Evidence, Encounters and Effects of South Africa's Reforming Gluckman National Health Services Commission, 1942–1944

Abstract

The progressive recommendations of the National Health Service Commission of 1942–1944 have attracted historical attention but the three and a half million words of evidence given to it have hardly done so. This article reviews this testimony, which gave unrivalled detail on the fragmented state of South Africa's healthcare structures and on the variety of its personnel. In addition it supplied insights into social attitudes and prejudices related to health and medicine in a racially segregated society on the eve of apartheid. The paper analyses the problems that this ground-breaking commission encountered, and explores whether there were ‘lions in the way’ of its reforms, as was suggested in an encounter with an influential witness. The article probes whether there was a tangential relationship between the evidence, and the commission's conclusions on new health centres as the basis of a radical new national health system. In evaluating whether these reforms were stultified by the election of an apartheid government in 1948 (as others have argued), it concludes that the Gluckman recommendations had already failed before this because they ignored political and professional interest groups. The article also assesses reasons for the contrast between the commission's grandiose recommendations and its modest effects.

Keywords:

• National Health Services Commission
• national health service
• health centre
• malnutrition
• Henry Gluckman
• H.F. Pentz
• Dr S.L. Kark
• Beveridge Report

Acknowledgements

I am indebted to Lukas Spiropoulis for his able research assistance.

Notes

¹S. Dubow and A. Jeeves, ‘Introduction’ in S. Dubow and A. Jeeves, eds. South Africa's 1940s. Worlds of Possibilities (Cape Town: Double Storey, 2005), 9–10.

²A. Jeeves, ‘Health, Surveillance and Community: South Africa's Experiment with Medical Reform in the 1940s and 1950s’, South African Historical Journal, 43 (2000), 248.

³H.M. Clokie and J.W. Robinson, Royal Commissions of Inquiry (Stanford: Stanford University Press, 1978), 18.

⁴D. Harrison, ‘The National Health Services Commission, 1942–4 – Its Origins and Outcome’, South African Medical Journal, 83 (1993), 679–684; A. Jeeves, ‘Delivering Primary Care in Impoverished Urban and Rural Communities: The Institute of Family and Community Health in the 1940s’, in Dubow and Jeeves, South Africa's 1940s, 88; H.T. Phillips, ‘The 1945 Gluckman Report and the Establishment of South Africa's Health Centres’, American Journal of Public Health, 83 (1993), 1037–1039; S. Marks, ‘South Africa's Early Experiment in Social Medicine’, American Journal of Public Health, 87 (1997), 452–459; S. Marks and N. Andersson, ‘The 1944 Health Commission in South Africa’, in S. Feierman and J.M. Janzen, eds. The Social Basis of Health and Healing in Africa (Berkeley: Berkeley University Press, 1992), 131–161; Y.G. Pillay, ‘The Problems and Promises of Decentralisation of Health Services – A Commentary’, South African Medical Journal, 85, 4 (1995), 238–240.

⁵South African government papers, UG 30-1944, Report of the National Health Services Commission, ch. IV, para. 4.

⁶UG 30-1944, Report, ch. IV, para. 12.

⁷UG 30-1944, Report, ch. IV, para. 14. The flimsy typescript minutes of interviews were donated to the libraries of the Universities of Cape Town and the Witwatersrand. There is no subject index although lists of witnesses preface the various sessions.

⁸UG 30-1944, Report , ch. II, para. 7.

⁹NHSC evidence, 12, 118.

¹⁰Quoted in obituary by P.V. Tobias, ‘Henry Gluckman’, South African Medical Journal, 15 August 1987, 303.

¹¹University of the Witwatersrand, William Cullen Library, A 1207 Gluckman papers, B12 notebook.

¹²UG 30-1944, Report, ch. II, para. 8.

¹³S.G. Checkland and E.O. Checkland, eds, The Poor Law Report of 1834 (Harmondsworth: Penguin, 1974), 9, 41–42.

¹⁴M. Blaug, ‘The Poor Law Report Re-examined’, Journal of Economic History, 14 (1964), 151–184.

¹⁵University of the Witwatersrand, William Cullen Library, A 1207 Gluckman papers, B12 notebook.

¹⁶Jeeves, ‘Health Surveillance’, 247; NHSC evidence of Dr Peter Allan, Secretary for Public Health, 1593–1594, 1597, 1907.

¹⁷NHSC evidence of D.L. Smit, Secretary for Native Affairs, 2757; Dr George Gale, 1692.

¹⁸NHSC evidence of P. Allan, 495.

¹⁹NHSC evidence of D.L. Smit, 2731.

