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Abstract
This article is a critique of and comment on two revisionist articles by Bill Freund and Anne Digby, which appeared in the SAHJ in June 2012. The authors maintain – from different standpoints – that the National Health Services Commission (NHSC or Gluckman Report) was doomed to failure, largely because of the failings of its Chairman, but for opposite reasons: Freund because he was not radical enough, Digby because he was too radical, and failed to carry the medical profession and the politicians with him. After outlining their arguments, this article contends that paradoxically these assessments both overemphasise and underestimate Gluckman, by failing to examine the role of Smuts, the Commissioners, the Department of Public Health, the views of leading members of the medical profession and the radicalism of many in the profession during the war. It highlights the international influences, especially ‘social medicine’, on the Commission, and explains why it selected the health centre at Pholela as the model for the health centres it envisaged as the foundation of a national health service. Finally it suggests that the Gluckman Commission's recommendations are still relevant to South Africa and the wider world.
Notes
1 My understanding of the Gluckman Commission and its context has been greatly enriched by many conversations with Marcia Wright, though I alone am responsible for what follows.
2. B. Freund, ‘The South African Developmental State and the First Attempt to Create a National Health System: Another Look at the Gluckman Commission of 1942–1944’, SAHJ, 64, 2 (2012), 170–186; A. Digby, ‘Evidence, Encounters and Effects of South Africa's Reforming Gluckman National Health Services Commission, 1942–4’, SAHJ, 64, 2 (2012), 187–205.
3. Union of South Africa, Report of the National Health Services Commission, 1942–1944 (Government Printer, Pretoria, 1944), 1. (Henceforth Report).
4. Freund, ‘The South African Developmental State’, 174, my italics.
5. Freund, ‘The South African Developmental State’, 170.
6. Freund, ‘The South African Developmental State’, 175.
7. Freund, ‘The South African Developmental State’, 175.
8. Freund, ‘The South African Developmental State’, 175. See below for Digby's very different interpretation.
9. For discussions over the relationship between the national government and the provinces at the time of Union, see L.M. Thompson, The Unification of South Africa, 1902–10 (Oxford: OUP, 1960), 169, 250–252, 260; and W.K. Hancock and J. van der Poel, eds, Selections from the Smuts Papers, vol. I (Cambridge: Cambridge University Press, 1962), document numbers 399, 408–410, 415.
10. Smuts was briefly responsible for public health as Minister of the Interior (1910–June 1912), together with his many other duties. For the profession's lobbying for a national Department of Health see ‘Medical Matters in Parliament. The Public Health Portfolio Question’, South African Medical Record (hereafter SAMR), 8, 24 (December 1910), 324ff; and ‘Public Health Portfolio’, SAMR, 9, 2 (28 January 1911).
11. ‘South African Public Health Services’, South African Medical Journal (hereafter SAMJ), 9 January 1937. The SAMR became the SAMJ (South African Medical Journal) in 1927.
12. This is a recurrent concern. See, for example, General Hertzog's attack on the profession in ‘British Medical Association Meeting’ and ‘OFS Medical Council’, SAMR, 9, 3 (11 February 1911), 34, 44. Reports of such attacks on the profession were published intermittently in the SAMR and SAMJ the 1920s and 1930s, and continued into the war years and beyond.
13. I. Frack, A South African Doctor Looks Forwards – and Back (South Africa: Central News Agency, 1943), 30, 32.
14. Digby, ‘Evidence, Encounters and Effects’, 187–188.
15. H.M. Clokie and J.W. Robinson, Analysis of Royal Commissions of Inquiry (Stanford: Stanford University Press, 1978), 18.
16. Digby, ‘Evidence, Encounters and Effects’, 188.
17. For what the NHSC meant by ‘the modern conception of health’, see especially chapters 4 and 28 of the Report. For further discussion of ‘social medicine’, see below. For the later use of the term in South Africa, see G.W. Gale, ‘Health Centres and the Report of the National Health Services Commission’, SAMJ, 23 (July 1949).
