The gaps in the gaze in South African hospitals

Social Science & Medicine 59 (2004) 2013–2024

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The gaps in the gaze in South African hospitals

Diana Gibson

Department of Anthropology and Sociology, University of the Western Cape, Western Cape, South Africa

Abstract

Analysis of health care systems, especially hospitals, could benefit from Foucault’s description of the medical gaze

and the panopticon. Foucault’s perspective sheds new light on the South African transformation from an oppressive to

a more democratic State and is played out in particular ways in hospital settings. Analyses of the South African health

care system and its interface with patients in hospitals seldom draw on the work of Foucault, despite its pertinent

description of the diffuse and insidious forms of social surveillance (the ‘gaze’) and processes of ‘normalization’ brought

about in panoptical settings. The gaze has become a metaphor for the processes whereby disciplinary ‘technologies’,

together with the emergence of a normative social science, discipline both the mind and body of the individual, as in my

example of a medicalised institutional setting. Transformation from an oppressive State system to a democratic South

Africa has impacted in particular ways on the hospital setting. Instead of being subject to the constant surveillance of

the gaze of the State or of medicine, there are numerous instances where patients to all intents become ‘invisible’, and

end up beyond its perimeters. In the hospital, as in the heterogeneous South African community, there is a continuous

process of adjustment, with patients, services and staff being rotated in an attempt to provide redress and equal access

to health services for all. A large, long-standing lack of funds forces the medical staff to make decisions as to who

should get access to beds and to optimal care, and this permeates the everyday experience of institutionalisation and

care-giving. It also militates against neutral policy objectives, consistent surveillance or a homogenised system of care.

r 2004 Published by Elsevier Ltd.

Keywords: Equity; Hospital; Resources; Medical gaze; South Africa

Introduction

South African hospitals must contend with a changing

health care system that continues to be unequal, despite

the efforts of the post-apartheid government to elim-

inate inequities, broaden access to health care distribu-

tion and provision, and emphasize the role of primary

health care. One of the legacies of colonialism and

apartheid, which ended officially when former President

Nelson Mandela signed the new Constitution of the

Republic of South Africa in December 1996, is a

persistent disparity between the array of services

available to patients using State-financed health services

and those who have access to privately funded health

care and medical aid schemes.

Butchart argues that the work of Foucault has not

been accorded sufficient attention in the analysis of

ess: [email protected] (D. Gibson).

e front matter r 2004 Published by Elsevier Ltd.

cscimed.2004.03.006

social sciences and medicine in South Africa (Butchart,

1997, 1998). He critiques local authors who write on

medicine and who perceive power as something to be

‘held and wielded’ (Butchart, 1998, pp. 177–80) and

states that:

y the failure of Foucault to take hold in the South

African socio-medical sciences may reflect nothing

more than the inability to appreciate the more elusive

ramifications of his writingsy(Butchart 1998,

p. 179).

Butchart subsequently stresses the relevance of

Foucault for generating new insights and ways of

thinking about current medical practice since Foucault’s

work suggests that the body, power and disease are not

only material processes or external realities but are

deeply embedded in social strategies of surveillance and

visibility (Butchart, 1998, p. 181).

ARTICLE IN PRESSD. Gibson / Social Science & Medicine 59 (2004) 2013–20242014

It is my contention that Foucault’s (1979a) notion of

surveillance and the ways in which it enables the

automatic functioning and sustaining of power, while

providing a useful analytical tool, does not always hold

true when dealing with the everyday realities of State-

funded hospitals in South Africa. While conducting

research in medical wards in a teaching hospital in Cape

Town, South Africa in 1993/94 (followed by further

research in 1997/98), I found Foucault’s ‘gaze-thinking’1

to be useful in analysis of my findings, in particular his

perception of the gaze as a technology of power by

which the object (the body) becomes visible and thus

knowable to the observer. Foucault says the gaze

requires a particular kind of seeing which is not the

‘‘gaze of any observer’’, but that of a doctor endowed

with the power of decision and intervention (Foucault,

1973, p. 89). The medical gaze is a concept employed to

denote the power of modern medicine to define the

human body. Through codified and categorised knowl-

edge,2 the medical practitioner acquires expertise con-

cerning and control over the observed (the patient).

According to Foucault bodies of ‘scientific’ knowledge

such as medicine and psychiatry contribute to the power

of governmentality (Foucault, 1979b). The gaze is

closely intertwined with Foucault’s (1979a) understand-

ing of the diffuse and insidious forms of social

surveillance and processes of ‘normalization’ brought

about in particular settings, as epitomized by the

panopticon. The panopticon has become a metaphor

for the processes whereby disciplinary ‘technologies’,

together with the emergence of a normative social

science, discipline both the mind and body of the

individual, in this case in a medicalised institutional

setting (Dreyfuss & Rabinow, 1982, pp. 143–67;

Foucault, 1979a). According to Foucault, power and

knowledge became intimately connected in the modern

age, as conceptualised by his notion of ‘power-knowl-

edge’, the production of truth through power and the

exercise of power through the production of truth.

Power is analysed as a productive force, as a particular

relationship between method and object, constructing

‘truth’ by its way of seeing and doing (Jay, 1986).

This paper argues that in South Africa, hospital

settings seemingly ‘magnify’ the ideal of the panoptical

gaze, but in turn exclude other realities that are not

given credence by it, precisely because the gaze does not

permeate everywhere. As in the wider South African

society, there are people in different wards in different

hospitals who supposedly fall under the scope of the

1Personal comment, Dr. Els van Dongen.2By linking knowledge and power, Foucault parted with the

Marxist derivative that saw ‘‘power as unitary, imposed from

above, and manipulated through a state apparatus of coercion

mingled with practices of ideological legitimation’’ (Fox, 1993,

p. 24).

gaze, but by and large remain invisible. Research in

health facilities in Cape Town (Gibson, 2001) shows

that, as in the past, the medical gaze and its concomitant

knowledge legitimates the mobilisation of treatment and

therapies for patients. Despite efforts aimed at ensuring

equity and because of cumulative effect of the vast

numbers of patients involved, the worsening HIV/AIDS

epidemic, reductions in the health budget, staff attrition

and other constraints, access to different levels of public

health facilities has become increasingly layered and

uneven (Department of Health, 2001, p. 7). A patient

must be ‘constructed’ as suffering from a condition that

requires particular specialized services, technology, care

and expertise; an act that only a doctor can perform.

