Monopoly on Madness?
Private Long-Term Black Mental Institutions in South Africa Between 1963 and 1989

Presentation to NEWSA (North Eastern Workshop on Southern Africa) 2003

Tiffany F. Jones
History Department, Queen's University
Kingston, Ontario, Canada

Tiffany Jones studies African history, with a particular interest in the construction of race, gender and sexuality in the modern era. She currently teaches the history of the New Imperialism, Modern African History, and the History of Southern Africa. She is working on a book project that examines the history of madness in South Africa from 1939 to 1989. She also has interests in the history of the third world, African literature and comparative medical history.

The number of these human warehouses where care is reduced to a minimum and cure a forgotten word is growing year by year — as are the profits of the company which now has such a monopoly on madness that as one authority told me, "it can virtually dictate mental health care in South Africa" (de Villiers 1975).

In 1962, the South African government contracted long-term mental health care — particularly care of long-term black patients — to the private company Smith Mitchell & Co. The numbers of patients placed in Smith Mitchell's mainly rural institutions increased significantly so that by the mid-1980s Smith Mitchell provided over forty percent of all mental health care beds in the country. Only about six percent of the beds were reserved for whites (Tabatznik c1996, 5, Annexure B).[1] The movement of long-term black patients to contracted private institutions fit with the Nationalist government's separate development initiatives. It enabled urban-based state institutions to transfer their black patients so that they could concentrate on their white patients. In the 1970s and thereafter, charges of abuse in these institutions, such as those stated by Fleur de Villiers at the beginning of this article, were widespread. Investigations by the Church of Scientology's Citizen's Commission of Human Rights (CCHR), the International Committee of the Red Cross (ICRC), the World Health Organization (WHO), the American Psychiatric Association (APA) and an American psychiatrist, Dr. Stanley Platman and his wife Vera Thomas, substantiated claims of patient mistreatment.

Despite allegations that Smith Mitchell could "dictate mental health care in South Africa," in reality, the company's role was more complex than its critics portrayed. On the one hand, its position was inextricable from that of the national government. The state appointed most of Smith Mitchell's medical, psychiatric and nursing staff and controlled the admission of all patients. Smith Mitchell profited from apartheid policies that produced poor conditions for blacks and benefited from the state's indifference to the welfare of black patients. Indeed, the company made most of its money by minimising its expenditures on housing, clothing, feeding and treating its patients. On the other hand, even though Smith Mitchell institutions remained strictly under the control of the apartheid government, it was not simply the instrument of the government.

In her examination of white civil servants working within the apartheid government structures, Deborah Posel (1999) has effectively shown that although civil servants appeared contented with the workings of the government, and certainly they were far from liberal, in reality they were often dissatisfied and frustrated. Few openly protested though because of the tight control exhibited by the National Party and the deferential nature of their Public Service Association. A similar assertion can be made about the employees of Smith Mitchell institutions where the close ties between Smith Mitchell administration and the government meant that few were prepared to overtly challenge policies. Yet many did express frustration with the DOH regulations and they often found their institutional role frustrating and unsatisfactory. Indeed, the relationships between the company, the state, state employees, company workers and even patients were not always clear-cut, and hospital workers often expressed frustration at state policies and to some extent shaped practices within the institutions.

Discussions about the relationship between private commercial interests and the colonial state in African countries have become increasingly popular since the 1970s. South African studies on the role of business during apartheid focus on the collusion between companies and the apartheid state. They also highlight the effect of forces such as labour resistance or the economic profligacy of apartheid policies on company practices. Therefore, they show the somewhat paradoxical position that companies held within apartheid — at times supporting the apartheid government, at other times directly opposing it, and sometimes doing both.[2] This paper supplements these studies. However, Smith Mitchell held an even more complex position during apartheid than most companies in South Africa. Not only did the company face internal conflict and contradiction from the myriad of state and company-hired staff with their disparate interests, but it also had to contend with critical investigative bodies bent on forcing fundamental changes.

A discussion of Smith Mitchell institutions inevitably reveals the extent to which officially sanctioned mental health practitioners and workers within the private health sector understood questions of race, political domination, inclusion and their own position in South Africa in the later years of apartheid. In turn, it leads to questions about the very nature of psychiatry in South Africa. What influenced psychiatric practice in South Africa? What deemed an individual mentally "ill" and/or "disabled?" How were diagnoses applied? To what extent did socio-political forces shape practitioners' notions of "mental health" or "normality?" Indeed, underlying many of the contradictions within the Smith Mitchell institutions was confusion over the very definition of mental health. As we shall see, differing ideas about mental wellbeing existed among various levels of government and practitioners, and the distinction between mental disability, physical disability and mental illness was often unclear.

Background

A wealthy entrepreneur, David Tabatznik, established Smith Mitchell in 1948 just after the Herenigde (Reunited) National Party won its election. It had begun as a company that provided beds first for white then black tuberculosis patients.[3] Smith Mitchell later adjoined or converted these TB hospitals to mental sanatoria. In 1962, when Alistair Lamont, the Commissioner of Mental Hygiene, faced extensive overcrowding in state-run mental hospitals, he approached Tabatznik to temporarily provide psychiatric beds until the state could create more beds or build new state hospitals. In April 1963, Smith Mitchell opened its first mental institution. As the Department of Health (DOH) never built state mental institutions for black patients, Smith Mitchell gradually became a permanent fixture in the mental health sector. By the mid-1980s, it had opened about 20 hospitals throughout South Africa that provided over 12,000 mental care beds for patients, three of which were in homelands (Tabatznik c1996, 5, Annexure B).[4]

NameNo. of Beds after 1973
Black
Allanridge, Welkom, OFS (1974-85)400
Kirkwood, Port Elizabeth, Cape (1979) A-Section700
    Kirkwood B-Section (1985) 
Randfontein South Complex, Randfontein, TVL (1963) 
    i) Homelake (1964)280
    ii) Millsite (1968)175
    iii) Randfontein (1964)760
    iv) Randmore380
    v) Randaf (1963)1575
    vi) Randwest (1963)1130
    vii) Randwest (children)400
Waverley Sanatorium, Germiston, TVL (1972)520
    Waverley (children)200
 
Homeland
Ekuhlengeni, KwaZulu Natal (1975)1300
    Ekuhlengeni (children) 
Poloko, Thaba 'Nchu, Bophuthatswana (1973)1200
    Poloko (children) 
Thabamoopo (1972)1000
    Thabamoopo (children) 
 
White
Hillbrow Lodge Halfway House, Jhb, TVL (1974)60
Majestic Hotel, Kalk Bay, Cape (1974-82)170
Simmer, Germiston, TVL (1969-78)255
Struisbult, Daggafontein, TVL (1961-1987)100
Turrets, Johan[n]esburg, TVL (1974-1978)131
Witpoort, Brakpan, TVL (1978)386
 
Indian and Coloured
East Rand, Benoni, TVL (1975)450
    East Rand (children)50
Springfield, Durban, Natal (1964)250
Table 1