18. Digby, ‘Evidence, Encounters and Effects’, 187.
19. Freund, ‘The South African Developmental State’, 173.
20. Digby, ‘Evidence, Encounters and Effects’, 187.
21. S. Marks and N. Andersson, ‘Industrialization, Rural Health, and the 1944 National Health Services Commission in South Africa’, in S. Feierman and J.M. Janzen, eds, The Social Basis of Health & Healing in Africa (Berkeley: University of California Press, 1992), 156.
22. F.R. Luke, ‘The National Health Service’, SAMJ, 19, 1 (27 January 1945), 376. See also G.W. Gale's account in Abiding Values. Speeches and Addresses by Henry Gluckman (Johannesburg: Caxton, 1970), 497.
23. C.J. Albertyn was another formidable Commissioner. According to his Afrikaans obituarist, Prof Pijper of Pretoria, he became one of the outstanding figures in the medical world despite coming from ‘n doodgewone praktisyn op ‘n doodgewone dorpie’ [‘a very ordinary medical practice in a dead ordinary little village’ – my translation]. According to Pijper the work of the NHSC ‘was close to his heart, and he participated in it with his heart and soul’ (‘In Memoriam. Dr C.J. Albertyn’, SAMJ, 9 December 1950, 1028–1029; my translation).
24. Landau was MOH to the Local Health Commission at the time. He headed the Social Medicine Division of the Department of Public Health in Natal and acted as locum for Sidney when the Karks went on study leave to Britain in 1948. He died in August 1948, at the tragically early age of 42. According to his obituary by Kark, he was ‘one of the outstanding pioneers in the newly conceived practice of Social Medicine in South Africa’ (SAMJ, 12, 11 December 1948, 777).
25. In addition to being a Deputy Director of the South African Institute of Medical Research (SAIMR), James Harvey Pirie was President of the Federal Council of the Medical Association of South Africa (MASA) and chaired the committee it established to set out plans for a future health service.
26. Eustace Cluver was then Director of the SAIMR, but had been Secretary for Health 1938–1941.
27. Private Collection, London, in author's temporary possession: Gale Papers, Gale to Sidney Kark 15 February 1968. He was writing from Malaysia where he was World Health Organisation (WHO) Professor of Social and Preventive Medicine in Kuala Lumpur.
28. The pattern was similar in the UK.
29. P. Bonner, ‘South African Society and Culture, 1910–1948’, in R. Ross, A.K. Mager and B. Nasson, eds, The Cambridge History of South Africa, vol. 2 (Cambridge: CUP, 2011), 305.
30. GES 155 1/62 64/82/5 79/33 Cape Town 465: Cluver to the Secretary for Finance Cape Town 1 May 1939, especially Item 9.
31. ‘[People] get sick, they die, they are merely simply buried’ (my translation). Report, chapter XIX, p. 100, para. 52.
32. Very similar evidence was given to the Commission by ‘Mrs M. T. Soga’, which Digby quotes with approval. I assume this was Miss Minah Tembekile Soga, Founder and Organising Secretary (1937–1939) and then President of the National Council of African Women between 1937 and 1954.
33. F.R. Luke, ‘The National Health Service’, SAMJ, 19, 1 (27 January 1945), 374–376.
34. The witness is cited in Luke, ‘The National Health Service’, p. 19
35. NHSC, pp. 120–121, Ch. 25, pp. 120–128, esp. paras 18–22, 27–30 and 34–35.
36. University of the Witwatersrand, William Cullen Library, Historical Papers, South African Institute of Race Relations, B 41.1.2, 1939: Rheinhalt Jones, was writing to the Free Hospitalisation Commission, 22 May 1940, on behalf of the Medical Work Committee of the Christian Council of South Africa.