However, doctors are constrained by policy, economic

realities, reductions in staff and ageing equipment.

Medical personnel are forced to make choices that

would probably not be expected of them in private

facilities where the number of available beds have

increased and almost all kinds of care is available to

those who can afford it (see South African Health

Review, 2002).

I give particular attention in this paper to the possible

suitability of the panoptical gaze, and its shortcomings

when analysing health care practice in a tertiary training

hospital in South Africa. During the apartheid regime,

the State divided South African society in line with

supposedly ‘scientific’ principles of racial difference. In

conjunction with racially based legislation, a security

surveillance network was created and its carceral powers

were extended, for example, through the criminalisation

of certain members of the population by their presence

in particular places (through the ‘pass’ laws) and the

creation of Bantustans or ‘homelands’ to ‘accommodate’

the land hunger of Black people. While Whites were

subject to what Simons (1995, p. 37) calls the production

of ‘‘macro-governmental rationalities’’ through the

‘‘articulation of numerous mini-programmes and tech-

nologies of government’’, data were often lacking on the

status of a large section of the Black population, the

majority of whom fell outside the purview of the State. It

was known that ‘‘the infant mortality rate for the black

population is six times the rate for the white population;

life expectancy at birth for black South Africans is 9

years less than for white South Africans’’ (UNFPA,

1998, p. 4). The planning and provision of housing,

education and health care was directed by apartheid

policy and constricted by bureaucratic measures that

provided for services strictly within pre-planned ‘sepa-

rate’ facilities and levels. In terms of provision, this

might have seemed adequate but it often bore scant

resemblance to the reality of where services were needed

or what kinds were required. Health resources and

services were accordingly fragmented and distributed

along racial lines in four provinces and ten ‘homelands’.

The emphasis was on hospital care, the primary health

ARTICLE IN PRESS

3 I use this in the sense of a code of regulations and of

enforcing a sort of conformity and normalization.

D. Gibson / Social Science & Medicine 59 (2004) 2013–2024 2015

care system underdeveloped and insufficient (Depart-

ment of Health, 2001, p. 5). With the broadening of

democracy it became clear that while those considered to

be a security risk had previously been under very close

surveillance, the remaining majority of the population

had effectively been left to self-regulation, outside the

purview of the gaze. Twenty-three million South

Africans lived in a state of poverty in 1996 amid huge

demographic distortions, which included insufficient

access to health, clean water and sanitation (Department

of Health, 1997, p. 11).

While the private health sector is responsible for more

than half the expenditure in health, it only covers 20%

of the population (Department of Health, 2001, p. 7).

For the 80% dependent on State-financed health

services, access to the highest level of care has become

more circumscribed. In 1993/94, anyone who reported

to a teaching hospital could be admitted. By 1997/98,

only State patients were admitted directly to teaching

hospitals, usually after referral from less specialized

hospital settings and only if the severity of the condition

and the level of expertise required for treatment

warranted admission. While this arrangement was aimed

at achieving equity in the distribution of services within

certain financial and staff constraints, teaching hospitals

were most acutely affected by the process of rationalisa-

tion and substantial downsizing, following the adoption

of the primary health care approach in public health

services (Department of Health, 2000). Instead of

relieving pressures, and despite the involvement of

non-governmental organisations within this ambit,

establishing the new primary health care facilities served

to compound the problem of capacity, especially in

poorly resourced provinces.

Consequently, while struggling to render the best

possible services to all, medical staff in the public sector

were forced to make choices that could ultimately affect

the chances of survival of a patient. The situation was

exacerbated when older and less ‘deserving’ chronically

ill patients, especially those who had a history of lack of

compliance to a health regimen, became acute (Gibson,

2001). Related to this Bradshaw and Steyn (2002) stress

that the chronically ill who are also poor do not have the

same access to health services than people who are

wealthier. They also show that the burden put on the

limited resources of the health services in the country

has been increasing. Under these circumstances people

with acute chronic illness have to ‘compete’ with other

acute, yet possibly ‘curable’ conditions such as trauma

and severe infections.

At micro-level this, in turn, means that even the

acutely chronically ill who have access to private health

care could ‘‘basically get any kind of service, all the tests

they need and even some they do not really need, all the

best expertise they can pay for’’ (Dr. Epstein: 15/3/98).

In the public sector, including teaching hospitals ‘‘some-

times it all comes togethery most depressingy number

of patients are huge, we do not have the staff, the

equipment is old, the tests expensivey(you therefore)

need permission (but it takes) time, we have to prioritise

but it can turn out bad for the patienty(like having to)

play Gody very demoralizing’’ (Dr. Kap: 20/6/98).

The need for more intense scrutiny of the concept of

the gaze was reinforced by my research both in 1993/94,

and more especially in 1997/98, when the classical

concept of panoptical surveillance seemed to grow

progressively more spasmodic. I developed the notion

of ‘unseen areas’ to illustrate the gaps where the gaze

was more erratic and disorganized, than would be

assumed in classical Foucaultian terms.3 At the same

time, medical definitions shifted and led to different

diagnostic and therapeutic outcomes for the same

patients in different settings, e.g. when comparing

teaching hospitals with private hospitals (see Foucault,

1979a, 1980).

The following section focuses on the visuality inherent

in the outlay of the wards, and shows that even within

the institution, as in wider South African society,

everyone was not necessarily within the circuit of the

gaze, especially since being admitted to a State-funded

hospital does not automatically make a patient the

subject of the gaze. This created problems: drawing from

the experience of patients and doctors, as well as a court

case, it is argued that in the transforming health care

system doctors increasingly found themselves in a

double bind—they wanted to render services to all

patients equally, but were at times expected to make

difficult choices in relation to specific kinds of patients,

the level of care and services they can expand on them.

Such patients increasingly fell through ‘gaps’ in the gaze.

Research methods

The study was conducted in two phases. In 1993/94 it

was part of a multi-disciplinary intervention study in

three medical wards in a teaching hospital in Cape

Town. Semi-structured interviews were conducted with

all medical and nursing staff on the wards, as well with

all discharged patients. The researcher and an assistant

spent between three and eight hours per day on the

wards and attended and observed focus group discus-

sions, ward rounds, social rounds and meetings related

to the three wards. Unstructured interviews were

conducted with staff and patients, and 10 patients were

followed up for post-hospital interviews.