Agreements between the DOH and Smith Mitchell at first were informal and the earliest written contract was only in 1975, almost twelve years after the first institution opened. Despite the large number of beds that Smith Mitchell provided and its continued expansion, the company never signed a long-term agreement with the national or homeland governments. Rather, the Nationalist government, insisting that the contracting out of long-term patients to Smith Mitchell was only temporary, renewed the contracts on an annual basis (Tabatznik c1996, 5). Terms for most hospitals were the same, except for the patient daily tariffs that varied between hospitals. Tariffs in the homeland institutions were particularly low and the company negotiated them annually with the Department of Bantu Administration and Development (BAD), while the DOH formed the overriding contract.[5] The company charged a per diem rate per patient that was almost half of the patient cost in state hospitals. For example, from 1974 to 1975, state hospital daily costs ranged from R2.13 ($2.88) to R15.04 ($20.39) per patient per day depending on the race of patient (black patients were designated lower rates) (Republic of South Africa 1978). The daily rate paid to private mental institutions by the Nationalist government the same year ranged from as little as R1.22½ ($1.65) to R4.31 ($5.85) per patient per day (Republic of South Africa 1975).[6]

The "temporary" status of Smith Mitchell institutions was somewhat conducive to all parties, allowing Smith Mitchell the flexibility to increase per diem rates on an annual basis while the state was able to retain control over the mental health care of patients. The temporary status also meant, however, that Smith Mitchell remained vulnerable to the policies of the DOH. The number of patients accommodated in Smith Mitchell facilities, most of whom were transferred from state or local general hospitals with the exception of a few children directly admitted from the community, were controlled by the DOH.[7] The DOH also appointed most of the employees working within Smith Mitchell facilities. State appointed or seconded staff, which included psychiatrists, general practitioners, qualified nurses and nursing assistants, were paid by the government and were a way that the government could retain some control over the treatment of patients, while also ensuring that Smith Mitchell would not poach the state hospitals' most capable staff. The complex role of seconded staff within the institutions will be discussed in further detail below, but suffice to say that their presence did enable the DOH to exert further influence over company procedures.

Yet Tabatznik was able to maintain command over his company by recruiting Nationalist party ministers into the various boards of directors of each institution. Smith Mitchell had approximately 89 subsidiaries in South Africa, many of which were mental sanatoria each with its own board of directors (Henning 1976). In the 1970s, Connie Mulder, the MP for Randfontein and Vorster's Minister of the Interior and of Information who later had his career ended by the "Muldergate" information scandal of the late 1970s, was accused of profiteering from his holdings of shares and his directorship of one of Smith Mitchell's largest institutions, Randwest. Mulder resigned from Randwest but apparently kept the shares (O'Donoghue 1989, 23-24). Although Tabatznik denied Mulder's financial interest in the company, he did confirm that other members of parliament had holdings in the company; the MP for Bloemfontein, Mr. P. L. S. Aucamp, was Director of the Smith Mitchell subsidiary, Poloko Sanatorium (Pty) Ltd., and a former Cabinet member, Mr W.A. Maree, and MPC and Johannesburg City Councillor, Mr. Alf Wideman, were also directors of the company (Menge et al. 1975a). Indeed, Smith Mitchell used its shares and directors' fees to secure political support.

It was not uncommon for medical companies to financially back or give gifts to National Party members, and admissions by doctors and ministers of receiving pay-offs from pharmaceutical companies were common (See Anonymous 1983c; 1983d; 1983e; A doctor 1983; Rees 1983; Allen 1983). In the 1980s, Tabatznik was one of the directors of South African Druggists. In 1983, its subsidiary companies, Labethica, Banstan Holdings and Copybrook Investments were implicated in a "gift-giving" campaign that included the Registrar of the Medicines Council and the Deputy Director of Hospital Services in the Transvaal. After initial denials, the company eventually admitted to funding a six-week overseas holiday for Dr G. Schepers, Transvaal Deputy Director of Hospital Services, and his wife (Anonymous 1983d). Tabatznik, on the other hand, denied his involvement stating that as a non-executive member of the South African Druggists he had no knowledge of any gift giving campaigns (McIntosh 1987a and 1987b; Tabatznik 1987; Anonymous 1983a).

Similarly, in 1986, the South African Medical and Dental Council of South Africa investigated allegations that Protea Pharmaceuticals, along with RX Pharmaceuticals with which it had an agreement, was paying kickbacks to doctors for prescribing their drugs. Tabatznik had holdings in the Australian pharmaceutical drug companies of Alphapharm Pty Ltd. and Protea Pharmaceuticals (a subsidiary of Tabatznik owned Protea Holdings in South Africa). It was alleged that Alphapharm and Protea Pharmaceuticals used inadequately tested drugs under investigation in Australia on Smith Mitchell patients (Citizen's Commission of Human Rights 1987, 14). Indeed, the pharmaceutical companies with which Tabatznik was involved did provide all the drugs for the Smith Mitchell institutions and many state hospitals. The investigation was later dropped and Tabatznik himself denied any direct connection to Alphapharm. However, he did state that his son, Anthony Tabatznik and other family members held shares in Alphapharm. Tabatznik also admitted to having been a director of Protea Holdings, but had resigned ten years earlier (Platman 2003; Citizen's Commission of Human Rights 1987; Smith 1987). All in all, David Tabatznik was reported to be a director of approximately 123 companies, some of which were general investment, multinational medical and pharmaceutical companies with subsidiaries in South Africa and in other countries such as Israel, Australia and New Zealand His private holdings were worth at least R120-million (Carte 1987). Tabatznik's substantial wealth and his likely use of "gifts" to Nationalist party members meant that he was able to gain lucrative government pharmaceutical contracts and continue to expand the Smith Mitchell conglomerate.[8]

Conditions and Treatment in Smith Mitchell Institutions

Although the situation varied among Smith Mitchell institutions, in general, conditions, particularly for black patients, were appalling and hospitals were mainly places of custody. For the most part, the company really did more to create psychiatric disturbance among their patients than offer any form of restorative therapy. Company institutions were mainly abandoned remote mine compounds and most were made up of blocks of large square buildings with a high barbed-wire fence surrounding them. As a 1975 newspaper article described it: "The atmosphere of compound rather than hospital clings to the uniformed guard at the entrance" (Menge et al. 1975b). Many historians have written about the substandard living conditions in which mineworkers lived in the compounds. In 1972 Francis Wilson, for example, described the older mine compounds as follows:

The compounds which house…99% of the labour force vary from very old pre-first World War buildings with rooms housing 50 or more men living like sardines in double-decker concrete bunks to modern hostels housing between 12 and 20 men in dormitories that compare not unfavourable with those of a white boarding school…In compounds built before 1939 beds are not supplied and men either sleep on the concrete bunks or they have to make, or buy from their predecessors, wooden beds specially designed to fit the short bunks…On the older mines there are no dining rooms and men either eat outside or in their dormitories which generally have a coal stove for heating purposes.…The organisation of a compound may be described both as authoritarian and as paternalistic…The size of compounds varies but all are very large by any standards (10).[9]

