The historian Robert Caro revised the old saying ‘power corrupts’ with the more insightful ‘power reveals’. 

Two types of people emerge when placed in positions of public power: good people who exercise their authority in the public interest; and bad people who abuse that power for personal gain. 

But it is only when a person gets some power, according to Caro, that the veil is drawn, and you find out who they truly are.

As we can’t be sure which person will emerge prior to their elevation to public authority, that power should never be given unconditionally and without constraints.

This will be the case in societies that have properly anticipated the worst that people can do and have therefore institutionalised governance frameworks that avoid the abuse of power.

For those societies that have unfortunately succumbed to authoritarian rule, all the evils that flow from a captured state leave them in darkness, fear and perpetual societal failure.

This is not to say that when the exercise of public authority is purposefully constrained that bad actors will not attempt to test the boundaries of what they can get away with.

They will in fact do so every day and every night until they succeed.

As example after example has shown across the globe, any failure to push them back from the boundaries creates a slippery slope to the unchecked exercise of power by the worst of people — those who desire power most.

Prior to 1994, South Africa did not have a Bill of Rights and a Constitution that framed the societal checks and balances fundamental to the workings of a decent society.

Of enormous credit to its developers, the very idea of decency embodied in the Constitution is deliberately applied, without exception, to “everyone” and not merely to “citizens”.

As a consequence, the arbitrary exercise of power by public actors is always challengeable in multiple fora. 

The resulting system was therefore designed both to offer good people the discretion to act in the public interest and to sanction bad people that invariably infiltrate the world of politics and positions of public authority.

Phophi Ramathuba

It is with this in mind that we should carefully examine the conduct of the MEC for Health of the Limpopo, Dr Phophi Ramathuba, who thought it fell within her mandate and discretion to berate a vulnerable Zimbabwean patient in a public hospital for daring to seek treatment in South Africa. 

The context for this unseemly abuse is the purported crisis for public health facilities that results from uncompensated cross-border flows of people from neighbouring countries.

A little more context is, however, required to demystify this issue. 

Having formed part of many health policy processes in South Africa since 1993, I can state with good authority that the issue of uncompensated cross-border flows formed part of policy discussion from the outset of our new constitutional dispensation.

As with interprovincial cross-boundary flows, a successful framework required a multilateral government process to ensure that such flows are compensated on an acceptable basis upon the presentation of proof of the expense incurred.

Unfortunately, as has become increasingly a matter of serious concern, national health policy effectively ceased to consider any complex health policy matters from the early 2000s.

Government failure

Government has therefore simply failed to establish any framework to address the obvious and unavoidable fact that South Africa exists within a regional and not just a national context.

Neither the cross-border (international) nor the cross-boundary (inter-provincial) flows are therefore properly compensated. This is despite 28 long years to get this right.

In stark contrast to the apparent screeching importance given to immigrants “raiding South Africa’s health services”, there are no policy documents or coherent data on the scale of the “problem”. None whatsoever.

After 28 long years, apart from a few exceptions, public hospitals are also unable to properly construct invoices — due to the apparent inability of provinces to procure ICT systems that work or to even develop a costed tariff schedule (the uniform patient fee schedule is merely derived from uncosted private sector tariffs and aggregated).

This is despite the existence of electronic billing systems throughout the private sector for more than 20 years.

Medical schemes tell me that public hospitals cannot even provide a diagnostic code for medical scheme members using public hospitals, resulting in delayed or declined payments (medical schemes can only pay an invoice with a valid diagnostic code).

The public health system therefore cannot even articulate the costs of South African public patients, let alone those from other countries.

Not only does this obstruct the development of public health strategies; but it also indicates that no one in government is particularly interested in the development of a resilient public health system.

The absence of any serious process to address cross-border compensation for health services furthermore indicates that this policy area is of no apparent importance to government. 

Distraction

So why do we then have the MEC railing at a Zimbabwean patient? 

In my view, the answer lies in distraction. 

The more a state fails its people, the more it must disguise this failure with scapegoats and bogeymen.

To do this effectively, you, as a person or body in power, first target someone or some group that effectively has no voice and can’t fight back. Put simply, you target vulnerable individuals and groups (usually migrants and minorities).

Second, you make out the focus of your target to be all-powerful, evil, wily and manipulative while you yourself are virtuous, vulnerable and bravely struggling for the greater good.

Third, through inaction or active steps, you provoke a Reichstag moment that legitimises the abandonment of constitutional protections and legitimises the authoritarian’s ultimate desire, the Kristallnacht moment.

The art of distraction is to be cruel and manipulative while plausibly pretending to act for the greater good. In a word: duplicity.

A central feature of this practice is to blame the victim for an outcome for which you yourself are culpable.

Endemic corruption and political patronage

Along these lines, it is worth noting that the systematic degradation of public healthcare in South Africa is directly attributable to endemic corruption arising from systems of political patronage operating at all levels of government.

This has led to failing health services, failing infrastructure, failing energy production and distribution, failing public transport and the failure to manage the regional movement of people.

These failures run so deep and are so pervasive that no reasonable person could attribute them to a lone Zimbabwean patient attempting to survive the vagaries of regional government mismanagement.

Under no circumstances was it ever okay for an MEC to enter a health facility, public or private, to berate a vulnerable patient as if it was her right.

Ethical boundaries crossed

Dr Ramathuba therefore crossed the ethical and potentially legal boundaries of a health professional, a public official and a private person. 

She had no business talking to a patient she was not treating or using that conversation to generate a vulgar political spectacle of scapegoating in front of health service staff — who were clearly influenced by her shocking behaviour. 

As a person of influence and power, her actions could have led to harm for the patient – either through influencing her psychological state or through legitimising discriminatory conduct by the facility’s staff.

What the MEC did was an embarrassment to any decent person and anathema to the society envisaged by the South African Bill of Rights and the Constitution.

While the South African Constitution is quite plainly painfully at odds with the authoritarian agenda of some, it is the foundation for a decent society, no matter how its purposes may have been betrayed by those in positions of public authority.

As someone who has worked for many years in the fields of healthcare and social security to better the social conditions of everyone in South Africa, I am appalled by these actions of Dr Ramathuba and expressly distance myself from such shameful conduct. South Africa deserves better than this. DM

Alex van den Heever is an adjunct professor at the University of the Witwatersrand’s school of governance, where he also serves as the research chair for society security systems administration and management studies.