In 1997/98, 20 patients from the original 1993/94

study were interviewed and 10 who had been hospita-

lised in the medical wards of the particular tertiary


hospital were included. Semi-structured interviews were

conducted with 10 doctors and 10 nurse practitioners at

different facilities to which the patients in the 1997/98

survey had been referred. I did not have access to patient

records, but with the permission of the patients or kin, I

discussed the diagnoses with health care givers and

observed the patients and their families as they engaged

with the health care system in five institutional settings,

including intensive care units. During both periods I

analysed policy and legislative documents pertaining to

health care. Informed consent was obtained and

pseudonyms are used in this article.

4To extend and elaborate on the concept of the gaze I drew

on the work of Feldman (1997). He critiqued Foucault’s notion

of the gaze as too neutral when writing about the compulsory

visibility of political prisoners in cells, the constant electronic

and other surveillance of individuals and of society, and on

violence in Northern Ireland. Feldman (1997, p. 30) developed

the model of the scopic regime which he defined to include:

‘‘...the agendas and techniques of political visualisation: the

regimens that prescribe modes of seeing and object visibility

and that proscribe or render untenable other modes and objects

of perception. A scopic regime is an ensemble of practices and

discourses that establish the truth claims, typicality, and

credibility of visual acts and objects and politically correct

modes of seeing’’ (Feldman, 1997, p. 30). Drawing on Lacan

(1977), Feldman stressed that in the scopic regime the

formation of the subject intersected with the control of space

through the posing of bodies (see footnote1). At the same time a

scopic regime had certain ‘blind spots’ or areas of inattention. I

drew substantially on Feldman’s work for my understanding of,

and efforts to extend and complexify, the medical gaze and its

authority. This enabled me to draw attention to realities that

were deemed largely irrelevant by western medical epistemol-

ogy, such as subjective experiences and knowledge, conse-

quently making it possible to reveal some which, though lacking

the same legitimation as the gaze, did not disappear but only

become less visible. In this way the study could widen the social

context in which medical practice was perceived and under-

stood within a transforming South African health care system,

which was seeking to become increasingly inclusive in its

understanding of healing.

The wards

In the medical wards in the teaching hospital, as in an

intensive care unit in a private hospital, it was clear that

the physical layout enhanced the ability of staff to

continuously scan the environment. This is reflected in

field notes:

To enter the intensive care ward, a visitor passes the

reception areay nursing and medical staff can enter

the ward through a separate entrance at the back.

The intensive care ward is a distinct, separate space

with one visible entrance, making strict access control

possible. At the center is the nursing station, above

which are bright fluorescent lights. A clock, various

notices, computers printouts, instructions and such

are on the wally. Situated at various intervals

around the nursing station are twelve beds. From the

nursing station staff are able to keep each individual

patient in sight at all times. Around each bed are

curtains that can be drawn. When I enter, all the

curtains are open and when I go to the station to ask

for Mrs. Dantjes, I can see all the patients if I rotate

my body. Mrs. Dantjes is still critical and her bed is

closest to the nursing station. There are four isolation

rooms with glass partitions. Although physically

separate from the rest of the ward, the curtains

around the patient’s bed are open and the patients

can be seen from the nursing stationy. There is also

an area for medication with a refrigerator, a safe, a

washbasin, working surfaces and cabinets. This area

is closed off by a glass partition, which allows staff

inside to survey the ward and staff members in the

ward to see that only authorized staff are in this area

(Fieldnotes: 17/2/97).

The ward was designed and organized to maximize

the ability to observe and be observed. This was also the

way in which the medical wards in the teaching hospital

could be perceived.

In Foucault’s terminology the privileged visuality of

the hospital and of medicine is a mechanism of power

and not merely an individualised act of seeing. The gaze

is both a form of knowledge, and a method of control

used to train and discipline bodies. In the teaching

hospital, spaces were designed for the purpose of

treating patients with specific kinds of illnesses, and

also for training a ‘work force’ of doctors, nurse

practitioners, therapists and other professionals capable

of administering the necessary treatment.4 The design of

the wards seemed to be at once a tool for close scrutiny,

a mechanism or matrix of power, and a place to

command ‘‘through sight’’ (Certeau de, 1988, p. 36). It

entailed a partitioning or ‘gridding’ of space through

which individuals, like the aforementioned Mrs. Danjes

(and the nursing staff), could be transformed into

objects for observation, measurement and surveillance,

in order to ensure optimal serviceability, efficiency and

usefulness of bodies, and to train, discipline and

administer to them in the hospital (Foucault, 1979a).

This kind of visuality was stressed by early morning

nursing rounds, before the day-shift nursing staff began

their activities in the medical ward. This opportunity to

inform other staff about the condition of and care given

to patients also served an educational function. Staff

met at the nursing-station and the registered nurse gave

them an ‘overview’, providing a verbal and cognitive

‘map’ of the distribution of the patients on the ward,

their diagnoses and treatment. After such a session,

ARTICLE IN PRESSD. Gibson / Social Science & Medicine 59 (2004) 2013–2024 2017

nursing staff knew that Mr. Coen, lying in cubicle B, was

dying. All his treatment had been stopped, but he was

still ‘fighting’ to stay alive. Close by him,5 ‘‘Mr. Klaaste,

he is lying in D cubicle, he is the one with liver failure.

They have discontinued his intravenous therapy yester-

day, so he is on oral agents. Mr. Bam lying in H cubicle,

the gentleman with the lung disease: he is just on his

nebulisers, oxygen and receiving antibiotics’’.

In the ward, the positioning of bodies in space was

maintained through ward organisation and management

(Foucault, 1979a; Rabinow, 1984). The open-plan

design of wards facilitated hierarchical observation,

and staff working in the nursing station could monitor

patients, as well as each other. The architecture, general

layout, and administration of the wards enabled and

enhanced the production of manageable bodies, espe-

cially in relation to nursing staff and patients.