Because of the so-called "temporary" status of these sanatoria, Smith Mitchell at first did few upgrades to the abandoned buildings other than remove the concrete tiered bunks that had served as beds for the miners. Thus, many of the poor conditions as described by Wilson in which mineworkers had lived were transferred to mental patients. Patient buildings, particularly those accommodating black patients, remained impersonal, poorly ventilated, dilapidated, crowded and unhygienic. Wards housed on average forty patients, with some at the larger institutions accommodating as many as 250 patients in a ward. Most patients in Smith Mitchell institutions did not have their own beds. Patients initially had to sleep on coir mats on the floor. In the mid-1970s, these were replaced by four-inch foam and rubber mattresses and shortly thereafter Smith Mitchell began to introduce beds (Menge et al. 1975b). However, many black patients were not provided with bedding (Platman 1984 Ekuhlengeni, 3; Waverley, 21). Clothing was inadequate. Black patients, had two-piece pyjamas to wear during the day, and females wore, what the American Psychiatric Association described as "sack-type dresses" (Pinderhughes et al. 1978, 16). Few patients had shoes and infestation of warts and athlete's foot spread among them.[10] During the winter, the hospitals failed to provide adequate clothing and patients often complained of the cold. Moreover, heaters frequently did not work and electrical problems were common. Hot water geysers did not function properly and many patients had to take cold showers in the winter (Platman 1982 Poloko, 7; Smith Mitchell 1982b). Bathing facilities in general were poor and lacked privacy. At the bigger institutions, patients lined up at a central outside shower, undressed and a little liquid soap was placed on their heads before they went into the shower. Standing naked in a large crowd, staff herded patients into communal showers, where they washed themselves (Platman 1982 Randwest, 5; 1984 Millsite, 26).

Toilet facilities were also sub-standard and frequently the cause of disease. While toilets for whites and Coloured had doors and toilet paper, black wards often made do with buckets. In some black hospitals, toilets were outside the wards in a central yard and these were mainly rows of squat toilets with no doors or seats (Platman 1982 East Rand, 4; 1984 Randfontein, 19). Flush toilets, when installed, frequently did not flush and there was often no toilet seats or toilet paper (Platman 1982 Randfontein, 6; 1984, 10). Sewage gutters were open and patients sometimes used them as urinals, which made them sites for the spread of disease (Platman 1984 Millsite, 26). In most black hospitals, there were neither sinks nor taps near the toilets and soap and towels were not provided for patients to wash their hands (Pinderhughes et al. 1978, 15; Platman 1982 Poloko, 7; 1984, 3-4). As patients often took food from pots with their hands, food was unsanitary (Platman 1982 Ekuhlengeni, 3; Poloko, 3). Moreover, meals were often inadequate and worse than the food provided for black miners in the 1930s and 40s who had at least received a "scientific diet" for the heavy manual work they performed.

Some patients worked in what was called "industrial therapy" programmes in on-site factories assembling asbestos heaters and plugs, constructing hair accessories and watch labels, or making coat hangers, clothes and shoes for patients.[11] Patients also created crafts, such as toy animals, baskets, macramé items or potted plants, all of which were sold to the general public (Platman 1982 East Rand, 4; Randfontein, 2; 1984 Poloko, 12; Waverley, 22; Millsite, 17) However, like prisoners in South Africa's jails at the time, most patients worked on the grounds of the facilities. Many worked in the gardens, wards, kitchens, laundry and even in the adjoined TB sanatoria (Platman 1984 Randfontein, 10; Millsite, 7; Cronje 1984, 1). Between thirty and fifty percent of the patients worked within the hospitals, saving the company a considerable amount of money.[12] Patients were paid very little to nothing for their labour. Some were paid in tobacco, others in tokens that they had to spend at the onsite tuckshop, which charged higher prices than the shops in the closest towns. By 1984, institutions began remunerating some patients and patients could be paid between 50 cents ($0.42) and R8 ($6.84) a month, depending on the type of work they did.[13] TB patients fulfilling the same duties as mental patients in their sanatoria were paid considerably more, between R12 and R16 ($10.26 to $13.68) a month, while white patients could be paid up to R30 ($25.65) a month. Labour practices therefore reinforced both racial and mental discrimination (Platman 1984 Waverley, 30; Witpoort, 2).

At night, staff locked all patients in the wards in order to stop them from wandering off, often without adequate on-duty staff for the evening (See for example, Platman 1984 Ekuhlengeni, 4; Poloko, 2-4). Some more "chronic" patients were locked up in wards not only in the evenings, but also for most of the day. So-called "difficult" patients were locked in seclusion rooms that had no toilet facilities, no windows through which staff could see the patients, and were dirty. Many staff who used "seclusion rooms" as a form of discipline subjected patients to physical abuse as well. Sexual abuse was also evident, both on the part of patients and by staff. The numbers of patients sexually assaulted by staff or other patients is not known, mainly because patients' complaints received little credence and many incidences remained unreported. Patients had practically no opportunity to voice complaints as practitioners and administrators spent little time with them, and their families did not have regular access to them. Both physical and sexual abuse by staff could continue unknown for many years. Staff and superintendents seemed aware of the predominance of sexual activity, but took few steps to investigate it.[14] Instead, female patients either were "sterilized" or were put on the birth-control pill, had IUDs or were given the controversial birth control injection of Depo-Provera (Platman 1982 Poloko, 2).

Medical care was poor. On average, general practitioners spent a few hours a day at the hospitals treating patients within the hospital clinics. Most doctors spent very little time at the institutions. Death rates were high and frequently deaths went unexplained.[15] Patients with easily treatable illnesses, even if visiting physicians would accurately diagnose them, rarely received medications such as antibiotics, and many died unnecessarily (Pinderhughes et al. 1978, 11).

Psychiatric care was even more deficient than general medical treatment. Psychiatrists' [sic] rarely worked full-time at company facilities. They usually served several institutions and held university appointments as well (Platman 1984 Waverley, 27). Consistent reviews were rarely done and many patients retained the same diagnosis as when they were first admitted (Platman 1984 Waverley, 27). Patients were also over medicated and harmful combinations of drugs were often administered. For those psychiatrists who attempted to see patients regularly, they simply could not cope with the large workload.

To the extent that patients were treated at all, it was mostly by nurses and nursing assistants. However, a "gentleman's agreement" with the DOH involved the company's agreement not to recruit psychiatric nurses in government service" (Cronje 1982a, 3). Chronic shortage of nurses throughout the health system meant that Smith Mitchell had to make do with inexperienced nurses and those without psychiatric training. Although the DOH granted Smith Mitchell higher staff/patient ratio, these were rarely met. Because of the stigma attached to psychiatric patients, many general nurses did not like to work in psychiatry. The working conditions were more difficult than in general medicine (Platman 1984 Ekuhlengeni, 28). The job was physically demanding and intensely stressful psychologically. Moreover, staffing problems were compounded by apartheid policies. Smith Mitchell was strongly encouraged only to hire staff members who were from the same ethnic group as the patients, or who were citizens of the designated homeland in which some of the institutions were based (Smith Mitchell 1974). In the 1960s, the government also directed that white patients be solely under the care of white nurses. Because of the difficulty of finding adequate numbers of white nurses, this prohibition was dropped in the mid-1970s as long as the company made every effort to obtain white staff and that white patients indicated "in writing that they have no objection to be nursed by black staff" (Gilliand, 1976; Cronje 1982b, 4). There is no evidence of white patients granting such permission, but black staff did become more evident in white institutions.

