Annual David Sanders Lecture in Public Health and Social Justice

and the coming revolution’. His organisation Digital Health aims to use technology to address diseases like HIV and TB, lifestyle issues and pregnancy, wellness and exercise, and more. “We seek to ensure seamless integration across the health services system in terms of drug prescription, review, dispensing, provision and delivery, including a fully-tracked health logistics service that allows people to monitor the door-to-door delivery of medicine.” Digital Health supports start-ups to mature, to enable them to access commercial contracts and obtain long-term sustainability and stability. It helps local entrepreneurs to engage with mentors, leading health care organisations and business leaders to refine their innovations. Siraaj is also the strategic partner to Iyeza Health, which started out as a ‘last mile logistics’ service in Cape Town – i.e. the fast and efficient movement of goods from one place to another, from a central location to the final delivery destination. As a subcontractor to the Western Cape Government Chronic Dispensing Unit, Iyeza Health has been responsible for the delivery of chronic medication to 30 public sector clinics in low-income areas in Cape Town – and sometimes to patients’ homes. “In addition, one of the critical things for us as pharmacists and pharmacy researchers, Iyeza Health has achieved the required cold chain compliance, and built the required digital infrastructure in order to scale the business nationally.” Siraaj credits his MPH as being a turning point in his career to focus his skills on health innovations at a population level, and at the same time partner with local entrepreneurs to apply digital solutions to community level initiatives. “I was lucky in that I also got involved very early on in getting involved – and this unique network was something that I’ve been able to work with over time as well - and that can help empower others.” “Digital health is an evolving space. Everybody’s trying it, nobody’s really got it right yet - but we’re going to keep trying. And ultimately, people in need of better care are going to see the difference. That’s what we need to see.”

To celebrate Emeritus Professor David Sanders’ contribution as founding director of the School of Public Health at UWC, and his influence in the field of public health generally, an annual lecture was instituted in 2012 in his name. Each year an eminent speaker is invited to engage scholars, practitioners, policy makers and activists in contemporary challenges and opportunities for public health research, teaching and practice. In bringing scientific excellence and implications for political and social action to bear on their chosen issue, they continue the vigorous, socially engaged, scholarly debate and practice that characterised much of David’s engagement. Previous speakers have included Prof Hoosen Coovadia, Prof Richard Laing and Dr Mary Bassett, among others, and have focused on issues including access to medicines, the link between race and health, and the challenges of devising public health systems in developing nations. • The 2019 lecture was given by Advocate Adila Hassim, lead counsel for the Life Esidimeni case, who presented on ‘Decanting Life Esidimeni: Valuing life and human dignity in South Africa’. • No lecture was given in 2020, given the constraints imposed by COVID.

2019: Adila Hassim

Advocate Adila Hassim was lead counsel in the Life Esidimeni arbitration – a legal investigation into one of the biggest human rights failures in democratic South Africa, and the deaths of at least 144 mental health care service users from causes including starvation and neglect. Her lecture, entitled ‘Decanting Life Esidimeni: Valuing life and human dignity in South Africa’ delved into the truth behind the Life Healthcare Esidimeni scandal, and the inability of those involved to take responsibility for their actions.

“Of all that we learned during the hearings, all of the terrible things, there was one vein that ran coldly through the evidence,” Hassim said, “and that was the repeated claim by government officials that they were obeying orders, and that they could not take individual responsibility.” They did it to save money, they said; and because nobody could have foreseen how bad things would get. And because, as would be repeated so many times, they had “instructions from above”. In 2015, Gauteng health MEC Qedani Mahlangu announced the province would terminate a decades-old contract with the private hospital group Life Esidimeni to provide state-subsidised care for about 1,700 mental

health patients. The contract, Mahlangu argued, had become too expensive. The cost per patient per day at Life Esidimeni was R320. The budget allocated to the NGOs who took the patients was R112 per patient per day.

“Just imagine: R112 per day, to provide all of the care – the medical care, the residential care, the food and water and basic necessities and more – that a patient might need,” Hassim noted. “The idea that in the name of costs you would spend so little on the lives of citizens, that human beings would matter less than money, is reprehensible. And in fact it cost the government much more than that in the end.” Hassim asserted that the conditions that led to the disaster really had “nothing to do with resources” but had “everything to do with civil servants who did not perform their jobs in a manner consistent with the law, or with the rights of the patients or the families.” “The department and the MEC were warned four times in writing before November 2015,” Hassim explained. “They were warned by people who worked in the field; people who understood what the implications of the transfer would be, and what would be needed to make them work. There was media, advocacy, protests, litigation.” “Not a single individual in the department took responsibility,” Hassim noted. “Not one. The officials involved in decision-making were eager to eschew individual accountability, to explain why they could not be held accountable for their own actions. The responsibility, they noted, was collective – belonging to the system as a whole, and in no part to them.” That held even for those at the very top. Dr Barney Selebano, former Gauteng Health Department Head, testified that, despite his senior position, and his acknowledgement that he was the person signing documents and approving the project, he was powerless to stop the project.

Decanting

While ‘decanting’ is an international description of the careful process of moving to community-based care, this is not what happened in the Esidimeni case, where over a thousand mental health care patients were forcibly transferred from Life Esidimeni – the private healthcare provider where they were, by all accounts, well cared for – to unlicensed and unqualified NGOs in Gauteng province. The transfers happened in a short period of time, due process was not followed, and patients were not cared for anywhere near adequately. Family members of deceased patients reported seeing patients walking around naked, that one NGO gave the same standard set of medication to every patient, and that bodies were badly decomposed. Justice Moseneke described the account of the Esidimeni removals as one of death, torture and disappearance. “These are not words that are used lightly, especially in law. And they are not words that one would expect to be used to describe treatment of human beings in South Africa at the hands of the government in 2016. They are words that should have died with apartheid – but didn’t.”

The power of the law

In March 2018, after 44 days of testimony and contemplation, arbitrator Justice Dikgang Moseneke ruled that families of the affected patients must each be paid R1.2 million, made up of R20,000 for funeral expenses‚ R180,000 for shock and psychological trauma, and R1 million in constitutional damages. “Most lawyers would consider the story to be a victory from a legal perspective,” Hassim commented. “After all, the families were vindicated in the end, and awarded damages for the loss of their loved ones – an absolute first in South African law. But I would like to suggest that this is not a story of victory but one of law’s failures. Why? Because despite the fact that we have one of the world’s most progressive constitutions, if not the most, it was not enough to prevent the loss of life that occurred.” If the system is as poorly functional as it was in that situation, at that time, in that place, why should we not expect to be repeated?

“I think that what helps is simply to listen,” Hassim said. “You don’t have to agree with what you hear, but you need to take stock of it. As a manager, if you create a culture where you think people can speak in your presence and express their real opinions, and know that they will be heard, then that will go a long way towards coming to the right decision eventually.” And that goes not just for public health, or even for the public sector – that matters wherever people make decisions that affect the lives of others. “We have to start in another part of the constitution – Section 195,” she said. “We have to demand the appointment of public servants who are capable, honest and serious about their constitutional obligations: public servants who put people first. Maybe then we’ll obviate the need for lawyers to protect us from our government – and our society will be the better for it.”