As indicated above in the case of Mrs. Dantjes, the

spatial distribution of patients in the ward simulta-

neously differentiated between patients, based on the

severity of the patient’s physical condition, level of

contagiousness, his/her tendency towards disruptive-

ness, and the similarities or differences in diagnosis of a

number of patients. The arrangement of the beds was a

code for the seriousness of each individual’s illness, with

the most severe being placed closest to the nursing

station, where they could be under constant surveillance.

In the teaching hospital wards, patients were the

objects of examination and discussion, often referred to

in terms of diagnosis, as a ‘‘CA lung’’, a ‘‘query BE’’, an

‘‘asthmatic on Ventolin’’, an ‘‘intercerebral bleed’’ from

G166 (another ward), or a patient who was a ‘‘hysterical

asthmatic’’ who would ‘‘hyperventilate’’, had ‘‘social

problems’’ and needed to be ‘‘sorted out’’. Contagious

patients like Mr. Kongwane, whose ‘‘resistant’’ tuber-

culosis bacilli would linger in the air, would be in a single

cubicle. These cubicles were also used for dying patients,

like Mr. Cornelis, whose treatment had been stopped to

expedite his death.

In the teaching hospital, the spatial dimension of

managing the ill was paralleled by the spatial distribu-

tion of nurses according to their tasks for the day, such

as dressings, visidexes, medicine rounds and such. This

enhanced the surveillance, not only of the patients, but

also of the nurses. As demonstrated by the nursing

round, the ward formed an extended classificatory

template comprising a network of scrutiny and inter-

vention into which bodies were ordered. The head-nurse

5See Foucault (1979a) for a discussion on the production of

docile bodies.6Thus ‘‘belonging’’ to another ward, but being ‘‘boarded’’ in

the specific ward for the time being. The registrar responsible

for the patient would be from ward G16, but the nursing staff

from G8 (the ‘‘boarding’’ ward) would care for the patient

while he/she was in the specific ward (Fieldnotes 27/6/93).

knew who was supposed to be working in which

cubicles, and was accordingly able to keep track of

individual nurses.

The nursing staff were trained and disciplined through

the mechanism of real or perceived surveillance. Nurse

practitioners were assigned to a specific ward, and

sometimes even to a specific section of a ward. They

were largely restricted to the wards on which they were

working and consequently they were highly visible, yet

like cogs in a smoothly running machine, it was

generally noticed when their absence left gaps in the

visual grid. In their perceived similarity to each other,

nurses were thus not intrusive but they were visible as a

result of spatial restriction and surveillance.

The unseen areas and distortions in the gaze

In neither 1993/94, nor 1997/98, did admission to a

hospital always ensure that a patient immediately gained

access to full treatment. Despite the apparent surveil-

lance there were observed instances of patients who were

‘forgotten’ or ‘lost’ in transit while in foyers, in waiting

bays, and between wards. Similar incidents were

reported in the media, and the frequency of such reports

increased in 1997/98 with the introduction of referrals

within the primary, secondary and tertiary hospital

structure.7 At the teaching hospital under discussion

many of the wards had been closed since 1993/94, along

with staff and budget cutbacks.8 The total budget for the

hospital in 1993/94 was R382.8 million. By 1998/99 it

had risen to about R540.1 million, whereas the buying

power of the Rand had steadily declined. Personnel

salaries made up R434 million of the budget while only

about R2.6 million was spent on new equipment

(excluding money raised by NGO funds drives).

According to a spokesperson for the hospital, the

main constraint on the rendering of services was (and

still is) related to under-funding, and this impacts in

clearly visible ways. In order to remain within budget

there was also a general public service moratorium on

filling posts, and posts at the hospital were ‘frozen’. Only

key personnel were replaced, ageing equipment could

not be upgraded and funding for new equipment was

woefully inadequate. There was not enough funding to

raise the salaries of nurses and because they were

overworked, nurses left for the private sector or went

overseas to improve their financial prospects and work-

ing conditions. The teaching hospital under discussion

had a capacity of 1700 beds in 1993/94 but since then

many of the wards have been closed, along with staff

7The Argus 27 May 1997.8The budget for the 1997/98 year was R545 million, while the

1998/99 budget had been reduced to R486 million.


and budget cutbacks.9 In 1998 the hospital had between

1100 and 1200 beds available, and this number had been

reduced to 950 available beds by 2003, according to

hospital spokesperson.

In both research periods a lack of funds, having to

‘‘get beds available’’ (Dr. Lett: 28/10/98), to ‘‘get

patients in and out ASAP’’ (Dr. Sanko: 17/3/97), to

‘‘empty beds’’ (Dr. Moses: 8/3/98), and having to decide

who should get access to optimal care and who had to

‘‘take their chances’’ (Dr. Moses: 8/3/98), affected the

everyday experience of institutionalisation and care-

giving, and often made it impossible to achieve

homogenising and purportedly neutral policy objectives.

While training and the treatment of bodies were major

goals of the institution, the availability of bed space was

the means by which it was accomplished. During both

research periods, the ‘freeing-up’ of beds was a major

issue. In the 1993/94 research period, patients had either

to be discharged, or referred to other institutions where

bed occupation was not as expensive a commodity as it

was in the teaching hospital. Thus, during social rounds

it would be stressed that ‘‘too many patients have not

been discharged’’, ‘‘it is not a rehabilitation hospital, it

costs hundreds in real terms per day to keep her here’’,

another patient ‘‘is taking up a bed at great expense’’, or

a bed ‘‘is needed’’ and ‘‘pressure’’ had to be put on the

patient’s family because he had already occupied a bed

for too long. The ‘‘plug’’ had to be ‘‘pulled’’ on another,

to force his family to take him home. A social worker

was reprimanded for not finding a patient a bed in a

rehabilitation hospital, while the registrar was not

willing to sign any forms which would enable the

hospital to ‘‘shift the load’’ of the patient’s care onto

such a facility. A patient who could not be rehabilitated,

could not ‘‘be allowed to stay in the hospital forever’’;

his family had to take him home (Field notes: 9/3/94).

By 1997/98, I found that the competition for beds had

intensified. As a result of efforts by government to

reallocate financial resources to previously disadvan-

taged provinces, the Department of Health in the

relatively better-off Western Cape had to continue to

downsize and rationalize its services. The National

Department of Health (2001), through its Provincial

Health Plan, emphasised that patients should be

managed at the most appropriate level of health care.

