Are South African health workers being silenced into malpractice?

By Karessa Govender, Published in The Daily Maverick, 17 November 2017

https://www.dailymaverick.co.za/opinionista/2017-11-17-are-south-african-health-workers-being-silenced-into-malpractice/#.Wg6MYROCxE4

“There is really no such thing as the ‘voiceless’. There are only the deliberately silenced, or the preferably unheard.” The words of Arundhati Roy, a writer turned human rights activist, rang particularly true through the course of the Life Esidimeni saga. The 118 deceased residents who have now risen to 141 were the preferably unheard – their cries for help through pressure sores and other unaccounted wounds, signs of starvation and dehydration, all fell on deaf ears. However, it is only in retrospect we see that they were not the only ones who were preferably unheard – those who predicted the train wreck and voiced their concerns were no more acknowledged than those that have fallen.

There has been a general narrative surrounding the role of the health care workers in the Life Esidimeni tragedy. Health care workers have come under fire from civil society and others who have questioned how it could have been that health care workers did not speak out throughout the process that eventually led to the death of 141 people. Dr Morgan Mkhatshwa, the former managing director of Life Esidimeni openly criticised the health care workers: “How could they not stand up and say ‘over my dead body, I will not do that’.” Yes, it is true that there were many health care workers who did not speak out and that is of grave concern. But the efforts of those who did speak up must be acknowledged. And there are lessons to be learnt.

For instance, concerns were raised internally repeatedly by health care workers but were not listened to. According to Dr Bernard Janse Van Rensburg, a psychiatrist employed in the public sector, concerns were raised through appropriate “line function channels” by clinical heads of departments in a number of Gauteng hospitals. The Ombudsman’s report following the Life Esidimeni tragedy spoke of a “climate and culture of fear and disempowerment observed amongst staff members to challenge or engage with authority”. Many who have had first-hand experience working within the public health sector would not be surprised by the threat of intimidation and victimisation after speaking out. Shelley Wilsnach, who was part of a collective of University of the Witwatersrand OT students who raised their concerns through a letter to the Gauteng MEC of Health, believes that health care workers are not adequately supported or heard when raising complaints.

This lack of support further disempowers health care workers. The Gauteng Ministry of Health clearly stated that they were not obligated to consult with stakeholders prior to transferring the Life Esidimeni residents. This shows a lack of regard for the expert advice from skilled health professionals and a somewhat “master-servant” relationship rather than a partnership where the employee feels empowered to provide input from their profession’s perspective.

Contrary to public perception, I do not believe it was simply a lack of compassion on the side of all health care workers. Patient rights get violated daily in a crumbling health system. The vast majority of health care workers I have worked with within the public sector do care about this state of affairs. However putting caring into action boils down to a faith in the health system and that there will be an appropriate response. For individuals to have spoken out, a premise must have existed that there would be recourse. This is the primary reason we speak out. We assume that the systems in place are fair and that just action will follow. We trust the systems in place or if we do not, we trust in our abilities to force the system to change. This distinguishes the silent health care workers from the different external groups that spoke out repeatedly, which had trust in their ability to stop the tragedy.

Life Esidimeni was never a once-off incident. It is a very graphic representation of the fear of speaking up, the failure to stand up because of health care worker despondency and most disturbingly, the failure on the side of the department of health to listen to those health care workers who did indeed speak up. For every Life Esidimeni tragedy that reaches the media, there are thousands that go unnoticed daily. This is the real tragedy behind the Life Esidimeni debacle.

So we have seen a variety of responses. Some health care workers raised the alarm internally but were not heard. Some, sadly, seem to not have cared, and went on with daily life. But I have argued that in general most health care workers do care but the system took away hope that speaking out would make a difference.

Ultimately, the tragedy unfolded and no matter the explanations, no excuse can be strong enough to justify staying silent. The new Gauteng MEC of Health, Dr Gwen Ramokgopa uttered the following words in reference to the Life Esidimeni tragedy: “Never again should a tragedy of this magnitude occur.” The unfortunate part is that this has happened before. In 2007, 17 children who were moved from Life Esidimeni to an NGO, demised. The tragedy on the scale of Life Esidimeni islikely to happen again if we do not intervene as health care workers. Universities need to equip health science students and health professionals on how to effectively advocate for their patients. Some health care workers sought help from external organisations. That was an appropriate response when internal mechanisms fail. We need to teach our students and health care workers that there are options when internal reporting fails or when reporting is too frightening. Clinical training must go hand in hand with advocacy skills. The HPCSA has included “health care advocate” as a core competency in undergraduate training of medical practitioners, dentistry and clinical associates. This acknowledgement is a step in the right direction but is only the first of many steps.

Finally, health worker advocacy is more than just speaking truth to power – it requires a shift in the power base from the Department of Health to the foot soldiers that are on the forefront of South African health care – the nurses, doctors, clinical associates, pharmacists and therapists and most importantly, the communities that these cadres serve. These health care workers and communities are the real custodians of health care in South Africa. They collectively must determine the standards of health facilities in which they serve and receive care. The quest for quality health care must go beyond yearly audits and countless checklists. Health care worker advocacy dictates that the environments in which health care is provided, is open and responsive to advocacy – not an environment that is hostile and rewards subservience at the expense of patient dignity and quality health care.

History shows us that the greatest social justice movements rose from the ground up – this challenge is no different. It is up to South African health care workers to organise, collaborate and mobilise and continue to speak up until there is no choice but to be heard. DM

Karessa Govender is an occupational therapist with seven years of public sector experience. She is currently an intern for the Rural Health Advocacy Project.