²⁰NHSC evidence of D.L. Smit, 2742–2743, 2831; Gale, 1669; Allan, 1593–1594, 1599. The changing character of this malnutrition and remedial attempts have attracted attention by historians: D. Wylie, Starving on a Full Stomach (Charlottesville: Virginia University Press, 2001); D. Wylie, ‘The Changing Face of Hunger in Southern African History, 1850–1980’, Past and Present, 122 (1989), 159–199; A. Digby and H. Sweet, ‘Social Medicine and Medical Pluralism: the Valley Trust and Botha's Hill Health Centre, South Africa’, Social History of Medicine, 24, 3 (2011).

²¹NHSC evidence of Sir E.Thornton 576; D.L. Smit 2741–2742, 2771.

²²NHSC evidence, Gluckman's summary, 2888.

²³NHSC evidence of D.L. Smit, 2783, 2839.

²⁴NHSC evidence of Dr P. Allan, 501.

²⁵NHSC evidence from Roman Catholic mission hospitals at Aliwal North and Herschel, 7575; the Roman Catholic Glen Grey Hospital, 7595; the Anglican Holy Cross Hospital in Pondoland, 8753.

²⁶NHSC evidence of Father Hoffend, 7997.

²⁷NHSC evidence of Dr Allan, 1907, 503.

²⁸NHSC evidence of Dr Mears, 7360–7361, 7373; UG 30-1944, Report, ch. XIII, paras. 142–146.

²⁹NHSC evidence of Dr Mears on the Transkei, 7357–7360.

³⁰NHSC evidence, Dr A Hay-Michel of Queenstown, 7452.

³¹A. Digby, Diversity and Division in Medicine. Health Care in South Africa from the 1800s (Bern and Oxford: Peter Lang, 2006), 323–328.

³²UG 30-1944, Report, ch. XIII, paras. 84–87.

³³NHSC evidence of Mrs M.T. Soga, 7492.

³⁴NHSC evidence of Dr R. Bokwe, 7289, 6945.

³⁵NHSC evidence of J.B. and M.J. Krige, 6713–6714.

³⁶For example, NHSC evidence 3405, 7179, 8394, 8237. See also UG 30-1944, Report, ch. XIV, para. 23.

³⁷NHSC evidence, 7172–7175.

³⁸For example, NHSC evidence on Healdtown locations, 6086-6088; Port Elizabeth location, 6471–6475; Dr Ella Britten of Grahamstown, 6706–6709; Dr R. Bokwe of Middledrift, 6954, 7284.

³⁹For example, NHSC evidence by Dr C. Bligh-Wall of King Williams Town, 7178; Dr R. Bokwe of Middledrift, 6946.

⁴⁰T.G. Mashaba, Rising to the Challenge: A History of Black Nursing in South Africa (Cape Town: Juta, 1995), 174.

⁴¹NHSC evidence of Miss Williams of the South African Trained Nurses Association (the coloured section), 5685–5688; Miss Saint, Matron of New Somerset Hospital, 4636; Dr W.C.J. Cooper, Medical Superintendent of Lovedale Hospital, 7002–7003.

⁴²NHSC evidence of Non-European Nursing League, 3160.

⁴³NHSC evidence of S. Sebeta, 8035.

⁴⁴NHSC evidence of Miss B.L. Drysdale, 7320.

⁴⁵NHSC evidence of King Edward VII Order of Nurses, 5020–5029.

⁴⁶NHSC evidence of Dr S.E. Rolfe of Queenstown, 7439.

⁴⁷K.A. Shapiro, ‘Doctors or Medical Aids?’, Journal of Southern African Studies, 13 (1987), 234–255; V. Noble, ‘“Health is Much Too Important a Subject to be Left to Doctors”: African Assistant Health Workers in Natal during the Early Twentieth Century’, Journal of Natal and Zulu History, 25–6 (2006/7), 95–134; A. Digby, ‘The Mid-Level Health Worker in South Africa’, in A. Khalid and R. Johnson, eds, Public Health in the British Empire (London: Routledge, 2011), 171–191.

⁴⁸NHSC evidence of Dr F.S. Drewe, 8657.

⁴⁹NHSC evidence of Dr S. Kark, 8653–8655.

⁵⁰NHSC evidence, 2763–2764, 2868.

⁵¹NHSC evidence of Dr G. Gale, 1713.

⁵²NHSC evidence of Mrs M. Gibbons of Ladysmith native nursing service, 8281–8282; see also A. Digby, ‘Early Black Doctors in South Africa’, Journal of African History, 46 (2005), 427–454.

⁵³NHSC evidence of Mrs M.T. Soga, 7495, L. Madalane and E. Cindi, 7747.