If patients had any capacity for self-reliance, they soon lost it in the regimented world of the institutions. Although Smith Mitchell began what they called occupational therapy programmes in the 1980s that taught patients the basics of "self-care, exercises, color concept training, transportation, sports and recreation," the lack of occupational therapists and staff meant that even these cursory programmes were extremely limited (Platman 1984 Poloko, 12). For example, Platman who visited the institutions regularly in the 1980s reported of patients that could have used some sort of occupational therapy, but due to a lack of staff and appropriate programme, they remained incapable of taking care of themselves. He described the patients in one ward as follows:

There are young late adolescent retarded girls…who drag themselves around and yet do not appear to have a reason for not being able to walk. There is a young hydrocephalic girl…who has reasonable intelligence and flaccid paralysed legs probably from spinal damage. Her arms are also effected [sic] and yet she is capable of using both arms and hands. Yet she is fed when she could be taught to feed herself. She probably could be taught to drive a suitable wheelchair and yet she is being made more dependent. This is very sad in view of her potential long life. There are many more examples like these patients and each one requires a careful individual multidisciplinary review (1984 Randfontein, 13).

Patients were placed in wards according to a crudely graded system. Four categories were set up depending on the amount of effort a patient was to staff. "A" type patients were those patients who showed no signs of psychosis. These patients were well aware of their surroundings and had insight into their condition. "B" category patients were those who were not obviously psychotic, but needed help with some activities. B type patients could easily be promoted to the A category. "C" type patients were those that "looked" mentally disturbed and were not as aware of their surroundings as the previous categories. "D" category patients included patients who required special nursing such as those who were incontinent, physically disabled or blind (Smith Mitchell, 1978). The indistinctness of these groups reveals the confusion that practitioners and staff had between mental acuity and psychosis, and physical and mental ability. Indeed individuals showing no signs of psychosis or those with physical disability could easily find themselves swept into the institutions. For instance, many Africans with limited intelligence due to chronic malnutrition from childhood or blind individuals with no signs of mental disability were placed in long-term care. As social services for Africans were not a main priority of the apartheid government, and the government had means other than mental institutions to control the black majority, such as the military, police and prisons, most who ended up in Smith Mitchell institutions were those who were difficult or inconvenient to leave loose in the streets.[16] Trends in community psychiatry that began in the 1940s in South Africa as I have argued elsewhere (2004), really only affected whites in South Africa and in turn perpetuated the use of these private institutions. Blacks were rarely diagnosed with short-term mental disorders and psychiatric diagnoses were racialised. Psychiatrists' biases meant that they would more likely diagnose white patients with short-term illnesses, such as depression, and blacks with more long-term disorders, such as schizophrenia. The difference in diagnoses could have been because only those blacks that caught the attention of the government would have been attended to. However, the biased views of the practitioners, many of whom saw blacks as mentally inferior to whites and more likely to need long-term care, also affected diagnoses. Black patients rarely benefited from community psychiatry programmes. Company institutions therefore became a place where the government and practitioners could warehouse problematic black individuals for long periods away from society.

Overseeing these custodial institutions were divisional and hospital superintendents. These men (and all of them were men) were usually former public servants sympathetic to the Nationalist government's initiatives. They had held jobs as former staff sergeants in the South African Defence Force, former prison wardens, town clerks, or BAD administrative officers (Platman 1982 Poloko, 1; Ekuhlengeni, 1; 1984 East Rand, 6; Poloko, 6; Witpoort, 2; Randfontein, 21). Few had medical or psychiatric training. Since the company was in the business of simply warehousing people, it is not surprising that they hired former prison wardens and other types of custodial staff. Nor is it surprising that these administrators rarely challenged the sub-standard conditions for black patients or the policies forwarded by the apartheid government. Indeed, most accepted the racial, gender and class endemic in the National Party (Platman 1984 Kirkwood, 4; East Rand, 6).

State appointed practitioners and nurses also seemed to simply accept government and procedures that created the substandard conditions for patients. Psychiatrists and general practitioners never took any unified overt stance in opposition to the regulations creating poor conditions for black patients, nor did they attempt to make changes through their representative body, the Medical Association of South Africa (MASA) established in 1927.[17] MASA failed to investigate or concern itself with Smith Mitchell institutions. As the Health and Human Rights Project, which was initiated jointly by the Trauma Centre for Victims of Violence and the University of Cape Town, argued, MASA's main concern was "maintaining the security of the State above human rights considerations" (Truth and Reconciliation Commission 1997, 78). MASA itself recently acknowledged that it was "a part of the white establishment…and for the most part and in most contexts, shared the worldview and political beliefs of that establishment" (Truth and Reconciliation Commission, 1998, 146).

Complaints and suggestions for improvement from MASA members working in Smith Mitchell institutions, all of whom, with the exception of one Indian doctor, were white, were also sporadic and rarely challenged the policies of the government or the company. Psychiatrists and general practitioners worked part-time and rarely spent enough time within the institutions to form any working coalition. Tensions also existed between psychiatrists and general practitioners who were often confused about their responsibilities and their working relationships with each other. One psychiatrist at Waverley complained that no communication existed between general practitioners and psychiatrists at all. No group meetings were held, and often differences of opinions existed over the treatment of patients, particularly epileptic patients whom most general practitioners felt were their jurisdiction.[18] When both psychiatrists and general practitioners worked at the same institutions, psychiatrists were held responsible for patient well-being, but with little interaction between the two, often they became critical of one another's treatment of patients (Smith Mitchell c1975). The fact that some company-paid practitioners worked within the institutions caused further conflict. As Platman relates, one nursing staff manager for various institutions described the tenuous relationship between a state-paid psychiatrist and a company-paid general practitioner:

She stated it was not a good relationship and they had many fights over the new medical record. She found herself caught between the wishes of psychiatrist and the health department and those of Dr. Sachs. Unfortunately Dr. Sachs is anti-state. However as a nurse she has the state and nursing council to please (1984 Waverley, 28).

The above description is an example of the multifaceted and somewhat tenuous relationships between the various levels of state-paid and company staff that existed within the mental institutions, particularly between psychiatrists and general practitioners, but also between nurses and psychiatrists.

[Figure 1]

As can be seen from the above organizational chart, head nurses and nursing staff, the majority of whom were black women, held the most difficult position of all within Smith institutions having to deal with the often conflicting and contradictory pronouncements of the state, company, superintendents, general practitioners, and psychiatrists, while trying at the same time to cope with the demands of their patients.[19] Nurses performed most of the labour within the institutions and constituted the majority of the employees, but had the least say in the overall policies of the institutions. As Shula Marks points out in Divided Sisterhood, nurses throughout South Africa were "subject to highly contradictory political and social pressures" and these pressures were just as prominent in the semi-private world of contracted psychiatric institutions (1994, 10). In the 1960s, with the government's 1950s onslaught against political dissent and the banning of the ANC and PAC, the complaints of nurses went largely unheard. Up until the mid 1980s, black nurses had little official influence on government policies except through the South African Nursing Council (SANC) and its associative body, the South African Nursing Association (SANA), which the DOH established in accordance to the Nursing Act, No. 45 of 1944. The SANC and SANA's leadership was white and its mandate was to control nursing standards and education on behalf of the government, not deal with labour issues or concerns of its black workers. Indeed, the SANC and SANA staunchly penalized any nurses who did not adhere to its policies or who showed any form of political dissent (Marks 1994, 166). Those working in Smith Mitchell institutions had even less say about government and company policies and had to conform if they wanted to keep their jobs. No organised labour union existed for South African nursing staff and even in the 1980s, when more organized forms of protest and strikes were erupting around the country, nurses working within Smith Mitchell institutions were never represented. Without an organized union, there were limited opportunities for Smith Mitchell nursing staff to voice their concerns without trepidation. The remote areas in which Smith Mitchell institutions were located meant that it was difficult for individuals to organise with staff from other institutions. Moreover, the mixture of state-paid and company-paid staff meant that they did not have a shared employer to which they could voice their complaints; nor did they necessarily have the same concerns. Company and seconded employees had different salaries, work guidelines and benefits, and they even lived in separate areas (Platman 1984 Allanridge, 3). Without collective representation, many staff members were apprehensive of communicating their individual complaints and they believed that if they did give suggestions, they would not implemented (Platman c1982, 2). The lack of a coalition among Smith Mitchell nursing staff also was affected by the fact that many nurses and assistant nurses became institutionalized themselves and over time failed to recognise the sub-standard conditions in which they and patients worked and lived. Sometimes the line between staff member and patient blurred, particularly as many patients worked side-by-side with nurses and domestic staff and staff lives revolved around the institutions.

