submitted for another degreein this or any other university. I empower the University to reproduce forthe purpose of research either the whole or any portion of the contents in any manner whatsoever. Signature Removed _/cl,.!�./Cf/1, a (Date) ACKNOWLEDGEMENTS This survey is dedicated to all those ex-detainees who were willing to share their often painful experiences with me at considerable risk to their personal safety. I would like to express appreciation for the ongoing encouragement and support received from Govan Mbeki, Rev Mxolisi Xundu, Patha Madalana, Vuyiswa Matshaya, Manityi Blaauw, Ndeleka Qangule, Kobus Pienaar, Judy Chalmers and Bettie Grant, and further afield the Albany Council of Churches and the Black Sash, in particular Sox Leleki, Hlemi Mangcangaza, Ruth Plaatjie and Priscilla Hall from the Eastern Cape. In similar vein I received support from the Repression Monitoring Group [RMG], National Association of Democratic Lawyers [NADEL], the social workers of the Western Cape Relief Fund [WCRF] attached to the office of Essa Moosa and Associates, the South African Prisoners Education Trust [SAPET], the Association of Ex-Political Prisoners [AEPP], the Advice Office Forum as well as the local and rural offices of the ANC in the Western Cape. I am indebted to the Executive Committee of the Teaching Hospitals Central Advisory Committee of Groote Schuur Hospital for approving sabbatical leave which enabled me to conduct interviews at a time when this kind of work was not encouraged. I would also like to thank my supervisors, Prof S R Benatar, Prof M Savage (until December 1993) and, in particular, Prof Frances Ames, who unstintingly devoted time and intellectual energy to help shape this project. Prof Benatar kindly authorised bridging funds until the Equal Opportunity Foundation came to the rescue and supplied funding without which this work could not have been completed. With patience and humour Digby Warren generously contributed his remarkable editorial skills to transform a factual document into a cohesive report. I thank him for turning an insurmountable hurdle into a stimulating challenge. A special word of thanks is owed to those individuals who painstakingly helped with the mundane work of typing, developing the questionnaire, collating figures and ii layout. Only Cynthia Woollgar, Heather and Margaret Collins know what a protracted and tedious task it has been. Without the encouragement and good cheer of the secretarial staff of the Department of Medicine this document may not have seen the light of day. Time and energy will have been well spent if this study inspires the enhancement of the quality oflife for prisoners in our new democratic society. iii ABSTRACT This quantitative and qualitative study investigates the type and quality of health care and conditions of imprisonment that prevailed in some South African prisons in the late 1980s. It was inspired by political activists who were incarcerated, yet despite, or because of, the harsh conditions in prison persisted with their struggle for human rights. Appeals for the improvement of prison conditions which they submitted to the authorities are unique primary source documents. By implication, this survey adds value to their cause, for several issues examined in it had already been raised while they were m pnson. With most information on prisons restricted until 1992, there was no body of literature on South African prison health care to review. Instead, Chapter 1 outlines the historical background of imprisonment in South Africa and key penal legislation. It also deals with events like the Biko affair which, in the recent past, affected the medical profession, the response of professional organisations to these events, and the national and international repercussions. Chapter 2 on the methodology describes the study design, data collection process and the limitations of the survey. Numerous attempts to interview District Surgeons and visit prisons were fruitless, consequently reducing the intended scope of the primary research. Because these external limitations affected the study design, they are discussed under methodology. A semi-structured questionnaire was developed to collect information about health care while imprisoned during the States of Emergency ( 1986-1990). Interviews based on this questionnaire were conducted with 123 ex-detainees from the Eastern and Western