⁵⁴NHSC evidence of Indo-European Council, 9110.

⁵⁵NHSC evidence, 9103–9110; 4800–4816.

⁵⁶NHSC evidence, 6931–6956, 7382–7390.

⁵⁷NHSC evidence, 8035–8038; 7747–7749.

⁵⁸NHSC evidence, 7497. Unfortunately, further biographical details on Mrs Soga remain obscure.

⁶⁰NHSC evidence, 7480.

⁵⁹NHSC evidence, 7492–7493.

⁶¹UG 30-1944, ch. V, para. 51.

⁶²UG 30-1944, Report, ch. XIII.

⁶³The sessions lasted from 28 October to 3 November 1942.

⁶⁴The Transvaal Provincial Executive had earlier decided that the Craib Report should remain confidential because the difficulty of interviewing witnesses in wartime meant that it was incomplete, but access to it was promised to the Gluckman Commission (NHSC evidence, 51, 56).

⁶⁵NHSC evidence, 7–8.

⁶⁶NHSC evidence, 407.

⁶⁷NHSC evidence, 856.

⁶⁸NHSC evidence, 19.

⁶⁹NHSC evidence, 68.

⁷⁰NHSC evidence, 18.

⁷¹NHSC evidence from Orange Free State, 7868–7924; Natal, 8371–8324; Cape, 3390–3603.

⁷²NHSC evidence, 7913.

⁷³NHSC evidence by G.M.H. Barrell and B. Muller, members of the Cape Executive Council, 3395, 3398, 3437.

⁷⁴NHSC evidence of L. van Zyl, Provincial Secretary of the Orange Free State, 7913, 7916.

⁷⁵NHSC evidence, 7917.

⁷⁶NHSC evidence by D.E. Mitchell, a member of the Natal Provincial Executive Council, 8411–8412, 8415.

⁷⁷NHSC evidence, 3556.

⁷⁸NHSC evidence, 3603.

⁷⁹NHSC evidence, 414, 434, 469, 448.

⁸⁰NHSC evidence, 526.

⁸¹NHSC evidence of Dr P. Allan, 1867.

⁸³NHSC evidence by Pirie, 1142.

⁸²NHSC, comment by Gluckman, 1121.

⁸⁴UG 30-1944, Report, ch. II, para. 19.

⁸⁵NHSC evidence by Dr Allan, 439, 504–505.

⁸⁶NHSC evidence by Dr Allan, 443, 505–506, 512; Colonel van der Spuy, Deputy Director of Medical Services, 1428–1429; G.A.C. Kuschke, Secretary for Social Welfare, 1046, 1085–1086 and Dr C.F.A. Marnewecke, Knysna District Surgeon, 6241.

⁸⁷S.L. Kark, ‘A Health Service among the Rural Bantu’, South African Medical Journal, 16 (1942), 197–198.

⁸⁸The Umtata scheme was later publicised in R. Smit, ‘The Umtata Rural Health Unit’, South African Medical Journal, (22 April 1944), 139–141.

⁸⁹NHSC evidence, 7275–7778.

⁹⁰NHSC evidence, 7274.

⁹³NHSC evidence, 8649.

⁹¹Jeeves, ‘Health Surveillance’, 251.

⁹²S.L. Kark, ‘A Health Service among the Rural Bantu’, South African Medical Journal, 16 (1942), 197–198; S.L. Kark, ‘Health Centre Services’, in E.H. Cluver, ed, Social Medicine (Johannesburg: Central News Agency, 1951), 661–700; S.L. Kark and J. Cassell, ‘The Pholela Health Centre’, South African Medical Journal, 26 (1952), 132–136; S.L. Kark, and G.W. Stueart, eds, A Practice of Social Medicine (Edinburgh: E.S. Livingstone, 1962), 245–255; S.L. Kark and E. Kark, Promoting Community Health: From Pholela to Jerusalem (Johannesburg: Witwatersrand University Press, 1999); M. Susser, ‘A South African Odyssey in Community Health’, American Journal of Public Health, 83 (1993), 1039–1042; S. Tollman, ‘The Pholela Health Centre’, South African Medical Journal, 84, 10 (1994), 653–658.

⁹⁴NHSC evidence, 8649.

⁹⁵NHSC evidence, 8657.

⁹⁶NHSC evidence, 407–408.

⁹⁷UG 30-1944, Report, ch. XXVIII, paras. 1 and 6.

⁹⁸UG 30-1944, Report, ch. XIX, paras. 7–8.

⁹⁹NHSC evidence, Dr G. Gale, 1765.

¹⁰⁰H. Gluckman, ‘The National Health Service’, South African Medical Journal, (9 November 1946), 660–661.