This was aimed at ensuring the highest possible quality of

care and the most cost-effective use of resources. The

general principles were that primary care and district level

facilities within specified suburbs referred patients to

designated secondary care regional hospitals. These

secondary care regional hospitals in turn referred patients

to tertiary care hospitals according to designated zones

(Department of Health: spokesperson: 20/7/2001).

9Whom Mrs. Ruiters subsequently befriended and I inter-

viewed at home 7/2/97.

By 1998/99 the Department of Health had lost about

8000 staff members and closed down about 3500

hospital beds, of which 714 were in tertiary teaching

hospitals. In line with this, the hospital in question had

downsized 31.1% of its posts and closed 17% of its beds

between 1996 and 1998 (Provincial Department of

Health: spokesperson: 1/2/2001). For staff it was a

struggle to get patients in at different levels of hospitals

and often the load ‘‘kept shifting’’ between institutions.

The process of referral became increasingly circum-

scribed. Patients had to be referred according to specific

protocols and within designated zones. The number of

beds (and thus patients) per health caregiver increased in

some wards. In the medical wards the number of beds

had been increased from 28 to 32, while staff numbers

had remained constant or decreased. With the number

of beds decreased, especially in wards where bed

occupancy was lower, came the perception that ‘‘beds

were not used to the full’’ (Sister Smart: 12/12/98). This

was in fact an administrative decision posing as a

medical necessity and had nothing whatsoever to do

with the reality of the wards, where nursing staff in

particular faced a constant struggle to procure bed space

for patients. According to a senior nursing staff member

(Mrs. Roman: 28/7/98): ‘‘They have never looked at it

from the nurses’ or the patients’ point of view’’. While

doctors dealt with patient admissions, nursing staff had

to ‘‘sort out the beds’’. Consequently:

Many times we shuffle beds around. I can give you an

example of one ward. One ward has two registrars so

a ward with 32 beds cut in half is 16 for each

registrar: but it never works that way because

sometimes a registrar’s intake is more than the other.

So the nurses quietly just shove people in, because if

it is your ward on intake you must take them, so you

shove them in. So when they come round and ask

whose patient is this, you say this patient is just

boarding here for the night and then you shift the

patient off to the next (one). But you know what

effect it has on that patient, one patient can be in four

wards in one week. One patient we counted was in 12

wards over a period of a week.

When the hospital became overburdened, and there

was not a single unoccupied bed, admissions staff had to

refuse new admissions for up to 4 h at a time. This did

not always change the situation, because ambulances

would wait or drive around for a time before bringing

patients back to the specific tertiary hospital again. The

result would be ‘‘an influx of patients, that is defeating

the whole system.’’ In such cases medical staff tried to

treat and discharge patients as rapidly as they could or,

if possible, to refer them to other hospitals, which might

also be extremely busy, or try to cope by sending

patients back to the referring hospital. Accordingly:


You find one patient being discharged and two others

waiting to come in, what do we do, we fill up the

admission ward, then we send patients up to other

beds, we keep them there for the night, in the

morning we send them right back (to the admission

ward) (Mrs. Roman: 28/7/98).

In terms of the application of policy changes in the

hospital, bed space was a construct, an abstract that had

little to do with the physical reality. Rhodes (1991)

described many similar contradictions faced by mental

health professionals in an emergency psychiatric unit in

a big community health centre in America. Like the

psychiatric staff described by Rhodes, doctors in the

teaching hospital under discussion had to deal with

macro-policy issues concerning the equitable redistribu-

tion of services while also facing the reality of shortages

when making decisions related to individual patients at

micro-level.

If patients were admitted to the hospital, nursing staff

had to somehow make beds available and patients were

sometimes shifted between wards in the course of 12–

24 h. A doctor who admitted a patient was responsible

for handing the patient over to another doctor in a

particular ward, but because of the lack of beds in one

ward, the latter doctor might be working in one area and

then have to follow the patient to another. Normally,

the kind of services and treatment the patient required

determined the ward to which he/she was sent. Medical

and nursing staff worked in specific wards for periods of

time, and thus within specializations. A patient who

needed to be in a medical ward might be sent from

admission for the night to the ward for an unrelated

specialization, sent back to admission the next day and

then sent to a medical ward, or if there were not enough

beds, to another ward as a ‘boarder’. In this process the

patient had to be ‘handed over’ to nursing and medical

staff separately on each occasion. For patients, the

experience of occupying a bed could be very transient.

For administrative and policy purposes the available

bed space was like a map of the services of the hospital.

Bed space could be taken away and allocated to

disciplines, to consultants and by extension, to regis-

trars. If beds were not ‘fully’ occupied, they became a

commodity to be negotiated. An open bed was under-

stood to indicate the availability of the necessary

services and nursing staff to care for a patient. Beds

were supposedly ‘open’ spaces that could be filled,

thereby ‘fixing’ patients and their diagnoses in a spatial

way. In theory, all that needed to happen was to wrest

the space from another registrar or discipline. Therefore,

bed space was often being contested between disciplines,

between registrars and between nurses and doctors. In

truth, especially in the case of the nursing staff and

patients, the amount of bed space was never constant, or

equal to the sum of its parts. It could expand and

contract when extra beds and patients were ‘shunted’ in

and moved out. Bed space was produced through a

constant rotation of patients between different wards,

subject to change as patients were shifted around. The

notion of a patient as a ‘boarder’ in particular spaces

was indicative of the vacillation of bed space and of the

patient’s own position within it. The movement of

patients through the different levels of health care was

mirrored at ward level in their ‘between-ness’ as

‘boarders’ (see above). Yet hospitalisation did not, in

either research period, necessarily mean that the

particular patient automatically came under the purview

of the panoptical, and ultimately the medical gaze.

