Healthcare worker Liberia Salasa has written a response to Judge Edwin Cameron who is of the view that prisoners are often overlooked in an unequal health system.
First of all, I'd like to acknowledge the contributions of retired Judge Edwin Cameron in his historical efforts in securing the rights of marginalised communities as well as ensuring access to quality HIV treatment which has left a lasting impression on the healthcare sector as a whole. His recent opinion article obviously serves to improve awareness of deficiencies in healthcare services to inmates, another marginalised population, however, there are flaws in his discussion.
If someone has no experience of working in a correctional facility/prison, they may not understand the nuances of serving a population of convicted criminals or awaiting trial inmates.
Cameron's view seems to disregard the tireless efforts of Department of Correctional Services (DCS) healthcare workers relegating them to being the malleable tools of the department rather than independent champions of healing, which is how they would rather be identified. Often, DCS Healthcare workers are battling against two dysfunctional systems (namely the Department of Health – DoH) as well as DCS officials who would try, at times, to impose their own will on the conduct of healthcare workers within correctional centres.
To further illustrate this, I'd like to challenge five points Cameron made.
The article was prefaced by implying that some remnant of the apartheid system of enforced abuse remains in correctional centres. In the writer's opinion, DCS nurses and doctors serve as spineless stooges who serve at the behest of twisted prison bosses covering up abuses by officials in the hopes of pleasing their employers.
The reality, in my experience, is different.
There have been cases where DCS healthcare workers will plead with officials to stop assaulting offenders or even put their own bodies in the way serving as shields to end the onslaught of attacks on offenders. Whether this approach is driven by altruism or a self-serving interest (as these injuries will increase the work of the attending healthcare worker) is not totally clear but what is clear is that the absence of this additional protection would mean that there would be no one left to come to the aid of such offenders if DCS healthcare was removed entirely.
Cameron mentioned 'independent healthcare' as the option to remedy DCS healthcare deficiencies where mention was made of the DoH taking full responsibility or implying private practitioners get involved.
Anecdotally, I can provide some experiences to give you a better idea of the reality of such a suggestion.
Offenders seen by private or sessional doctors are very often only given a repeat prescription without even being reviewed by the visiting doctor. I have heard tales of private doctors, during the admittedly difficult times of Covid-19, meeting DCS nurses at the gates of correctional centres, just to sign a prescription document because the doctor believed the correctional centre was 'infested' by the virus. These same doctors are not available for after-hours work, which means any adverse drug reactions or complications during their treatment will need to be managed by the DCS healthcare workers on site.
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The public health sector is already an over-burdened, semi-functional mess with its current patient load. Shifting all offenders onto such facilities would only serve to deteriorate the already collapsing structures further. The extent of burnout and compassion fatigue is so rife that it has no patience for DCS patients. Often, sick offenders, identified as urgent or emergency cases, are triaged as low risk when referred to external facilities, where they are often given a panado and sent back to correctional centres only to drop dead the next day.
At times, healthcare workers at public facilities have said outright that DCS patients are 'just prisoners', implying that there is no need to work harder on managing them when the queue is made up of ill women and children. Offenders with lower gastro-intestinal illnesses are often accused of self-inflicted injuries from smuggling or 'deviant' behaviour even when the condition is due to some or other pathology (like Cancer).
In these cases, it is often DCS nurses and doctors who are the only involved party with a vested interest who will need to advocate for interventions for their patients. It is obvious that most of the poor treatment of offenders in public facilities is due to the ongoing decay at these facilities due to corruption. This has led to the staff becoming disillusioned and overworked during their service. However, if there was no-one left to take responsibility for DCS patients then this kind of neglectful treatment would never be confronted.
It is true that offenders do not get regular access to doctors and nurses in certain clinics. This is often due to the fact that a single DCS nurse would be covering multiple correctional centres due to understaffing or a DCS doctor only visits specific centres during a rotational schedule. This could be remedied by instead increasing post availability or funding to smaller centres so that more staff can meet the needs of patients. The lack of medication is due to an ever-decreasing budget for pharmaceutical services despite the burgeoning prison population. Medication often has to be sourced from local healthcare facilities souring the working relationship between DCS and DoH.
Sometimes medication from specialist facilities needs to be provided by correctional centres despite DCS facilities functioning on a primary healthcare level. This means that rarely used expensive medications need to be purchased from a budget meant to serve the same services as a rural Primary Healthcare Clinic in the DoH would.
I would also note that in a correctional centre, should an offender feel sick during any odd hour of the night, a DCS nurse is dispatched to review and assess the patient immediately. Should the nurse's assessment conclude that the patient is more severely ill then the DCS doctor would be called or, in the event of no doctor being available, the patient would be referred to the next level of care. I'm sure there any many people in our country who do not have anything close to this level of bedside service or call-out access (even with a medical aid).
Mental health challenges
Cameron mentioned rising mental healthcare challenges affecting the offender population. This is mainly due to the poor funding and post availability for psychology and other multi-disciplinary services. It, however, makes more sense to have a multi-disciplinary team of DCS healthcare professionals rather than to shift the entire patient population to the public sector.
South Africa is notoriously under-resourced when it comes to mental health practitioners, so this reform requires interventions from all sectors to be resolved. It should also be noted that Cameron mentioned hunger strikes in the same vein as suicides, whereas hunger strikes are often initiated by offenders to pressure a correctional facility into enacting a transfer rather than out of a mental health condition.
Cameron mentioned that Judicial Inspectorate for correctional Services is of the opinion that all deaths due to natural causes could have been avoided with closer monitoring and regular access to medical assistance. It should be made clear that everyone in every sector can always do better, however, this point should make use of comparing crude death rates. DCS facility death rates range from 3-5 deaths per 1000 offenders as per the latest statistics. When this is compared to the general South African population with a crude death rate of 9,4 per 1000 (as per the World Bank statistics of 2020) then we can see that DCS offenders fare better than other South Africans.
It should also be noted that in DCS facilities, every single death requires a detailed report and leads to a subsequent investigation. After the investigation is concluded then there is a mortality review wherein healthcare workers and relevant stakeholders should identify areas where improvements can be made to avoid future negative outcomes. This is not the general approach for every death in other healthcare facilities (except perhaps paediatrics or obstetrics) which would mean that this valuable process would be lost if DCS healthcare was done away with.
There may well be correctional centres which fall short in every regard but to claim that all DCS healthcare workers serve only to please their employer spits in the face of all the good work done in the name of patient care. It would be reductive to say all public sector healthcare staff are bitter, overworked and apathetic but there have been enough instances to allow one to point it out when it occurs. It would also be reductive to say all private sector healthcare staff are profit-driven, haphazard and uninterested, when it comes to offenders, but there have been instances where such treatment has been witnessed.
I hope this can at least shed some light on some misconceptions when it comes to DCS healthcare and promote some of the intelligent suggestions included at the end of Cameron's opinion article.
- Liberia Salasa, a DCS healthcare worker writing in their own capacity.
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