Cape. The results of the study are presented in Chapter 3, both quantitative, in the breakdowns of the data relating to each of the 14 questions, and qualitative, in the tables which reflect individual experiences and comments. IV The significance of these results is examined in the discussion in Chapter 4, backed by other supportive evidence. It begins by sketching general conditions of imprisonment, using unsolicited information from the interviewees, and proceeds to discuss health care services as they pertained during the study period. Many points of discussion also draw on the seven Case Reports and the report on North End Prison, Port Elizabeth, which have been added as an appendix to that chapter. The research indicates a disregard for the well-being of and failure to provide adequate health care for individuals at the mercy of detaining authorities. This situation was compounded by collusion among the forces of law and order and District Surgeons, and a scant response by academics and professional organisations to problems associated with imprisonment, isolation and torture. In the conclusion, Chapter 5, strategies for improving prison health care are explored. They are based on current national and international literature, policy and practice. The main proposals for reform are then summarised in the recommendations in Chapter 6. These range from revising legislation so as to accord with the constitutional rights of prisoners to addressing the training and attitudes of personnel, establishing health care standards and auditing mechanisms, and creating a more open prison system. V TABLE OF CONTENTS DECLARATIONS (i) ACKNOWLEDGEMENTS (ii) ABSTRACT (iv) List of Appendices (xiii) List of Tables (xiv) List of Documents (xvi) List of Maps (xvi) List of Figures (xvi) I INTRODUCTION 1 AIM AND OBJECTIVES 1 Political Imprisonment 2 SOUTH AFRICAN PRISON HISTORY 3 Background 3 The Dutch East India Company [DEIC], 1652-1806 4 The British 4 Diamond and Gold Mines 4 Agriculture 5 Protest 5 The 1959 Prisons Act 5 Press Restrictions (1959-1992) 6 The SAAN Case 7 Prison Abuses in the 1970s and 1980s 8 The "Privilege" System 9 The Bill of Rights 10 vi HEALTH CARE IN PRISONS 11 Detention Laws 13 The Public Safety Act of 1953 13 The Internal Security Act 74 of 1982 13 Organisational Responses 15 The Biko Affair 17 Action by Detainees 20 II METHODOLOGY 33 METHOD 33 Study Design 33 Target Population 33 Study Sample 34 a) Study Period 34 b) Sampling Area 34 c) Sample Size 35 d) Demography 35 Measurement 35 Ethics 36 a) Confidentiality 36 b) Access 37 Coding 37 DATA COLLECTION 38 Pilot Study 38 Research Period 38 Fieldwork 38 1) Eastern Cape Experience. 38 Preparations 38 Obstacles 39 Geographical Area 40 Interviewing 41 Documentation 41 vii 2) Western Cape Experience 42 Preparation 42 Obstacles 43 Field Trips 44 LIMITATIONS 45 Health Care Providers 45 Random Selection 45 A Single Interviewer 46 III RESULTS 62 1. DEMOGRAPHICS 62 1.1 Region 62 1.2 Race 62 1.3 Gender 62 1.4 Age 62 1.5 Occupation 63 1.5.1 Students 63 1.5.2 Scholars 63 2. DETENTION 68 2.1 Detention laws applicable 68 2.2 Date of arrest 68 2.3 Change in detention (legal) status. 69 2.4 Period of detention. 69 2.5 Number of places held. 69 2.6 Previous detentions 69 3. ILL AT TIME OF ARREST 72 3.1 Illness 72 3.2 On treatment 72 3.3 Continuation of treatment 72 3.4 Ill without requiring medication 72 vm 4. INJURY OR ILLNESS RESULTING FROM ARREST 75 4.1 Injury or illness 75 4.2 Need for treatment 75 4.3 Request for treatment 75 4.4 Treatment given for injury/illness as result of arrest 75 5. MEDICAL RIGHTS 77 5.1 Informed about rights 77 5.2 Type of information provided 77 5.3 Informed about MASA panel 77 5.4 Requests to see MASA panel members 77 6. MEDICAL SCREENING AFTER ARREST 79 6.1 Incidence of medical screening 79 6.2 Time of medical screening 79 6.3 Requests for examination after arrest 79 6.4 Details of history 80 6.5 Details of examination done 80 7. PHYSICAL SYMPTOMS 83 7.1 Incidence of physical symptoms 83 7.2 Changes in body weight 83 8. PSYCHOLOGICAL SYMPTOMS 85 8.1 Incidence of psychological symptoms 85 8.2 Changes in sleep patterns 85 9. MEDICAL MANAGEMENT 87 9.1 District Surgeons [DS] 87 9.2 Dentists 87 9.3 Hospitals and hospital doctors/specialists 87 9.4 Psychiatrists/Psychologists 88 9.5 Other health care providers 88 ix 10. SICK WHILE IN DETENTION 89 10.1 Requests for medical care.