Yet, not all of those working in the institutions remained mute about their views or were completely powerless to generate change. Rather, some took advantage of various surveys to express their discontent against the company, psychiatrists, general practitioners, administrators and to some degree, the state. From the late 1970s, investigations by the Church of Scientology's Citizen's Commission of Human Rights, the American Psychiatric Association and especially Dr. Stanley Platman became the principle means by which staff members could convey their dissatisfaction of governmental and company policies and could initiate improvements within the institutions. It is to these investigations that we now turn.

International Investigations and the Effects of Criticism

In 1975, thirteen years after Smith Mitchell opened its first mental health facility, Fleur de Villiers wrote the article that I quoted at the beginning of this paper. She highlighted the appalling conditions within the Smith Mitchell hospitals and accused the company of profiting from psychiatric illness. A month later, the Rand Daily Mail published a series of articles describing the sub-standard conditions and treatment within both public and private mental hospitals in South Africa. In 1976, Scope magazine published a series of articles about an ex-psychiatric patient's experiences within mental institutions in South Africa that eventually caused debate within parliament (Republic of South Africa 1976a). Internationally, newspapers such as The Observer in London, Dagens Nyheter of Sweden, the New York Voice also described the atrocious conditions within South African mental institutions (Anonymous, 1976, 6; Wästberg, 1976a; 1976b; 1976c; Deeley 1979; O'Donoghue 1989, 23-24).

These articles originated from investigations and articles written by the Church of Scientology's Citizen's Commission of Human Rights (CCHR), established in 1969, that staunchly opposed psychiatry and psychiatric drugs in general. CCHR reports described Smith Mitchell facilities as "human warehouses" and "labour camps" where patients were forced to work in order to increase company profits. They also accused the government of using these institutions to detain opponents of the apartheid system (See Citizen's Commission of Human Rights 1976). The CCHR had self-promoting reasons for attacking the psychiatric field (Scientology dismisses psychiatry as a valid science and promotes its own doctrine as a means to obtain mental clarity) and its accusations are often very difficult to substantiate. However, the CCHR claimed that it obtained most of its information from staff working within the institutions. Nurses, in particular, I was told, have always been an important source of information. Indeed, CCHR's articles often quoted anonymous nurses as a source.[20] Other newspaper articles by international reporters, who obtained much of their information from the CCHR, also quoted staff members' specific complaints about the substandard conditions for patients.[21]

Although much of the CCHR's evidence cannot be substantiated, it was known for its ability to obtain information, albeit at times unreliable. The CCHR even broke into government offices and stole files (Republic of South Africa 1972, 16-17). Despite its self-promoting reasons for attacking the psychiatric field, the CCHR played an important role in publicizing the overall substandard conditions in the hospitals and began a succession of investigations that would ultimately enable some staff to force changes in the institutions.

In the immediate years after the publication of the articles and the CCHR's investigations, the government responded in a contradictory manner. On the one hand, the government attempted to seriously thwart the ability of individuals to express their concerns about the mental institutions. In 1976, the government enacted the Mental Health Amendment Act, similar to the interdictions in the Prison's Act, that prohibited the publication of any photographs, sketches, or information regarding mental patients or institutions and declared violators "guilty of an offence and liable on conviction to a fine not exceeding one thousand rand or to imprisonment for a period not exceeding one year," or given both a fine and imprisonment (Republic of South Africa 1976b). While the act was promoted as a means to protect patient privacy and curb false accusations, it was really about shielding both the government and the company from public scrutiny.[22] To ensure that individuals adhered to the act, the Bureau of State Security (BOSS) consistently placed pressure on journalists and CCHR members threatening to publish material.[23]

At the same time however, in opposition to the government's staunch stand against publication of information about mental hospitals, the criticism by the media and the CCHR prompted the DOH to attempt to show that the allegations were unfounded. In June of 1976, the Minister of Health, Dr. Schalk van der Merwe, invited the International Committee of the Red Cross (ICRC) and the World Health Organization (WHO) to inspect South Africa's mental institutions (Politieke Beriggewer 1976; Korrespondent 1976). The ICRC, whose main concern at this time was the treatment of convicted and political prisoners, conducted a preliminary investigation into whether any political detainees were held in state and private institutions. As the ICRC found no evidence to suggest that political prisoners were detained in psychiatric institutions, it conducted no formal investigation (International Committee of the Red Cross 1977, 18; 1978, 17).

The WHO, which the United Nations Special Committee Against Apartheid had also requested to conduct a review of Smith Mitchell institutions, decided against visiting South Africa, stating that the 1976 Amendment Act would taint inquiries and distort any investigation. Instead, it wrote a report based on House of Assembly debates, government reports and medical publications. Its scathing report discussed the atrocious conditions in the hospitals. It condemned the custodial nature of the institutions and stated that in general, the institutions were "open to abuse" and were manifestations of apartheid (United Nations Centre Against Apartheid 1977, 25). Soon after the release of the WHO report, the Nationalist government began publicly talking about the phasing out of the use of private mental institutions. In 1977, the government released a press statement to local press stating that it would allocate sixty million rand to the building and expansion of state-run black institutions that would replace private institutions and gradually phase out the use of beds in private hospitals (Our Correspondent 1977; Anonymous 1977). This plan was never implemented and no state expansion programme for black patients was ever undertaken. Thus, criticisms of South Africa's use of private facilities for black patients persisted, particularly in the international press.

In 1978, in an attempt to quell allegations of human rights abuse raised in the WHO report, Smith Mitchell invited the American Psychiatric Association to visit their institutions. Soon thereafter, the DOH backed up this invite with an official invitation to visit all mental health facilities in the country. Unlike the WHO that rejected the invitation, the APA accepted under the condition that they would not be charged under the 1976 Amendment Act. In September 1978, a committee made up of four members arrived in South Africa prepared to investigate all types of South Africa's mental health institutions. Once in South Africa, however, the DOH told the committee that they could not conduct detailed inspections of state institutions. The APA therefore based its report on their visits to nine Smith Mitchell institutions and a few guided tours of state and general hospitals. Its findings echoed many of those of the WHO. They found evidence of unnecessarily high death rates in the hospitals, unsatisfactory care, abusive practices, deficiency of professional staff, improper use of drugs, and general exploitation of patient labour. But they found no evidence of the improper institutionalization of black dissidents or abuse of ECT, accusations that had initially formed the main basis for the APA's investigation (Pinderhughes et al. 1978, 5-6).