37. Dr E.P. Baumann, House of Assembly Debates, Hansard, 27 March 1934, Column 1852 and 5 February 1935, Columns 1123–1146; Dr K. Bremer, House of Assembly Debates, Hansard, 13 May 1940, Column 7516. National Archives, GES 1756 2/95/33, Department of Health memo on Gluckman's motion, Order No. 1, House of Assembly, 17 February, 1942
38. National Archives, GES 1756 2/95/33, Department of Health memo on Gluckman's motion, Order No. 1, House of Assembly, 17 February, 1942.
39. H.S. Gear joined the DPH as an Assistant Health Officer in May 1935, appointed by Cluver's predecessor, Edward Thornton.
40. H.S. Gear, ‘The First General Epidemiological and Morbidity Survey of China’ (MD thesis, University of the Witwatersrand, 1938).
41. Earlier Ting Hsien, and now known as Dingzhou, a province south-west of Beijing.
42. This was started by Dr Hsuan-Yuan Yao in 1930–31, but was greatly expanded by Dr Chen. Nevertheless, the first two reports by Yao in the Milbank Memorial Quarterly Bulletins, 9, 3 (July 1931), 66–77, and vol. 10, 1 (January 1932), 253–266, are interesting guides to the early stages of setting up a rural health centre. Chen's autobiography traces its further development. (C.C. Chen, MD in collaboration with F. Bunge, Medicine in Rural China: A Personal Account (Berkeley: University of California Press, 1989).
43. For more on Grant and his role in South Africa, see ‘Survey’, 26, 36–37.
44. ‘Survey’, 26, 36–37.
45. S. and E. Kark, Promoting Community Health. From Pholela to Jerusalem (Johannesburg: Wits University Press, 1999), 10.
46. Although Gale was a ‘civil servant’, as Freund describes him, this was only after he joined the Department of Public Health. The rest of Freund's description is even more misleading. He writes, Gale ‘[…] had been unable to convince Prime Minister J.B.M. Hertzog to pursue his radical ideas so that the 1939 shift in government gave him an unprecedented opportunity’ (171). As Gale only joined the Department of Public Health in Pretoria in December 1938 as a lowly Medical Inspector, it is highly unlikely that he met Hertzog before the beginning of the war, or Smuts thereafter.
47. Gale Papers, Gale, London, to J. Reid, University of Natal, 25 January 1976.
48. For the Fort Hare scheme, see K. Shapiro, ‘Doctors or Medical Aids? The Debate Over the Training of Black Medical Personnel for the Rural Black Population in South Africa in the 1920s and 30s’, Journal of Southern African Studies, 13, 2 (1987), 234–255. For Gale's dissatisfaction, see my ‘Doctors and the State: George Gale and South Africa's Experiment in Social Medicine’, in S. Dubow, ed., Science and Society in Southern Africa (Manchester: Manchester University Press, 2000), 194–195. It was abandoned after a departmental enquiry in 1942 and replaced by a BSc (Hygiene) at UNISA.
49. Bonner, ‘South African Society and Culture, 1910–1948’, 305.
50. House of Assembly Debates, Hansard 5 February 1935, column 1123.
51. House of Assembly Debates, Hansard 5 February 1935, column 1133. ‘The average medical income in South Africa is surprisingly low’, he remarked, ‘[…] probably under £500 pa. Very much medical work is unpaid or at least underpaid. […] This has been particularly the case of recent years during the depression.’ He believed that ‘under the present system’ doctors were ‘under great strain’ (House of Assembly Debates, Hansard 5 February 1935. column 1126).
52. E. Fee, ‘The Pleasures and Perils of Prophetic Advocacy: Socialized Medicine and the Politics of American Medical Reform’, in Fee and T. Brown, eds, Making Medical History. The Life and Times of Henry E Sigerist (Baltimore & London: The John Hopkins University Press, 1997), 199. For Cluver's view of the USSR, see A. Cluver Weinberg, Looking for Goodness. Exploring Eustace Cluver and his Family, 1657–1982 (Johannesburg, Sapler Press, 2008), Ch. 30.