The Case of Mr. Mbatha

Mr. Mbatha was admitted one Saturday night (1993/

94). He received stitches for a head injury, he had earlier

undergone a tracheotomy, and he was currently suffer-

ing from pneumonia. Mr. Mbatha was admitted by an

intern who had to officiate at several wards that

particular weekend and he was transferred from the

admission ward to another ward, before being trans-

ferred to the medical ward. On Monday, which was

intake day, new patients were admitted, the ward rapidly

filled up, and the medical and nursing staff were

extremely busy. Mr. Mbatha (who spoke Xhosa and

had a basic command of English) had difficulty breath-

ing and groaned constantly. Nursing staff gave him

routine care but he was not examined by either of the

two registrars, or the four interns who did ward rounds

and administered to numerous other patients during this

time. Many of the doctors also had patients ‘boarding’

in other wards. On Monday afternoon and Tuesday

morning nursing hand-overs, Mr. Mbatha’s case was

repeatedly mentioned by the exasperated registered

nurses. On the day of his admission he was placed in

the second bed from the nursing station. A nursing

decision that indicated he was seriously ill. He con-

tinuously groaned and even to the untrained eye, he

appeared to be in distress. During three and a half hours

spent observing activities around his bed, a registered

nurse read his bed letter, looked through his file and

checked it against the computer print-out in her hand. A

staff nurse and a student nurse tidied up his bed. They

had a long conversation but never addressed him. A

student nurse took his blood pressure while speaking to

another nurse who was busy at the next bed. Later, a

staff nurse took Mr. Mbatha’s temperature but did not

address him. Another student nurse arrived to take his

blood pressure. She saw that it had already been

recorded but recorded it again. One of the registrars

finally came to examine Mr. Mbatha late on the Tuesday

afternoon, more than 60 h after his admission to

hospital.

ARTICLE IN PRESS

11Personal comment, Dr. Allen Feldman.

D. Gibson / Social Science & Medicine 59 (2004) 2013–20242020

Mr. Mbatha was in a sense medically marking time

before he would be treated, while simultaneously being

subjected to the time-discipline of the ward. Like all

other patients he had his ‘four-hourlies’, and accordingly

his blood pressure and temperature were taken and

charted. He had a medical prescription and received his

medication, and was he fed and washed. Having been

institutionalised, his body ‘qualified’ for upkeep and the

indicators for this were carefully recorded and inventor-

ied but further medical therapies were not yet being

deployed for him. He was to all intents being ware-

housed,10 while awaiting therapeutic interventions. This

situation was emphasised by the following incident.

On the Monday morning (about 40 h after his

admission) an intern arrived and busied himself with a

patient in the bed next to Mr. Mbatha. The sick man

tried unsuccessfully to engage the intern’s attention by

speaking to him. The intern responded in English,

saying that he was ‘‘seeing to this patient here’’. He was

thus turning his attention to, or including within the

gaze, this sick person here, who was fully a patient and

who already had ‘value’ in the medical economy of the

hospital. ‘Seeing to’ the patient, meant that the intern

was also attending and administering to him. Foucault’s

(1976) gaze also involved action and thus material

practice that was directed at bodies, the presence of

which had been legitimated through the obligatory

rituals and protocols of visualization.

The intern discussed above subsequently told me that

he did not have Mr. Mbatha ‘listed’ and that he could

not ‘have a look’ at him until ‘handover’. Unlike nursing

staff who had to ‘look after’ all staff on the ward,

medical staff were attached to pavillions or specializa-

tions and their patients could be ‘spread out’. The intern

explained:

If I was rotating in admissions, we see them as they

come, we make an initial diagnosis and refer them (to

the specializations), but once here, we look a great

deal more specifically, related to fact that the patient

is now in this ward. He (Mr. Mbatha) was here but it

was not clear who and how we should see him, even

whether he belonged to usy there is so much to do

and you often feel even that is not enoughy It is

hardly ideal (but) to focus on what is before you at

that point.

Unlike the person in the next bed, Mr. Mbatha had

not yet gone through the requisite conventions and his

status as a patient was not as clearly defined and

sanctioned as that of the next bed’s occupant. Although

he was already partially caught up within the structure

of the hospital, Mr. Mbatha was at once both within

and outside it. The focus of the intern brought the

10My thanks to the reviewer for this comment.

patient in the next bed and his/her ailment into

‘visibility’. Meanwhile, Mr. Mbatha and his condition

remained medically ‘unseen’ in the specific specialized

ward. He did not disappear, but continued to be part of

the institution, although his condition and his patient

status had not been formally legitimated by the gaze.

His ambiguous position was in a sense the outcome of

uncertainty about his formal status as a patient that had

been officially transferred from one doctor to another

and from general admissions to the more specific

specialization of the medical ward. I would argue that,

for medical staff, there seemed to be a kind of perceptual

distortion that occurred as they worked within specific

specializations.11 Their ‘gaze’ seemed to become more

fragmented from the general wider vision of admissions

to a narrower, focused and specialized gaze and a

particular way of seeing not only the patient but his/her

condition and subsequent treatment. It can be argued

that by not ‘seeing’ Mr. Mbatha, the doctor was

exercising his power, yet he was also trying to respond

to more macro-level constraints and to find a way to

cope from one moment to the next.

The case of Mrs. Ruiters

A similar case occurred during the 1997/98 research

period, when a respondent, Mrs. Ruiters, who suffered

from asthma, collapsed at home on a Friday evening

and was rushed first to a primary health care facility by

her husband and daughter. She was transferred to a

secondary hospital and then to the tertiary hospital to

which she had been admitted briefly about 3 weeks

earlier. Mrs. Ruiters reported that at the tertiary

hospital she:

was pushed to so many places I don’t even know

where I went... and when I came back (to the medical

ward) they [the doctors] first ignored me. I did not

know who my doctor was, I saw them [on rounds and

in the ward] but no-one saw me.

According to a staff nurse:12

She came in with respiratory failure and was

transferred from the admission to a medical ward

during the night. The intern on duty in y. [another

ward], was also covering for us. He agreed that Mrs.

Ruiters could be sent up. The patient was unstable,

but a respiratory patient, and had to be accepted into

the medical ward. Shortly afterwards the patient

went into respiratory failure and was transferred to

the Intensive Care Unit. When she was returned to

the [medical] ward a couple of days later, she was

12Mrs. C formed part of a longitudinal study I was involved

in since 1993.


ignored by all the medical staff, although she received

nursing care. The doctor from admissions, who had

first admitted her to the hospital, was supposed to

hand the patient over to the registrar or intern [on the

medical ward]. But since the patient had left the ward

some time ago, responsibility for her was not

officially transferred to another medical practitioner

and the patient was only seen by a doctor a day later

after the SRN [senior registered nurse] had com-

plained to the registrars [on the admission and

medical ward].

