When agents of the state gunned down 34 striking miners at Marikana in 2012, it left a mark on the psyche of South Africa. We all hold images of that day in our minds -- men walking together across a veld, a man in a green blanket, police advancing with their guns drawn, and dust rising over the bodies of the dead.
On Wednesday, South Africans listened in horror as news emerged of another national tragedy precipitated by agents of the state, one that was less visible but no less violent.
Over the last year at least 94 people died as the result of a bureaucratic decision taken in the name of cost cutting. But this time there are no bodies left lying on the ground, there are no stark images to haunt us, only incomplete records, dry statements and the tears of grief-stricken family members.
In his report, "No Guns: 94+ Silent Deaths And Still Counting," health ombudsman Magelapuru Makgoba was clear in who should shoulder the blame for these deaths -- Gauteng health MEC Qedani Mahlangu, head of department Dr. Tiego Selebano and director Dr. Makgabo Manamela.
"The three have brought so much pain and anguish and disrepute to our nation and are not exemplars of good public servants and service," he wrote in his report.
Gauteng Premier David Makhura said on Wednesday that all patients who are still at risk will be transferred to public health care facilities and that he would "engage with the affected and bereaved families to find closure".
"I would like to reiterate that I deeply regret and profusely apologise for the tragic loss of lives of our fellow citizens who were patients under the care of our Provincial Department of Health," he said in a statement.
But DA spokesperson for health in Gauteng, Jack Bloom, said Makhura should have been monitoring the situation more closely in the first place and bears part of the blame.
"He should have acted far sooner. Even now, there are patients who have to be rescued from NGOs. This could have happened last year. The MEC should have resigned; if she didn't, she should have been fired. The premier is partly to blame," he said.
The EFF and ANC Youth League meanwhile have gone further, calling for criminal charges to be brought against Mahlangu and for Makhura to resign.
Meanwhile, Health Minister Aaron Motsoaledi, who said he was "distressed and very angry," told reporters at the release of the report that "something like this should have been avoided," which surely is one of the biggest understatements of the year.
This slow-burn disaster can be traced back to a policy to deinstitutionalise mental health. The policy itself is in line with international trends towards integrating mental health patients back into communities but the implementation was clearly disastrous.
What should have been implemented slowly over up to five years, was instead rushed through in three months. The result was no piloting, no proper due diligence and chaotic implementation.
Makhoba's 60-page report brings to light the massive negligence involved and makes for harrowing reading. It describes the provincial health department's decision to end a contract for the care of mental health patients at Life Esidimeni Care Centre and to send them instead to local NGOs, a process he described as "chaotic," "rushed", "unwise" and "flawed, with inadequate planning".
The decision to transfer the patients was reportedly based on a cost analysis. At Life Esidimeni, the cost of care per patient per day was R320; the department wanted to bring this down to R112 a day.
The result was devastating: 25 patients died within two months of the transfer; 77 within five months.
Records were poorly kept and so the ombudsman has not identified the cause of death in every case. What's clear is that some patients died of cold and dehydration, while others died as a result of uncontrolled epilepsy or pneumonia -– conditions that could be treated with appropriate medication and care.
Families were not kept abreast of what was happening to patients at the NGOs, even after they had died. Charity Ratsotso died on July 11 last year but his family were never notified. They found out almost five months later, when a relative went to visit. His body had been lying, unidentified, in the mortuary all that time.
The patient transfer, Makgoba said, had occurred against widespread professional, expert and civil society stakeholders' warnings and advice. Letters were written to the health department, protests were held, and families and health advocacy groups went to court to try to stop the process.
It didn't help. The project went ahead as planned (So much for meaningful consultation.) It's not surprising then that during his investigation of the department Makgoba found an almost pathological aversion to listening.
Several staffers interviewed reported that Mahlangu said her "decision was final and non-negotiable and the project had to be done" and that she left no room for engagement. There was apparently such a climate of fear and disempowerment among staff that they would not even name their so-called "principals".
This overwhelming revelation of frustration and disempowerment came across all the sectors of the department during oral evidence below the director's level. This finding is most troubling and a damning indictment on the leadership of the Gauteng Department of Mental Health.Ombudsman's report
Members of the provincial mental health directorate told Makgoba that there was haste in implementing the project, that voices of reason were ignored and that instructions were followed blindly.