53. ‘Report of the Departmental Committee of Enquiry: National Health Insurance 1937’ (the Collie Committee), SAMJ, 24 April 1937.
54. Cf. NHSC Report (p. 4), ‘A series of brilliant addresses [by Sigerist] led to the formation in 1940 of the Planning Committee of the Medical Association of South Africa (B.M.A.), which has played a leading part in ascertaining, expressing and […] in influencing South African medical opinion on the advisability of establishing a comprehensive national health service […]’
55. Editorial, ‘The Future. A Health Service for South Africa’, SAMJ, 16, 24 (26 December 1942), 425. Between May 1941 and December 1942, virtually every issue contained an article for or against national health. It also reported the evidence before the Commission in considerable detail.
56. GES 1756 2/95/33 Department of Public Health, ‘Dr Gluckman's Motion - Order no.1, House of Assembly, 17 February 1942. Arguments for the Appointment of a Commission, para 5.
57. GES 1756 2/95/33 Department of Public Health, ‘Dr Gluckman's Motion - Order no.1, House of Assembly, 17 February 1942. Arguments for the Appointment of a Commission, para 5. See also Footnotefn. 44.
58. J. Stewart, ‘The Battle for Health’: A Political History of the Socialist Medical Association, 1930–51 (Aldershot: Ashgate, 1999), 1.
59. E.g. D. Porter, Health Citizenship: Essays in Social Medicine and Biomedicine and Biomedical Politics (Berkeley: University of California Medical Humanities Press, 2011); E. Rodriguez Ocana, ed., The Politics of the Healthy Life: an International Perspective (Sheffield: European Association for the History of Medicine and Health, 2002); Paul Weindling, ed., International Health Organisations and Health Movements, 1918–1939 (Cambridge: Cambridge University Press, 1995).
60. For the urgency and wider purpose of doing this, see V. Berridge, ‘Social Medicine: National and International Transfer of Ideas’, Journal of Epidemiology and Community Health, 60 (2006), 558. Cited 11 July 2006 at www.jech.bmjjournals.com/cgi/content/full/60/7/558.
61. I. Borowy, Coming to Terms with World Health: The League of Nations Health Organisation (Berlin: Peter Lang Verlag, 2009), 21–22.
62. Perhaps the most influential, yet contrasting, figures in European social medicine in the first half of the twentieth century were the Belgian, René Sand (1877–1953), and the Yugoslav, Andrija Stampar (1888–1958). Both played a major role in the League of Nations Health Organisation (LNHO) and the WHO.
63. For Latin America, see H. Waitzkin, Medicine and Public Health at the End of Empire (Boulder & London: Paradigm, 2011).
64. Borowy, Coming to Terms, 21.
65. Borowy, Coming to Terms, 21.
66. H. Tilly, Africa as a Living Laboratory: Empire, Development and the Problem of Scientific Knowledge, 1870 to 1950 (Chicago: University of Chicago Press, 2011), Ch. 4.
67. ‘The SA Native Health and Medical Service’, SAMJ, 17, 1 (12 June 1943), 167.
68. Gale appears initially to have used the terms ‘social’ and ‘socialized’ interchangeably: Personal communication, Roy Gale, 3 August 1994.
69. Cited by Gale, ‘Health Centre Practice, Promotive Health Services and the Development of the Health Centres Scheme’, SAMJ, 22 June 1946, 326–330.
70. Cited by Gale, ‘Health Centre Practice, Promotive Health Services and the Development of the Health Centres Scheme’, SAMJ, 22 June 1946, 326–330.
71. Freund, ‘The South African Developmental State’, 185.
72. Gale to Sidney Kark, 15 Feb 1968.
73. G.W. Gale, ‘The Gluckman Report – An Abiding Value’, in Abiding Values. Speeches and Addresses by … Henry Gluckman (Johannesburg: Caxton, 1970), 496–497.
