On-line version ISSN 2078-5135
SAMJ, S. Afr. med. j. vol.99 n.3 Cape Town Mar. 2009
'Loose cannon' letlape says he was 'misinterpreted'
The charismatic, maverick ophthalmologist, Kgosi Letlape, who reluctantly resigned as chairman of the South African Medical Association (SAMA) 6 months short of his maximum 9-year tenure, became a 'loose cannon' who consistently flouted his mandate.
This is according to the organisation's president, Professor Ralph Kirsch, who broke SAMA's silence early in February, a week after Letlape resigned, claiming his anti-medical aid stance was 'sadly' misinterpreted as being anti-private practice.
Letlape was vociferous in his denigration of the Medical Schemes Act as a 'piece of apartheid legislation that divides our nation into have's and havenots,' contributing to rising infant and maternal mortality rates. He described private practice as 'privatised practice running on the coat tails of the Medical Schemes Act'.
He told Izindaba, 'I will not head an association that sees 42 million people struggling for health care and acting as if it doesn't matter when just 6 or 7 million are on medical aid'.
He claimed his public utterances were based on a 2005 SAMA national council resolution that centrally funded basic health care for all South Africans should be accessed free at point of service, both in the public and private sectors.
When senior colleagues told him this did not represent SAMA's position and the original resolution was sought, it had 'mysteriously disappeared' from the association's records.
Kirsch refuted and rebutted this, citing SAMA national council resolutions in 2007 and 2008 endorsing the funding of a system of universal access to health care through 'a synergy of public and private sectors under the banner of national health insurance'.
'SAMA is absolutely committed to finding ways to do this and the issue is how to bring the incredible capacity of the private sector into this system that provides universal access â it's simply disingenuous to imply that now he's gone this work will not continue,' he added.
Letlape's strident, well-argued and eloquent views were initially seen as putting a 'human face on SAMA', giving it an unprecedented public profile, as he regularly appeared in print and on prime-time radio and television on any given health topic.
He told Izindaba 'people thought SAMA stood for the South African Music Association â when I left they knew what it stood for'.
As South Africa's first black ophthalmologist, he became even more sought after by the media when he was elected for a term as President of the World Medical Association (WMA). A combination of explicit frankness never before exhibited by a SAMA leader, plus the offices he held, made him an instant 'dial a quote' for journalists. Examples included asserting that health services were much better during apartheid (a direct reference to the crumbling public health service) and accusing President Thabo Mbeki and his health minister, Manto Tshabalala-Msimang, of genocide for failing to act on AIDS. He withstood strong political pressure to persuade his colleagues to call off a doctors' march in Cape Town to protest against the ailing health care system and government AIDS denialism.
None of these issues, however, troubled the majority of his SAMA colleagues.
Lustre began fading
His lustre began fading when he 'strayed' from mandates on other issues, in spite of his regularly adding the caveat that he was 'speaking in my private capacity'.
Said Kirsch, 'in the public mind that doesn't mean much when he's introduced as the chairperson of SAMA'.
Said one senior SAMA office bearer, 'he wasn't taking mandates from the public or private sector in forums wherever transformation of the health system was going on. With Cosatu, Denosa, the NHI, the Health Charter, you name it. His ideology perhaps overstepped his common sense and those he was representing. We've got a lot of repair work to do.'
The 'final straw', according to Kirsch, came when Letlape called for the abolition of the 'iniquitous' Medical Schemes Act, labelling it 'evil' and responsible for separating rich from poor, tearing up his own medical aid membership card and urging other members and political leaders to do the same. This was in the midst of growing disaffection with SAMA by a powerful group of specialist members who allegedly used his utterances to help fuel the formation of a breakaway group called the South African Private Practitioners Forum, posing the threat of crippling subscription losses.
Asked to in 'just one sentence' say why he resigned, Letlape replied, 'because my personal position on medical aids was dividing the association'.
His voluble chairing of SAMA meetings, where he regularly descended into the arena of debate, prolonging sessions and leaving agendas incomplete, led to further disaffection among colleagues.
His gladiatorial, or as he would put it 'principled', style was never more evident than when he refused to resign last year in spite of unanimous votes of no confidence in him by both his executive committee and his board. He also insisted on continuing to chair council meetings, asserting that only SAMA's national council could fire him.
A special council meeting was eventually called in Pretoria, exclusively to address the 'Letlape issue', incurring major travel and accommodation expenses for SAMA. Here he agreed his recusal as chair was appropriate for the discussion.
