Portal de Periódicos da CAPES

The Steve Biko affair

2004; Elsevier BV; Volume: 364; Linguagem: Inglês

10.1016/s0140-6736(04)17634-4

1474-547X

Trefor Jenkins, G. R. McLean,

Neurology and Historical Studies

Steve Biko, a leader of the Black Consciousness movement in South Africa, died in 1977 while being detained by security police. The inquest into his death revealed gross inadequacies in the treatment he received from the two doctors legally responsible for his medical care. These doctors, Ivor Lang and Benjamin Tucker, were called in to examine Biko after he had sustained head injuries during interrogation by the security police. Over the five days in which they attended Biko, Lang and Tucker failed to take his condition seriously. The doctors failed to examine Biko under proper conditions despite clear signs of possible brain damage; they failed to take a history, they failed to do simple tests of Biko's mental state, and allowed the police to be present during their examination and to influence their diagnosis and management. (The police had variously suggested that Biko had suffered a stroke or that he was shamming.) Lang then wrote a false medical certificate in which he claimed to have found no evidence of abnormality or pathology. He failed to note the injuries to Biko's face and chest, his ataxic gait, and his slurred speech—all of which had been evident from the beginning. With subsequent deterioration in Biko's condition, further examinations (including those performed by an independent physician in consultation with a neurosurgeon) revealed a left-sided positive Babinski sign, left-sided weakness, urinary incontinence, and blood in the cerebrospinal fluid, in addition to the earlier signs of brain damage. Nevertheless Lang then wrote in his patient's notes: "No change in condition. Have informed [Biko] that [the specialist] and myself find no pathology, that lumbar puncture was normal, and as a result, I was returning him to the police cells." Thereafter Biko was not kept under close observation (despite the instruction of the specialist); he was not provided with adequate nursing care; and his deteriorating condition was not reported to the specialists. Finally, having been called again to examine Biko and finding him collapsed, glassy-eyed, hyperventilating, and frothing at the mouth, Tucker conceded to the plan of the police to send Biko under grossly unsuitable conditions to a prison hospital 750 miles away. Tucker failed to insist that an ambulance be used or that a medical attendant be present and failed to provide a medical report or a referral letter to accompany his patient. Biko died on the following night, having received no effective medical care at his destination. How could these doctors, trained in the best traditions of western medicine, have displayed such a profound failure of care? Were they simply incompetent? Were they constrained by bad apartheid law? Were they intimidated by the security forces? Not one of these suggestions is supported by the facts that later emerged. Both doctors clearly demonstrated that they understood the signs of brain damage and the required management of a brain-damaged patient. Bad apartheid law did not account for their behaviour, as the law regulating their offices in fact required them to provide fully competent medical care to prisoners in their charge. And there is no evidence to suggest that the doctors were under any clear intimidatory pressure from the police. However, the doctors did adopt a subservient attitude to the security police. It is this fact along with their related attitudes that helps explain why they did not take Biko's condition seriously and why they displayed such an appalling indifference to his wellbeing. The doctors were members of a society riddled by racist attitudes, and they had spent many years working alongside men who regarded people like Biko as dangerous terrorists. They had no doubt become habituated to the brutal methods employed within the security institutions where they practised medicine. A doctor's proper professional regard for every patient could very easily be eroded under these conditions (if indeed it had existed in the first place). Because these doctors approached Biko with insufficient respect, they were not motivated by the concern that would have led to a proper investigation of his condition and to his proper care. Because they had allied themselves with the security police they apparently attached an undue importance to the suggestion that Biko was shamming, and they allowed his treatment to be dictated by what the police wanted rather than by what the relevant medical considerations required. This interpretation of events is supported by Tucker's own confession some years later when he applied (successfully) for reinstatement to the medical roll: "I had gradually lost the fearless independence that is required of a medical practitioner when the interests of his patient are threatened. I had become too closely identified with the interest of the organs of the State … I have come to realise that a medical practitioner's primary consideration is the wellbeing of his patient, and that a medical practitioner cannot subordinate his patient's interest to extraneous considerations." Here Tucker is spelling out the moral that emerges for all health-care professionals everywhere. That a patient belongs to a particular racial or ethnic group, that the patient is a prisoner, that the patient has been detained as a security risk, are all facts that are irrelevant to a doctor's commitment to the patient as patient. The lamentable features of the Biko affair were not confined to the conduct of Dr Tucker and Dr Lang. In subsequent years both the South African Medical and Dental Council and the Medical Association of South Africa failed to respond as they ought to have done. Calls for a proper disciplinary inquiry into the doctors' conduct were rejected and protests by members of the profession were suppressed. An adequate inquiry only eventually occurred when a small group of doctors applied to the Supreme Court to intervene. Lang was found guilty of improper conduct and given a caution and reprimand. Tucker was found guilty of improper and disgraceful conduct and given a suspended sentence although a full Council meeting later struck him off the roll. How was it that the custodians of the standards of the profession could, for nearly 8 years, steadfastly refuse to accept that there was even prima facie evidence of misconduct on the part of the two doctors? The answer is that, like Lang and Tucker themselves, these professional bodies allowed irrelevant considerations—race, politics, state security, and so on—to cloud the issue. They failed to concentrate upon the only question that mattered: did Biko receive the kind of medical care that any patient was entitled to receive as a patient? When, directed by the court, they finally asked this question, the answer was simple and clear. The Biko affair is not an isolated episode of simply historical interest. There have been numerous other deaths in detention in South Africa, and similar abuses occur all too commonly elsewhere in the world. Doctors are implicated in many of these cases. And much more frequently they are implicated in other instances of discriminatory behaviour towards their patients. There is no reason to suppose that the Biko doctors or the members of the professional bodies who turned a blind eye to their misconduct were moral monsters. They were ordinary people who had allowed their moral sense and their medical professionalism to be undermined by corrupting attitudes reinforced by custom and habit. The profession of medicine is characterised by a very specific relationship between doctor and patient—a relationship founded upon the doctor's commitment to provide uncompromised medical care. The Biko affair stands as a reminder to all individual doctors, and to the guardians of their profession, of how vigilant they must be if this commitment is to be kept intact.