Dissection of human bodies for the teaching of human morphology remains a fundamental aspect of anatomy since the first documented evidence of its inception in ancient Greece (Ghosh, 2015; Jones, 2019) and is considered to be best practice in many parts of the world (Moore, 1998, Ellis, 2001, Pawlina and Lachman, 2004, Biasutto et al., 2006, Azer and Eizenberg, 2007, Izunya et al., 2010, Wood et al., 2010, Alexander et al., 2014, Ghosh, 2015, Romero-Reverón, 2017, Sotgiu et al., 2020). In the late 20th century, although some institutions within the developed world including the United Kingdom and United States of America (Ghosh, 2017) had abandoned dissection-based teaching in favour of artificial replicas or blended-learning interventions, many elected to reintroduce dissection. This was mainly due to students’ lack of knowledge and challenges experienced in later years (Rizzolo and Stewart, 2006; Ghosh, 2017; Flack and Nicholson, 2018; Memon, 2018; Onigbinde et al., 2021), but also because of the students’ interest in bringing back dissection (Rizzolo et al., 2006). Dissection-based teaching does not only provide foundational knowledge in anatomy but also fosters the development of many other skills such as teamwork and problem-solving (Huitt et al., 2015), spatial awareness (Vorstenbosch et al., 2013) and professionalism (Warner and Rizzolo, 2006, Arráez-Aybar et al., 2021), all of which are needed for the production of skilled health science professionals (Rizzolo and Stewart, 2006; Ghosh, 2017; Flack and Nicholson 2018). However, due to the rather dubious history of body acquisition, with anatomists’ party to unethical and sometimes illegal practices, the sourcing of human remains for education and research remains contentious (Ball, 1989, Jones and Whitaker, 2009, Ghosh, 2015).

Some of the practices of acquiring human remains which are deemed unethical, such as the use of unclaimed bodies for dissection, are legally accepted e.g. in South Africa (SA-NHA, 2003), or in certain instances are not governed by legislation (Chia and Oyeniran, 2019; Kramer, this issue). In Africa, countries such as Tanzania have legislation that governs the use of unclaimed remains, but no legislation for full body donation (Mazyala et al., 2014). While there were reports of sourcing of bodies of criminals who lost their life in incidents, (Anyanwu et al., 2011) there has been a shift towards bodies being sourced from hospital mortuaries which is in line with most African countries (Akinola 2011; Kramer, this issue). In Africa, Libya exclusively imports purchased human remains from India (Gangata et al., 2010). However, other global territories such as Micronesia and the Caribbean supplement their body numbers with imported remains from the USA (Habicht et al., 2018). The importing of remains raises the question of whether legalisation of such practices incentivises the ethically questionable importing of body tissues and remains. Due to poor central regulation, body brokerage practices are of increasing concern raising issues of unethical acquisition and inadequate or deceptive practices in obtaining consent (Champney et al., 2019, Jayakumar et al., 2020).

The International Federation of Associations of Anatomists (IFAA) recommends body donation with informed consent (IFAA. 2012). In addition, the consenting individual must be entirely free in their decision to donate, and this thus excludes donations by minors and those condemned to death (IFAA. 2012, p1.). In South Africa, human bodies at local health sciences institutions were historically acquired mainly from unclaimed sources (Kramer and Hutchinson, 2015, Alblas et al., 2018, L’Abbé et al., 2021). The use of unclaimed bodies remains legal in South Africa under the National Health Act of the Republic of South Africa (SA-NHA, 2003). Within the scope of this Act, “a person who makes a donation as part of their last will and testament or signed/oral statement must nominate an appropriate institute/person as bequester” (SA-NHA, 2003, subsections 62.1 to 62.3). In the absence of either a donation or a contrary direction by a donor issued while alive, then “the spouse, partner, major child, parent, guardian, major brother/sister of that person, in this order, may after that person’s death, donate the body/specific tissue of the person to an appropriate institution” (SA-NHA, 2003, subsections 62.1 to 62.3). Alternatively, the Director General of Health of South Africa, after the death of a person, and if none of the above persons are located, can provide any specific tissue of that person to an appropriate institution. As the South African Act makes provision for the donation of human bodies by individuals other than the donor themselves, it does not comply with the IFAA IFAA. (2012) recommendations for informed consent. This adds to the complexity of body donations in South Africa as the next of kin might not be aware of the death of a family member or there may not be a (local) next of kin, as in the case of substantial numbers of migrants from Africa who came to work on the gold mines in Johannesburg (Tal and Tau, 1983, Reed, 2013). In the latter instances, it often falls upon the community to proceed with “after-death” arrangements. The South African National Health Act (SA-NHA, 2003) makes no reference to the posthumous fate of unknown/unclaimed prisoners and to our knowledge, the use of bodies of prisoners for teaching and research purposes has not been documented in South Africa. This is likely due to the Correctional Services Act of 1989 (Act 111 of 1998, section 15(2)) which requires the investigation of all prisoner deaths by the Inspecting Judge of the Judicial Inspectorate of Correctional Services (JICS). Furthermore, according to the Correctional Services Act of 1989 all unnatural deaths of prisoners must also be investigated in accordance with the Inquest Act 1959 (Act 58 of 1959) (Barit et al., 2020). Bodies that have undergone autopsy are not accepted by anatomy departments due to the health risks posed to staff along with the challenges faced with embalming such bodies.

In response to unethical practices, both historically and contemporaneously, international anatomical professional associations have provided recommendations of good practice for the donation of human bodies and tissues for anatomical examination (American Association of Anatomy [AAA), 2009; American Association of Clinical Anatomy [AACA), 2008; Trans-European Pedagogic Anatomical Research group [TEPARG), 2008; IFAA. 2012. The IFAA also recommends that donors should have the next of kin co-sign the body donation form (IFAA, 2012). The role of the next of kin, while not mandatory, has been seen to be important particularly when the wishes of the donor require reversal for example, in the United Kingdom (Farsides and Smith, 2020).

In line with the role of the next of kin in donations, the establishment and success of body donor programmes in Africa also requires understanding cultural perspectives. Factors which influence body donations by the community include traditional African religions and the belief in ancestors (Anyanwu et al., 2011, De Gama et al., 2020, Anibezi, 2021; Kramer, this issue; Marima et al., this issue), the significance of peri-mortem rituals (Martin et al., 2013, Owino, 2017) and burial customs (De Gama et al., 2020). In addition, the COVID-19 pandemic brought into sharp focus the risk to body donor programmes globally. During this period of the pandemic South African institutions had to revisit the acceptance of donations (anecdotal evidence) until clear guidelines were communicated by government health institutions.

To contribute to knowledge on the practices of body donation on the African continent and to provide a more updated account of the global map of body acquisitions, this study interrogated the prevailing situation with regard to body donations in South Africa. The aim of the current study was thus to investigate the provenance and number of human remains in South African health sciences institutions during the period 2017-2021.