The APA's report was the first in-depth analysis of private mental hospitals and apartheid in South Africa based on on-site investigations. The APA had the opportunity to interview staff, patients and administrators on the daily affairs of the institutions. Their report showed that staff were concerned about some policies and practices perpetuated by apartheid: "Indeed, we were heartened," wrote the committee, "to discover concern about and criticism of these abusive apartheid practices among psychiatrists, physicians, medical students and nurses within South Africa" (5-6). The APA's investigation was limited, however, and while it publicised the racial differentiation that existed within the hospitals and highlighted apartheid's effect on the daily workings of the institutions, it did nothing to stop the DOH's continued movement towards the use of private mental health care. As Sean O'Donoghue (1989) points out, privatization of long-term care was "even more enthusiastically pursued" after 1978.

The WHO and APA criticisms led the Nationalist government to suggest that Smith Mitchell conduct its own surveys. Although the company conducted its own short reviews of its institutions that reported to the head office, David Tabatznik with the help of his brother, Bernard Tabatznik, a cardiologist living in Maryland, decided to recruit an American psychiatrist, Dr. Stanley Platman, to conduct comprehensive internal reviews of the facilities. Platman was then the Assistant Secretary of the Mental Health and Addictions centre for the State of Maryland. Platman agreed under the condition that he and his wife, Vera Thomas, a South African born midwife, were given full access to institutions at any time of the day or night and that they paid his expenses. In 1981, Platman and Thomas conducted their first review. Despite the unfavourable conclusions of their reports and some resistance by psychiatrists to their visits, Tabatznik invited Platman and Thomas back five more times for reviews, the last of which was in 1990.[24] As Tabatznik ensured that superintendents and staff gave Platman access to all files, free reign to drop in to any facility any time day or night and consent to interview any staff member, patient and administrator, Platman's reports and subsequent superintendents' responses offer a rare glimpse into the world within the institutions. They reveal surprisingly critical and candid accounts of conditions in the facilities by some staff members, and were generally well received by Tabatznik and Andre Cronje, the group superintendent.[25] Many staff were aware of this positive reception. In a letter to Vera Thomas, Rian Venter, a nurse working at one of Smith Mitchell institutions wrote: "Why get somebody to come and try get to the root of things? I have decided to come to a positive conclusion — that somebody up there has realized all things are not what they are dished up to be. That somebody up there has decided the patients are perhaps entitled to a better deal by the Company" (1982). Tabatznik was well respected among staff and practitioners and they were aware of the changes that were implemented after the surveys. As Venter (1982) wrote, some staff felt that "now we can get more out of them because they think the Platman's will be impressed — and if they threaten to come often enough we will get all we have been asking for." Therefore, Platman's reports became an effective vehicle for staff of all levels to initiate change.

Concerns voiced by the various levels of staff showed the different priorities of each group. Many nursing staff complained about lack of patient care. Some showed frustration at the difficulty of discharging patients; others objected to the limited medical and psychiatric coverage and noted the poor facilities and conveniences given to patients. Many also objected to their own working conditions and complained about the substandard living conditions for themselves and the lack of social activities (Platman 1985 Thabamoopo, 11). Nurses also frequently commented on the lack of staff in the institutions and complained about being overworked (Platman 1982 East Rand, 4, 17; Thabamoopo, 11). Other complaints were about general racial differentiation, such as when some black head nurses complained of having to eat lunch separately from the white staff or when superintendents did not know black staff's names (Platman 1982 Poloko, 2; 1984 Allanridge, 18). Others objected to differential pay scales. Even though the company could set its own wages and it usually paid more than the state, racial disparity in pay continued. For example, in 1978, it was estimated that black nursing assistants received half the salary of white nursing assistants (Bloch). In 1984, this inequality continued. The head black nurse at Randfontein earned R907 ($775.46) net annually, while the white head sister at Allanridge earned R1000 ($854.98) a month (Platman Randfontein, 7; Allanridge, 2).

Those at the higher levels, such as practitioners and superintendents on the other hand generally complained about the daily administration of the hospital and the discord between each other. Practitioners and superintendents of the institutions described a lack of communication among practitioners and nursing staff, while superintendents expressed frustration that practitioners left them out of decisions concerning policies and patient care (Platman 1982 Poloko, 2). They also complained about the DOH's regulations concerning patient transferrals, funding and general procedures, while superintendents voiced their discontent that they had no jurisdiction to discipline or control the actions of seconded staff (Smith Mitchell 1974, 3; Platman 1982 Poloko, 2).

Many of the concerns raised by staff led to some, albeit superficial, improvements in Smith Mitchell institutions. Improvements over the years were far from comprehensive, but they helped quell criticisms of the institutions and made the hospital environment more tolerable. Television sets were introduced, pictures were put up, old cars put in the playground for children, patients were given stationery, food and hygiene standards improved (Platman 1984 Poloko; Randfontein, 19; Waverley, 17). More activities were planned and patients were given better clothing (Smith Mitchell 1982a; Platman 1984 Poloko, 34). Some wards were renovated. Toilets and bathrooms were gradually decentralised and upgraded, new boilers were installed and patients had more access to hot water (Platman 1984 Waverley, 20). Ceilings were installed in the wards, floors were tiled, and drains were closed (Platman 1985 Thabamoopo, 1). Those invited to visit the institutions in 1987 commented on overall good conditions of the institutions. Helen Suzman commenting on Smith Mitchell's biggest institution stated that "it provides excellent care of the Black patients — young and old — entrusted to it" (Suzman 1987). One doctor stated: "what I saw on our visit, impressed me, especially the dedication of your staff and the standard of facilities" (Barnard 1987). A doctor from the United States, also visited one of Smith Mitchell institutions and argued that he was surprised to find no evidence of the "'shocking conditions' reported by the 1978 American Psychiatric Association investigation" (Crawshaw 1987). The superficial changes made to the institutions did not, however, address the custodial conditions in the hospitals. Just 5 years ago, the Centre for Health Policy at the University of Witwatersrand (CHP) conducted a comprehensive comparative study of public and private institutions in South Africa and found that the contracted institutions still were mostly "institutions for 'control'" and were "producing low quality care at low costs" (Porteus et al. 1998, 211, 219). The CHP, like many before it, called for a "strategic redesign" of these institutions (218).