Like the case of Mr. Mbatha, the medical ‘invisibility’

of Mrs. Ruiters was not necessarily the outcome of the

unwillingness of medical staff to ‘see’ her. Unlike

nursing staff who were responsible for all patients on

their ward, patients were allocated to particular doctors,

whose names appeared above the patient’s beds. The

registrars on the ward thought Mrs. Ruiter was a

‘boarder’, who thus ‘belonged’ to another specialization

or a doctor from another ward. This was possible

because nursing and medical staff often worked along-

side each other, but largely within their particular

knowledge domains. Medical staff did not necessarily

have the same mental map of the distribution of their

patients in and across wards, as the nursing staff had of

theirs within the wards. There were also shift change-

overs, involving a high turnover of staff. Both doctors

and nurses often worked very long shifts and keeping

track of the movement of patients as they were shifted

between wards and specializations was not simple. Mrs.

Ruiters had been shifted between wards and specialized

forms of knowledge and care. Each time she had to be

made medically ‘visible’’ to a particular practitioner

within a specific domain. And each time wider structural

constraints had to be kept in mind when making

decisions about her possible prognosis and treatment.

I have tried to illustrate the problems pertaining to the

medical gaze and its supposedly all-seeing visuality by

showing its gaps, for example when patients were

‘moved through’ wards to empty out and fill up beds,

or when they remained on the margins of medical

treatment. Yet even when patients were under the

surveillance of the gaze their condition as ‘invented’ by

it, was not as stable in this setting as Foucaultian

analysis would assume and this had particular material

outcomes for the patients themselves.

13Another example is the ongoing debate concerning the

provision of anti-retrovirals to raped women and pregnant

mothers who are HIV-positive. This is done in public health

care facilities in the Western Cape and in private hospitals, as

well as a number of pilot hospitals in other provinces, but most

patients will not qualify for it in the greater part of the country.

Falling through the gaps

The case of Mrs. Dantjes

The ways in which the condition of a patient was

defined by a doctor in the teaching hospital, as well as

the kind of therapies mobilized on his or her behalf,

could be quite different from that of a private hospital.

This was particularly evident in borderline cases, such as

the aforementioned Mrs. Dantjes. She was 73 years old,

a diabetic suffering from ischemic heart disease. She was

on thrombolytic therapy and had suffered a myocardial

infarct earlier in the morning. She had initially been

admitted to a medical ward in a teaching hospital, but

when her condition became critical the consultant

informed her family that she was going to infarct again,

and that Mrs. Dantje’s chances for survival were slim.

The doctor recommended that she not be resuscitated

again. Her family immediately had her transferred to a

private hospital, where the approach by the medical staff

was to ‘‘fight for her all the way’’ (Mr. Dantjes jnr: 30/2/

94).13 Mrs. Dantjes subsequently infarcted, was resusci-

tated and survived for nine more days before she died.

In both hospitals there was an understanding that

Mrs. Dantjes was going to die, but in the teaching

hospital the emphasis was on her poor prognosis. In the

private hospital, it was stressed that everything possible

would be done for her to survive a little longer. As one

physician, who had worked both in the public and

private health sector expressed it:

In the one (the tertiary hospital) I often seemed to

just lift the patient’s eyelid and get a sense that we are

not going to resus again. Here (private facility) we all

but fetch them from the morgue (to resuscitate).

Mrs. Dantjes did not have a medical aid scheme and,

as was the case with 92% of the patients in the teaching

hospital in 1998/99, she was not a private patient.

Depending on her income, she would at that time have

had to pay between R50.00 per day to a maximum of

R372.00 per day of stay as an in-patient in the teaching

hospital. This included stay in the intensive care unit. In

the face of her possible earlier demise her family chose to

have her transferred to a private hospital where they

would have to pay up to R2000 per day for her stay in

an intensive care unit.

The case of Mr. Soobramoney

Another scenario was exemplified by the landmark

constitutional court case of Soobramoney, The Minister

of Health, Kwazulu-Natal, 1998. Mr. Soobramoney was

a 41 year-old diabetic with ischemic heart disease and

chronic renal failure who needed renal dialysis to

prolong his life. He could no longer afford regular

dialysis at a private facility and sought treatment at the


Addington Hospital in Durban. As a result of financial

and other constraints the hospital had developed a set of

guidelines to determine eligibility for the dialysis

programme. Mr. Soobramoney, who also suffered from

cerebro-vascular and cardiac complications as a result of

his illness, did not meet the criteria and was not eligible

for treatment.

In July 1997 Mr. Soobramoney made an urgent

application to the Durban and Coast Local division of

the High Court for an order directing Addington

Hospital to provide him with ongoing dialysis treatment.

The application was dismissed and he appealed to the

Constitutional Court, citing Chapter 2, section 27(3) of

the Constitution which states that no-one may be

refused emergency treatment, and section 11 which

states that everyone has a right to life. In its 1998 ruling

the Constitutional Court was of the opinion that Mr.

Soobramoney’s case did not have to be decided under

the terms of section 11, as the right to medical treatment

was explicitly addressed in section 27. The Court

resolved that section 27(3) should not be applied in

relation to this section. Representing Soobramoney,

Chaskalson argued that:

The purpose of the right seems to be to ensure that

treatment be given in an emergency, and is not

frustrated by reason of bureaucratic requirements or

other formalities. A person who suffers a sudden

catastrophe which calls for immediate medical

attentiony should not be turned away from a

hospital which is able to provide the necessary

treatment. What the section requires is that remedial

treatment that is necessary and available be given

immediately to avert harm.

But Mr. Soobramoney’s condition was chronic and

incurable. In terms of the hospital criteria it did not

constitute an emergency and he was accordingly not

eligible for emergency treatment. As a result, the court

determined that his case should be considered in terms

of the provisions of subsection 27(1) and (2) which

entitles everyone to access to health services provided by

the state ‘‘within its available resources’’.

While applying these clauses the Court took cogni-

sance of the budgetary deficit of the Kwazulu-Natal

Department of Health and the fact that the nurse–

patient ratio in the renal unit was below accepted norms.

Judge Arthur Chaskalson stated that a ‘‘court will be

slow to interfere with rational decisions taken in good

faith by the political organs and medical authorities

whose responsibility it is to deal with such matters’’.