¹⁰¹NHSC evidence, Colonel van der Spuy, 1426–1427.

¹⁰²NHSC evidence, Dr G. Gale, 1765.

¹⁰³South African government papers, UG 30-1944, Report , ch. IV, para. 75.

¹⁰⁴UG 30-1944, Report, ch. XX, para. 5; ch. XIX, para. 51.

¹⁰⁵UG 30-1944, Report, ch. XXVII, para. 1.

¹⁰⁷UG 30-1944, Report, ch. IV, para. 73.

¹⁰⁶UG 30-1944, Report, annexure F, 206–207.

¹⁰⁸UG 30-1944, Report, p.6, para. 16.

¹⁰⁹Debates of House of Assembly, Hansard, 47 (1944), 800, 815, 1349.

¹¹⁰South African government papers, UG 53-1948 Report of Department of Public Health, 18–32.

¹¹¹Dubow and Jeeves, South Africa's 1940s, 10.

¹¹² Hansard, 47 (1944), 835.

¹¹³Gluckman papers, B5.4, Statement by Prime Minister, October 1944.

¹¹⁴Government Statement of Policy, 9 September 1944 reported in South African Medical Journal, 20 (1946), 538.

¹¹⁵Gluckman papers, B5.4, Statement by Prime Minister, October 1944.

¹¹⁶Gluckman papers, B1.2, Speech to Association of Scientific Workers of South Africa, 25 April 1946.

¹¹⁷ Hansard, 58 (1946), 6298.

¹¹⁸ Hansard, 65 (1948), 2449.

¹¹⁹H. Gluckman, ‘The National Health Service’, South African Medical Journal, (9 November 1946), 659, 661–663.

¹²⁰Gluckman, ‘National Health Service’, 660, 662.

¹²¹H. Gluckman, ‘Health Centre Practice in relation to Private Practice’, South African Medical Journal, (12 June 1948), 370–372; H. Gluckman, Abiding Values. Speeches and Addresses by Henry Gluckman (Johannesburg: Caxton, 1970), 468.

¹²²UG 30-1944, Report, ch. IV, para. 47.

¹²³A. Digby, ‘“Vision and Vested Interests”: National Health Service Reform in South Africa and Britain during the 1940s and Beyond’, Social History of Medicine, 21, 3 (2008), 494–495.

¹²⁴For example, C.C.C.P. Anning, ‘The Provincial Hospital Ordinances and a National Health Service’, South African Medical Journal (January 1946), 558–559; G. Alabaster, ‘Family Doctor and the State’, South African Medical Journal (January 1946), 565–566.

¹²⁵UG 18-1947, Report of Department of Public Health, 1945–6, 47.

¹²⁶G. Gale, ‘The Gluckman Report’ in Abiding Values, 508.

¹²⁷G. Gale, ‘Government Health Centres in the Union’, South African Medical Journal, (23 July 1949), 631.

¹²⁸ Daily Mail, 11 January 1950.

¹²⁹Digby, ‘Vision and Vested Interests’, 480.

¹³⁰H. Phillips, ‘The Grassy Park Centre: A Peri-Urban Pholela?’, in Dubow and Jeeves, South Africa's 1940s, 120–122.

¹³¹UG 30-1944, Report, ch. 1, paras. 4–15.

¹³²Restructuring the National Health System for Universal Healthcare, January 1996, part 1, para. 1.

¹³³Restructuring the National Health System, paras. 1, 2.3, and 4.3.9.2.

¹³⁴Restructuring the National Health System, para. 4.1.4.

¹³⁵Restructuring the National Health System, para. 4.3.2.

¹³⁶Marks and Andersson, ‘The 1944 Health Commission’, 158.

¹³⁷NHSC evidence, 209.

¹³⁸UG 30-1944, Report, ch. IV, para. 6.

¹³⁹Cmd 6404, William Beveridge, Social Insurance and Allied Services (London: Her Majesty's Stationery Office, 1942).

¹⁴⁰J. Harris, William Beveridge: A Biography (Oxford: Clarendon Press, 1977), 387, 413–414

¹⁴¹Harris, Beveridge, 420–422.

¹⁴²Harrison, ‘The National Health Services Commission’, 682–683.

¹⁴³UG 30-1944, Report, ch. II, para. 2.

¹⁴⁴UG 30-1944, Report, ch. IV, para. 25.

¹⁴⁵A. Digby, Diversity and Division, 414-419.

¹⁴⁶Dubow and Jeeves, ‘Introduction’, in South Africa's 1940s, 2.

¹⁴⁷Digby, ‘Vision and Vested Interests’, 485–502.