Fought to the last
At the point in proceedings when councillors were preparing to vote after some 'searching and robust' discussion on the 'irretrievable breakdown' of his relationship with his exco and board, Letlape finally tendered his resignation. A council resolution ratifying this was unanimously accepted, with no abstentions.
He told Izindaba he resisted resigning for so long because, 'when people talk about perceptions (that he was anti-private practice) which I knew were based on self interest, and you run, your integrity disappears with it'.
The exco had earlier offered to resign in toto if the board believed they were responsible. The board rejected their offer and passed their own unanimous no-confidence motion in Letlape.
Kirsch tempered his criticisms of Letlape by saying 'he did a great deal of good with his stance on AIDS and this is greatly appreciated'.
Letlape was the founder of and chief torchbearer for SAMA's Tshepang Trust, which harnessed private doctors to dispense ARVs and treat AIDS patients for a minimal fee paid by the State.
'But again there are many within the association who are as passionate as he is and will continue that work,' Kirsch added.
Kirsch admitted that he sent e-mails congratulating Letlape after media appearances but added that 'increasingly and unfortunately, many of his views bore no relationship to the mandate he was given'.
This was strongly echoed by Phophi Ramathuba, deputy chairperson of SAMA's public sector committee and a doctor at the Voortrekker Hospital in Limpopo.
'Letlape's leadership style led to all this. He began to see SAMA as his personal property where he could say anything he felt like without taking the membership into account,' she said.
No-confidence vote 'across racial lines'
She rubbished rumours that the move was 'rich white doctors getting rid of him'.
'They might have put him there, but the board and council no-confidence votes were majority black,' she stressed.
Kirsch said the resignation was 'not because of a single item and certainly not because of a single pressure group. There's no conspiracy here. It's a result of dissatisfaction at many levels within all sectors and components of SAMA.'
SAMA was proud of its' hard-won racial unity through the 50/50 principle (representivity of half the former Medical Association of South Africa (MASA) and half of the old NAMDA (National Medical and Dental Association) and its sister anti-apartheid affiliates).
'What is happening now could sow seeds of disunity and we'll resist that fiercely,' added Kirsch.
Ramathuba said that ever since the appointment of Aquina Thulare as Secretary-General of SAMA during Letlape's tenure, 'things have not been easy for public sector doctors to represent the association in various structures'.
Letlape and Thulare, the latter an unapologetic communist party member, would sit on Cosatu central executive meetings 'without us or our mandate and sell their personal views'.
Thulare's contract as SAMA Secretary-General ended in December last year. It was not renewed.
One top SAMA insider said of the working relationship between the pair, 'there seemed to be no accountability on the operational side'.
Ramathuba said Letlape was 'removed by both the public and private sector doctors,' adding that many of the private sector specialists who left SAMA after his utterances often helped treat poor patients she referred to them for no charge. 'If Letlape really wants to bring health for all he could have joined me over Christmas treating cholera victims for free in Madimbo village's health centre instead of going on SAFM and telling people to throw away their medical aids.'
'If he really cares about his people he could also go to Bara and help remove cataracts or go and help the three SAMA doctors struggling with cholera in Musina Hospital instead of telling us they should rely on the Red Cross or Gift of the Givers.'
Letlape said he wished Ramathuba 'well in seeking political space. To respond to that would be to allow detraction from the main issue. Suffice it to say the public sector is hugely underfunded and my record there speaks for itself. As least she's not accusing me of incompetence or of not taking public sector doctors seriously. But I will look at what she says objectively and see what I can learn.'
He said his inspiration to become a doctor was born of seeing private practitioners in the townships.
'I'm not anti-private practice. Even when it was illegal for blacks to belong to medical aids there was private practice in the townships â¦ the few doctors that qualified at that time would not be given an opportunity to work in the public sector.'
Letlape, who said the association's financial position strengthened appreciably during his tenure, offered to 'pay back in any way I can' whatever it was members might believe 'placed the association in a precarious financial position'.
He said his 'key assertion' was that while government was spending the comparably correct 8 per cent of GDP on health care, 42 million people received between 3 and 4 per cent of this while 7 million (on medical aid) got 5 - 6 per cent.
His chair will be filled by Professor Denise White until August when a new incumbent for it and the position of Secretary-General will be voted on by the SAMA council.