The death of 94 mentally ill South Africans in the Gauteng Province is a national tragedy. The families of every one of those who died put their faith in the state but they were betrayed and morally let down. The nation’s hearts must go out to them in their grief-stricken efforts to find solace and dignity in an unforgettable episode of disgraceful criminal neglect.

Some of the details of the horror of mistreatment and neglect of the mental patients by the non-governmental organisations (NGOs) so woefully ill-equipped to deal with seriously ill human beings reminded me of the Nazi and former East European socialist attitudes to the mentally infirm. They were seen as less than human, “cargo” in the words of the Treblinka concentration camp commandant, Joseph Stagl, as recorded by the great biographer Gitta Serenyi in her book Into that Darkness (1974).

Prompted by the DA’s Jack Bloom, Health Ombudsman Malegapuru Makgoba distinguished himself, as did Health Minister Aaron Motsoaledi, in lifting the lid off a reality none of us wished to see (see The Report into the ‘Circumstances Surrounding the Deaths of Mentally ill Patients: Gauteng Province’ Office of the Health Embed January 2017). There is no question that if we had credible health care facility surveillance the alarm to intervene would have gone off a long time ago and a chain of command would have reacted to prevent the deaths.

When there is reasonable cause to suspect that an unnatural death was due to neglect, individual inquests must by law be led for every one of 94 individuals. South Africa will therefore be rightfully confronted front and centre with the tragic individual stories of misery and death in the full glare of the public eye as the inquests proceed over the next two to three years.

Legalities must be confirmed, but there is enough evidence for us to take Gauteng Health MEC Qedani Mahlangu beyond mere resignation and have her, and the many civil servants identified by Makgoba in his Report, tried in a court of law. Gauteng Premier David Makhura must also take his full share of responsibility because Mahlangu was directly accountable to him.

Few seemed to have noticed that Makgoba recommended that Health Minister Motsoaledi should request the SA Human Rights Commission to undertake a “systematic and systemic review of human rights compliance and possible violations nationally related to mental health”. We agree, but, as the DA points out in Our Health Plan, there are two further vital compliance and regulatory reforms required:

First, the Office of Health Standards Compliance (OHSC) must become an independent, robust and pro-active body that sniffs out non-compliance to health and medical ethics’ standards. Presently, it is a reactive and passive institution that moves at a dolorous pace; and

Second, the vaguely defined and conflicted powers of Provincial Health MECs against which their appointment, performance and accountability are measured and exacted must be remedied with immediate effect. MECs have too much discretion in making appointments and signing-off tenders that must be constrained.

We must learn from this regrettable episode in the nation’s history and reform the appointment, performance and accountability practices and habits that led to the unnecessary deaths of 94 South Africans in the first place. There is vast gap between the constitutional imperative of a right to life and health care and the facts on the grounds that must be filled by institutions, practices and human behaviours that make our constitutional rights relevant to everyday life.

Dene Smuts’ book, Patriots and Parasites (2016) is enormously relevant in this respect. Focused entirely on the issues, Smuts, a greatly missed former DA colleague, was one of the few politicians who understood that the liberal democratic project is not simply about constitutional rights, fundamental a foundation block as that is, but that it (the project) required people who cared about it enough and developed systems to ensure everyday compliance, especially among vulnerable populations like the mentally infirm.

Makgoba documents the human rights violations: “There is prima facie evidence that certain officials” in the Gauteng government and the NGOs entrusted with patient care “showed a total disregard of the rights of the patients and their families, including but not limited to the Right to human dignity; Right to life; Right to freedom and security of person; Right to privacy; Right to protection from an environment that is not harmful to their health or well-being; Right to access to quality health care services, sufficient food and water; and Right to an administrative action that is lawful, reasonable and procedurally fair”, almost the entire Bill of Rights!

The “administrative action” in this case would be an active medical and medical ethics committee at every one of the government and NGOs involved to ensure that, with the right enforceable protocols, the following, as described by Makgoba (The Report, p.2), extraordinary violations never ever happen again:

• some patients were transferred directly from sick bays to NGOs;
• others were transferred with co-morbid medical conditions that required highly specialised medical care (bedsores and puss oozing out of sores or medical conditions such as epilepsy and hypertension) to NGOs where such care was not available;
• other frail, disabled and incapacitated patients were transported in an inappropriate and inhumane mode of transport. Some without wheelchairs but tied with bed sheets to support them;
• some NGOs rocked up at Life Healthcare Esidimine in open bakkies (trucks) to fetch mental health care users (or patients) while others chose like an auction cattle market despite pre-selection by professional staff;
• some patients were shuttled around several NGOs;
• during transfer and after death several relatives of patients were still not notified or communicated to timeously; and
• some are still looking for relatives.

As for the Gauteng provincial executive member Mahlangu, she appeared to have no professional legal advice to guide her decisions, violated procedure, exceeded her authority and behaved in reckless disregard of basic principles. As a matter of great urgency, premiers must tighten up on the job description and the reporting and accountability requirements of their executive members, a lacunae in our governance system as I point out in the DA’s Our Health Plan, to ensure that the following never happens again:

• The 2013-2020 policy framework and strategic plan were selectively interpreted, misrepresented and contravened to drive the universally-accepted objective of de-institutionalisation;
• Newly-established NGOs were mysteriously and poorly selected, poorly prepared, not ready, with untrained unqualified staff unable to distinguish between the highly specialised non-stop professional care requirements of assisted patients and a business opportunity; and
• Patients were transferred rapidly and in large numbers within a short time frame from the structured and non-stop caring environment of Esidimeni into an unstructured, unpredictable, sub-standard caring environment of the NGOs. (The Report, p.2)

But, important as fixing a job description is, this goes much further and looks possibly like corruption: tenders were handed out just like that to NGOs without histories in health care or audited capacity assessments in pursuit of business opportunities for the connected driven by the Gauteng Government seeking to save budget. As with these things, there is the real possibility that money changed hands to grease the way.

The needs of the families of the deceased should get first priority for attention and care. But this sorry episode in the life of our democracy exemplifies what is rotten with the Zuma administration: inappropriate appointments, poor compliance with the Constitution, law and ethics, poor accountability, immoral and unethical conduct and no integrity of purpose; this time, 94 lives were lost, and there cannot be a high enough price to pay. DM

Dr Wilmot James, MP, is the DA’s Shadow Minister of Health