It must be noted that a quandary existed for Smith Mitchell concerning improvements within the institutions. As buildings were upgraded, the situation within the hospitals often became better than the daily living condition for those in the rural and township areas of South Africa. Psychiatrists and staff continuously reported of cases of patients who should not have been in the hospital, but either chose to stay because their lives were better in than out, or had no other places to go as the local community had no rehabilitation programmes and had insufficient living facilities for these individuals (Platman 1982 Poloko, 4). Indeed, mental diagnoses are not all-powerful, or free from manipulation from "below." While conditions within mental institutions paralleled those within prisons and it is unlikely that many individuals chose to feign mental illness whereby they could be committed indefinitely, it is possible that individuals manipulated the system in order to stay within the institutions. For example, Platman reports of one individual from the Transkei who refused to leave as he felt he was better off in the hospital than in the Transkei. He stated that he was at least fed, clothed, given a roof over his head and was allowed to go into town whenever he wanted (Platman 1984 Kirkwood, 3). Many nursing staff also stated that patients "were better off then [sic] being cared for at home" (Platman 1982 Poloko, 3). Platman himself believed that there were many patients who had "learned [sic] to 'play the game' and spend their time gambling and even apparently are able to satisfy their sexual needs" (Platman 1982 Randwest, 5). While Platman and the staff's views should not be viewed without some scrutiny, it is possible that some used these private sanatoria as an escape from the hardships of everyday life, especially as conditions in surrounding areas deteriorated.

Conclusion

Although Smith Mitchell had a crucial role in the care of black, long-term patients between 1963 and 1989, it never held a "monopoly on madness" as Fleur de Villiers asserted in her 1975 article. Rather, Smith Mitchell ran its facilities as subsidiaries of the apartheid state. Government control was exercised through contractual oversight provisions, directorships and control of appointments. Yet, Smith Mitchell was more than a tool of the apartheid government. It held a paradoxical position within the structure of the apartheid. If its institutions operated as sub-standard places of custody for the DOH, they were also became places of refuge as conditions for the average black person outside the hospitals worsened. Smith Mitchell sanatoria were closed places of confinement in purposefully remote locations, yet their doors remained surprisingly open to inquiries and investigations originating in South Africa and elsewhere. The contradictions inherent in the Smith Mitchell setup were aggravated by the nature of its staffing and administration, which created a confused web of state and company controls and appointments. Like apartheid itself, the company harboured both apologists and critics of the system. Superintendents tended to conform to the values of the white establishment, however they often found their institutional role frustrating and unsatisfactory. Psychiatrists and general practitioners mostly accepted company and state policies concerning patient care, unsatisfactory as they were, yet were simultaneously confused about their roles in the company and in relation to each other. Nurses and nursing assistants, who held the most complex position of all within Smith institutions, were often torn between various company and state employees, the government while dealing with patient demands. Initially opportunities to dissent were mostly stifled by the confused yet authoritarian system. Only with the onset of external review and investigation did the voice of reform within the institution begin to be heard at decision-making levels in the company and the government. Living conditions gradually improved until they began to surpass those in surrounding black rural areas and townships. Ironically, these belated and cursory improvements simply underlined the extent of the immiseration of living conditions for blacks that were the legacy of apartheid.

Bibliography

Endnotes

[1] It must be noted that this paper only deals with those few black patients within government-sanctioned care and does not deal with those under the more community-orientated care of healers who were treating far more patients.

[2] See for example Torchia (1988) and McCulloch (2002). For a discussion on studies of the role of both local and multinational companies in Africa since the end of colonisation, see Hopkins (1987).

[3] In the late 1940s, when tuberculosis had become endemic in the country, Smith Mitchell obtained a contract with the Johannesburg municipality to provide care for the large number of white TB patients crowding Rietfontein hospital, the one central government hospital in Johannesburg that accepted TB patients. Smith Mitchell opened a few TB hospitals that catered to white patients. By 1954, however, doctors were also looking for beds for black TB patients. Smith Mitchell, under the precincts of the apartheid government, utilized abandoned mining compounds in rural areas for black TB hospitals. The company continued to expand so that by 1963, Smith Mitchell was providing 3342 TB beds for different municipalities. As tuberculosis drugs improved and TB became less endemic, many of these TB hospitals closed or were converted into mental sanatoria. However, with many AIDS patients today contracting tuberculosis, TB beds are once again required. Smith Mitchell, now known as Lifecare Inc. still provides TB beds for various provincial governments and in 1994 opened a new TB hospital known as Lifemed that has 175 beds for TB patients (Tabatznik c1996).

[4] This number of mental sanatoria includes Randwest, Randmore, Millsite, Randaf, Randfontein and Homelake, each part of the larger Randfontein Complex. This number excludes all Smith Mitchell TB sanatoria and elderly care facilities.

[5] Departmental responsibility for contracted institutions was not always clear. In 1977 Lage Vitus, Deputy Director of the South African National Council for Mental Health and Chairman of the Society of Social Workers, complained that "the Council had been running into a brick wall for years trying to get some action [for black mentally disabled individuals], but there were at least three Departments involved: Department of Bantu Administration, of Health and Social Welfare, and the buck is passed to and fro" (AG Africa 1977).

[6] All amounts are in Canadian dollars and are based on the exchange rates for the stated year. Records of rates prior to 1973/4 no longer exist.

[7] If patients had to be transferred to public hospitals for general medical care, they were officially discharged and their file sent to a state-run mental hospital. This arrangement was necessary to enable the national government to pay the medical costs to the provincial hospital. Once treatment in the provincial hospital was complete, patients were then returned to Smith Mitchell institutions as new admissions. In this way, the government only paid for the days that a patient stayed in a Smith Mitchell facility. However, the continuous discharge and readmission of patients together with the sheer numbers involved meant that keeping track of patients was difficult (Platman 1984 Randfontein, 5). Cases where patients became lost were common. One such case was of a woman who went to visit her brother in the state-run Sterkfontein hospital in Pretoria in 1974. Upon her arrival, she was told that her brother had been transferred to Randwest Sanatorium. At Randwest, however, she was told that her brother had died in a fire. But the body shown to her was not that of her brother. She never found her brother (Staff Reporter 1977). Platman also reports of "a mother who was looking for her child, who had apparently been transferred to Kirkwood…when 54 patients from the children's unit had been sent. They had apparently sent children who had addresses in the Cape. This child had apparently been sent inspite [sic] of the mother visiting on a two weekly basis" (Platman 1984 Randfontein, 11). Parents were rarely informed of their children's transferral and doctors regularly reported that families lost track of their relatives.

[8] Today, Smith Mitchell is known as Lifecare Inc. and is owned and operated by Afrox Healthcare. It has approximately 10,000 beds for chronically ill, elderly and mental patients all contracted by the South African government (Afrox 2002).

[9] For further descriptions about the living conditions in mining compounds, see Harries (1994), Moodie (1994) and Katz (1994).

[10] Randfontein issued shoes to all of their patients. This meant that the predominance of athlete's foot and warts that existed in those institutions that did not have shoes for all their patients was not found at Randfontein (Smith Mitchell 1982a, 7; and Platman 1982 Randfontein, 3).

[11] The shoe shop at Millsite later closed down due to the poor quality of shoes that the patients produced (Platman 1984 Millsite, 17).

[12] See for example, at Waverley in 1984 where 277 adult patients worked out of 553 (Platman 1984, 12). At Randwest in 1975 over 400 patients worked in the hospital and in the industrial areas. By 1984, this number had increased to 877, so that over thirty percent of all patients were working (Menge et al., 1975b). In 1984 at Ekuhlengeni, over forty-three percent of all patients worked within the institution itself. The Allanridge superintendent estimated in 1984 that the company saved R19,176 ($16,395.04) a year by having patients work in the institution. As Allanridge was one of the smaller institutions with only 350 patients, larger institutions that had a larger patient base to draw its labour from, saved considerably more (Platman 1984, 13).