This failure to listen to or to take advice was of "grave concern," Makgoba said.
He also found prima facie evidence that certain officials, NGOs and processes involved in the project violated the Constitution and contravened both the National Health Act and the Mental Health Care Act.
QUOTE: Mentally ill patients were transferred 'rapidly and in large numbers with a short timeframe' from the 'structured and non-stop caring environment' of Life Esidimeni into an 'unstructured, unpredictable, sub-standard caring environment' of the NGOs.Ombudsman's report
According to the report, there were no set criteria for granting licenses to NGOs, there was no discernable accreditation process and licenses were reportedly issued "on the spot".
Relatives of patients gave harrowing evidence of what they found when they visited the NGOs. The were described as filthy, poorly staffed, uncaring and overcrowded places, "like concentration camps". Patients were unkempt, inadequately clothed and left hungry. Relatives said they found unexplained bruises. Patients suffered severe weight loss and complained of not having been given their medication.
Makgoba found that 22 of the 25 NGOs involved did not have appropriately trained staff, facilities or capacity to offer appropriate care. At some NGOs, staff did not even have basic medical training; there was no emergency equipment or storage facilities for food or medical supplies and no facilities for the disposal of medical waste.
The NGO Precious Angel, where several patients died, had only ever cared for children with intellectual disabilities. Ubuhle Benkosi had cared for orphaned children. Rebafenyi offered women empowerment. And Shammah had housed homeless people.
The health department had apparently invited the NGOs to a meeting where the project was presented as a business opportunity not to be missed. There was no requirement for them to have any experience or qualifications in mental health care, and no requirement to provide social work, occupational therapy, physiotherapy or rehabilitation programmes.
Makgoba found that almost every national health norm and standard was breached by the NGOs that were visited and inspected.
Makgoba found a disturbing lack of data integrity and consistent information from health department. Documents he'd requested were withheld; at other times he was given documents that were either invalid or irrelevant to the request.
"There was no patient register and no database for the Life Esidimeni Project. None of the figures between the Gauteng Department of Health, Life Esidimeni or the NGOs added up and it is still not known exactly how many patients were actually transferred from Life Esidimeni to the various facilities,"he wrote. Mahlangu, Manamela and Selebano could not even reconcile the number of deaths on record among themselves, and none of their numbers matched up to what the ombudsman found.
If MEC Mahlangu, Dr. Selebano and Dr. Manamela did not know how many patients had died by the 29th November 2016 as confirmed in their evidence, in a matter that has caused so much 'pain and anguish' in families and has attracted so much national and international interest, then one must wonder what else they do not know in the system they preside over.Ombudsman's report
Disturbingly, a section of the report, which notes that the decision to move patients from Life Esidimeni to NGOs was taken "in the Premier's Office and not by the Premier". The implication of outside interference in the decision to push ahead with the plans is cleared but not explored any further in the report. Makgoba says only that "During oral evidence Dr. Selebano would not reveal who 'stalled his alternative approach plans', who was giving him instructions or 'placed them under pressure'."
Makgoba has recommended a systematic review of possible rights violations nationally related to mental health. He's also asked for legal action against unlawfully operating NGOs where patients died and a review of all 27 NGOs involved. In future, he says, all NGO certifications should be done through the Office of Health Standards Compliance (his office). And more urgently, patients from Life Esidimeni who are currently at unlawful NGOs must be urgently removed and placed in appropriate care facilities.
It's impossible to overstate the severity of what's been playing out in the health department over the past year or more. How an entire state apparatus, charged with the care and protection of some of the most vulnerable people in society, could defy expert advice, ignore the concerns of family members and cause such willful damage – the death of not one or two people but 94 and counting – is almost too painful to comprehend. It highlights not only the callousness of the state and the irresponsibility of civil servants but a systemic, cavalier attitude towards mental health and a complete lack of respect for basic human dignity, all in the name of cost-cutting.
Civil charges or a class-action suit are warranted and would deserve the support of every right-thinking South African. "Never again" is something we've become accustomed to saying in this country, but words mean nothing without action. To say that this should mean the end of the political careers of both Mahlangu and Makhura and a complete overhaul of the Gauteng health department would not be remiss.