Sachs, speaking for the Minister of Health said that:

‘‘the rationing of access to life-prolonging resources isy

integral to, rather than incompatible with, a human

rights approach to health care’’. Consequently, while the

court recognized the ‘‘hard and unpalatable fact y that

if the appellant were a wealthy man, he would be able to

procure such treatment from private sources’’ the appeal

was dismissed (Soobramoney, The Minister of Health,

1998) and Mr. Soobramoney subsequently died.

As the judgement indicated, in a private hospital Mr.

Soobramoney’s condition, like that of Mrs. Dantjes,

would have been constituted in terms of prolonging life.

In the public health system, even if it meant that the

sufferer would die without the necessary treatment,

irreversible chronic renal failure did not constitute an

emergency. To have access to public health resources

Mr. Soobramoney had to fall within the increasingly

strict circumscription of seriousness of condition,

chronicity and economic justifiability. Acuteness had

become redefined in terms of emergency and time-

duration.

The Court ruling accepted that rationing services,

therapies and life-saving interventions was an integral

process to a transforming health care system, even if this

perpetuated inequities in access to health care. This

could have major implications for the ways in which

health care policy and its implementation impact on

power relations and the subject positions of health care

givers in relation to particular patients in South Africa.

Conclusions

The everyday realities of State-funded hospitals in

South Africa force medical and nursing to deal with an

array of problems and hard choices about patients.

Their situation is intertwined with the larger political,

historical and socio economic context within which the

health care system is embedded.

My research, conducted in two phases with several

years intervening, showed that the transformation of the

health care system had brought many far-reaching

changes in policy and legislation and this impacted on

ways in which the medical gaze did or did not legitimate

‘valid’ significations and descriptions concerning health

care and sickness. As with the rest of post-apartheid

South Africa, the wards were subject to multi-layered

inconsistencies. While it was feasible to extend the scope

of health care by changing its nature and content to

focus on primary health features, and this was un-

doubtedly happening, the impact on personnel, funding,

equipment and the number of beds available ‘‘higher

up’’ in the health system should not be underestimated.

As the provision of primary health care improved, the

cost differential between this initial level of health care

and the tertiary level was moving ever further apart. By

2003, the Communication Director of the Western Cape

Department of Health reported that compared with the

cost of R70 a day to treat a patient at a primary care

facility, the cost of treatment at a tertiary hospital had

risen to R1200 a day.


An aim of the paper was to also apply Foucault’s

(1979a) concepts of surveillance and the ‘‘gaze’’. The

often imperceptible ways in which it functions to sustain

power, was found to be useful for analytical purposes

and to gain an understanding of the ways in which

certain definitions or classifications of bodies that did or

did not qualify for treatment were invented, legitimated,

validated or enforced through practices in the trans-

forming health care system. In the implementation of

health care policies the individual and his condition were

‘fabricated’ in the legal effort to define more clearly what

constituted ‘an emergency’. This was partly an exercise

to affirm the classificatory principles on which the social

mandate for the distribution of services to the ‘qualify-

ing’ was instituted. The practical implementation of such

policies through the construction of specific kinds of

‘cases’ as emergencies was indicative of the ways in such

bodies had become defined by the morbidity ‘read’ onto

them by the formal specialised knowledge of medicine

and how it affected decisions concerning redress and the

availability of services and therapies.

The Soobramoney case highlighted the constant

efforts of State health care services to clarify its scope

and categories. Emergency interventions were ‘one-off’

interventions where bodies could be repaired and

returned to the community. In relation to the medical

gaze the knowledge to interpret bodies as ‘qualifying’ for

certain interventions was constituted and reified through

the visual epistemology of medicine, the institution and

the panopticon.

While it proved useful, this kind of analysis also had

limitations when trying to grasp the problems involved

in giving health care in an unequal, heterogeneous

setting. As shown in the case of Mrs. Dantjes, the ways

in which such qualifications were understood and acted

upon could differ, in relation to the private and State

hospitals. At the same time people were materially

affected in very particular physical and other ways. Poor

patients who were suffering from acute chronic disease

were somewhere between the right of access to health

care and ‘emergency’ treatment, and the reality that they

would probably not qualify because of age, illness-

related complications or a relatively poor prognosis.

In the cases of Mr. Mbatha and Mrs. Ruiters, both

received nursing care, but the interns who had admitted

them had for various reasons not formally ‘handed’

them over to the respective ward medical staff. Neither

gained access to ‘official’ medical status on the ward,

and although supposedly institutionalized under the

regimen of the ‘gaze’, they were not noticed medically.

They received routine care but were not yet admitted to

the full scrutiny accorded to patients, because their

medical status and condition had not been validated by

the medical gaze, in ‘this’ particular space. They first had

to be made visible in an authoritative way, through a

prescribed ritual of hand-over. These two cases, as well

as those described earlier when patients were ‘shunted’

between 4 and 12 wards within a week, illustrated gaps

in the gaze. During the first few of days of hospitalisa-

tion, Mr. Mbatha and Mrs. Ruiters were largely dealt

with as bodies to be sustained and kept operative, but

not actively treated or accorded medical interventions:

while physically present, they remained on the periphery

of medicine.

I also tried to show that the resultant ‘invisibility’ of

certain patients was related to economics, policy

pressures and efforts to provide individual care within

the practical confines of a variety of serious shortages.

These shortcomings were the result of gaps in the

planning that should have underpinned the implementa-

tion of policies related to changes in the health services

at both national and provincial level.

Finally, while Foucault’s concepts were found to be

helpful in examining the complex story of health care in

South Africa, the study indicated that this approach

could be broadened through further ethnographic

studies of the process of establishing the gaze and

power. Ethnographic descriptions together with a

macro-analysis of the extant health system, showed

how complex and involved the different influences and

interests were, and how this affected actions at the

micro-level in a hospital. Ultimately, the study shows an

inherent paradox: the ways in which power works, the

decisions that are made and the influence this has on

providing health care for the wider society, can be to the

detriment of individual patients.

Acknowledgements

I would like to thank Dr. Els van Dongen, Prof. Sjaak

van der Geest and Prof. Murray Last for valuable

comments on earlier drafts.

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Documents

The gaps in the gaze in South African hospitals