[13] Poloko began paying patients who worked around the hospital R2 a month. As patients worked five and a half hours a day, six days a week, this meant that patients were paid approximately 1.5 cents an hour (Platman 1984, 6, 12). Patients who worked in industrial therapy at Waverley in 1984 could earn anywhere from as little as 50 cents to R5 a month, depending on productivity. Therefore, on average, patients at Waverley earned R2.16 a month (Platman 1984, 12, 23). At Millsite, average patient wages were R1 a month, ranging from 50 cents to R8 a month in 1984 (Platman 1984, 3-4). This meant that patients were earning 4 cents a day on average. In 1984, patients at Randfontein who made dresses for other facilities were paid between R1 and R6 a month. As it was estimated that 15 patients could make 30 dresses a day, and the institution charged about 85 cents per dress, if the institutions paid patients the maximum amount of R6 a month, it made a minimum profit of approximately R675 a month. (Platman 1984, 17; Cronje 1984, 3; and Anonymous 1984).

[14] One case of a staff member sexually assaulting a patient was at Allanridge in 1982 when a male assistant sexually assaulted two female patients. After the general practitioner conducted examinations of the women and found evidence of sexual assault, the company called the police. While it is not known whether criminal charges were placed, the staff member was fired. Superintendents at other institutions also complained about of sexual activities in the institutions and while some may have been consentual, power relations between staff and patient made consentual sex highly problematic (Platman 1984 Allanridge, 12).

[15] Death rates were higher in winter and for black patients. Randwest reported a death rate as high as 7.2 percent. Mentally challenged children also had a high death rate at 7.8% at Randwest and 6.5% at Ekuhlengeni. The high death rate among children was most likely due to the terrible conditions in which they lived and their more vulnerable immune systems. For psycho-geriatric institutions, these statistics were obviously higher at 15.3%, but as the APA Committee put it, "[m]any of these deaths cannot be attributed simply to old age or to allowing old patients to die comfortably…we saw charts of black patients in their forties and fifties who were apparently allowed to die…" (Pinderhughes et al. 1978, 11-12). The general practitioner at Poloko admitted that many deaths had "no apparent reason" (Platman 1984 Poloko, 23). At Allanridge, Platman examined five charts of some of the younger individuals who had died in 1983, and was confused as to how determinations of deaths were established. He stated: "I believe all these deaths are strange and that the death certificates at best were guess work. It must concern us when young patients die and they either have no prior history of a physical problem or the prior illness is at best difficult to understand" (Platman 1984 Allanridge, 6). Death rates in Smith Mitchell institutions were probably higher than those stated as many of the more serious cases were transferred to local hospitals where surgery was performed.

[16] The CCHR claimed that there were many political dissidents housed in Smith Mitchell facilities. While a few patients were burdensome prisoners and some were perhaps political agitators, numerous investigations by international bodies found no evidence of dissidents in Smith Mitchell institutions and the housing of political dissidents in South Africa's mental hospitals was the exception to the rule. The housing of political dissidents in South Africa's mental hospitals was the exception to the rule.[sic] An example of a political dissenter housed in mental hospitals is documented by Robert Edgar and Hilary Sapire (1999) who tell the story of Nontetha Nkwekwe, a prophet in the eastern Cape whose leadership during the 1920s and 1930s caused alarm among some government officials who ensured that she remained in mental institutions for most of her life. Similarly, the Truth and Reconciliation Commission revealed some cases of political detainees in mental institutions and the participation by practitioners in police investigations (1998, 139-140).

[17] The MASA subgroup, the South African Society of Psychiatrists (SASOP) was only established in 1990.

[18] See for example, Dr. Brett's comments in Platman 1984 Waverley, 3.

[19] Black men also worked within Smith Mitchell institutions as nurses, but were a minority. Smith Mitchell argued that male nurses were essential within these chronic care facilities as they were able to control patients and perform some of the heavy labour that came with care of mentally disabled patients. The shortage of black male nurses in South Africa, however, did not enable the company to hire the numbers of male nurses it would have liked. Thus, the majority of nurses caring for patients were female, although many male domestics assisted them with patient care.

[20] The CCHR also quoted psychiatrists, although not always with their permission. They reported the views of Jan Robbertze from the South African National Council for Mental Health who allegedly argued that the legislation for private mental health institutions needed to be revisited as it did not take into account the large nature of Smith Mitchell institutions (Citizen's Commission of Human Rights 1976). They also met with Lage Vitus, who was Chairman of the Society of Social Workers and Deputy Director of the South African National Council for Mental Health, and who had with [sic] who shared Robbertze's concerns about the Smith Mitchell institutions in an article in the Institute of Race Relations magazine (AG Africa 1977; Vitus 1976). Many practitioners and government members mentioned that the CCHR regularly contacted them or attempted to gain information from them, but few took them up on the offer. In 1969, Dr. E.L. Fisher M.P. of Johannesburg claimed that the Church of Scientology harassed him and he filed a damages claim against Hubbard Scientology Organisations in South Africa (Pty) Ltd. The case was settled out of court (Sachs, Berman & Schneider; Illiquid Case 1968).

[21] See for example Deeley (1975): "In an interview with one African nurse at a Smith Mitchell hospital, we were told that patients escaped 'because they hate the place'. This nurse, who asked not to be identified, said: 'The clothing is disgusting and we always have difficulty in getting blankets. It is very cold in winter yet last year there were no stoves in the rooms…They have no shoes and there is always a struggle to get some for them. In some of the hospitals, they sleep either on mats—which they make themselves, so it costs the hospital nothing—or on wooden boards.'"

[22] One needs only to look at newspaper articles in the 1990s for the degree of staff discontent that actually existed. When many staff members no longer felt the threat of the act, they began expressing their discontent to both local and international reporters. Some nurses even wrote letters to the DOH, voicing their opinions about the substandard conditions in which they and patients work and lived. See Matthes et al. (1991), Matthes (1991), and Erwee (1991).

[23] Shortly after the publication of the Observer articles, the government denied entry visas to all Observer journalists and the South African embassy in London reportedly tried to pressure the newspaper to withdraw its allegations (O'Donoghue 1989, 23-24; Citizen's Commission of Human Rights 1977).

[24] Platman describes his recruitment as being somewhat curious as he was approached by Bernard Tabatznik at a party after hearing that he had lived briefly in South Africa in the 1960s and was married to a South African. At first he thought it was a joke, but then realizing that it was serious, he accepted under the condition that he was given full access and his expenses paid. Over the years, Platman's mandate grew to conduct evaluations of all the Smith Mitchell facilities, give some training to staff on areas of concern, build relationships with medical staff and universities, and attempt to create a "nucleus of a community program that would assist in the discharge of patients and the prevention of hospitalization when possible." He was also asked to consult on various administrative activities, such as the creation of a form for new admissions and the implementation of computer programmes at some institutions. When I asked Platman why Tabatznik would continue to enlist his services over the years despite his criticisms, he stated that he believed that Tabatznik genuinely wanted to upgrade the facilities. (Platman 1983; 2003).

[25] Platman writes: "Mr Tabatznik … committed himself to do all that was economically possible to improve the facilities and public mental health … Much to my surprise my report was received with a positive concern and I was provided detailed reports on how they were reacting to each finding and recommendation" (Platman c1986, 2-4; c1982, 2).