74. Only two of the nine Commissioners opposed this; neither was medically qualified.
75. Gale, ‘Health Centre Practice’. By then Gale was Secretary of Health and Chief Medical Officer for the Union.
76. According to the medical anthropologist, J.A. Trostle, perhaps the most important contribution of the Institute of Family and Community Health established by the Karks to train health workers for the health centres planned by the NHSC, was its emphasis on teaching its staff and students the importance of anthropological understanding: J.A. Trostle, Epidemiology and Culture (Cambridge: Cambridge University Press, 2005), 29–34.
77. GES 2958 PN6.1. J.A. Ryle, ‘A Report on the Health Centres Service of the Union Department of Health.’ I am grateful to Alan Jeeves who found and then shared this document with me.
78. He was deputising for Sidney Kark who was on sabbatical – ironically attached to Ryle's department of social medicine in Oxford, which he did not find very exciting. For Landau's criticisms, see my article, ‘South Africa's Early Experiment in Social Medicine’, American Journal of Public Health, 87, 3 (1997), 456–457.
79. What Price Community Medicine? The Philosophy, Practice and Politics of Public Health Since 1919 (Brighton: Wheatsheaf Books, 1986), 38.
80. Ryle wrote this, despite hearing from Brock that the Nationalists had introduced apartheid into the IFCH in Durban. (UCT Manuscripts Collections, Brock Papers, BC 1041 B1.5, Brock to Ryle 21 December 1948).
81. Ryle wrote this, despite hearing from Brock that the Nationalists had introduced apartheid into the IFCH in Durban. (UCT Manuscripts Collections, Brock Papers, BC 1041 B1.5, Brock to Ryle 21 December 1948). Ryle to Brock, 18 January 1949.
82. Digby, ‘Evidence, Encounters and Effects’, 199.
83. See Grant's ‘Health Centers in Urban and Rural Areas’, in C. Seipp, ed., Health Care for the Community. Selected Papers of Dr John B. Grant (Baltimore: The Johns Hopkins Press, 1963), 21–23. For Grant, see S. Litsios, ‘John Black Grant. A 20th-century Public Health Giant’, Perspectives in Biology and Medicine, 54 (2011), 532–549.
84. Geiger said this many times, but see H.J. Geiger, ‘A Life in Social Medicine’, in E.L. Bassuk, ed., Doctor-Activist Fighting for Social Change (Plenum, 1996), 14.
85. For the history of community health centres and Geiger's pioneering role in the USA, see B. Lefkowitz, Community Health Centers: A Movement and the People Who Made It Happen (New Brunswick: Rutgers University Press, 2007).
86. Harry Gear almost certainly contributed to this as well. He had studied epidemiology under its leading exponents at the London School of Hygiene and Tropical Medicine before he went to China.
87. According to Gale, from 1942 and 1946, in the ‘intensive area the death rate fell from 38.33 to 13.11 and the infant mortality from 275 to 155; scabies and impetigo, which were very widespread in 1942, had almost completely disappeared by 1946’: ‘Government Health Centres’, SAMJ, 23, 30 (July 1949), 634.
88. Kark, The Practice of Community-Oriented Primary Health Care (New York: Appleton-Century-Crofts, 1981), 230–231.
89. ‘Current Anthropology and Epidemiology’, in C. Janes, R. Stall and S.M. Gifford, eds, Anthropology and Epidemiology: Interdisciplinary Approach to the Study of Health and Healing (Dordrecht: D. Reidel, 1986). Trostle shows in detail the contacts the Karks had with anthropologists such as Winifed Hoernle Max Gluckman, and Hilda Kuper and as well as the leading British anthropologists in 1947–1948 when they were in the UK.
90. For a succinct account of the run-up to and debates at Alma Ata, see S. Litsios, The Third Ten Years: 1968–77 (Geneva: WHO, 2008), 293–310. See also S. Litsios, ‘The Christian Medical Commission and the Development of the World Health Organization's Primary Health Care Approach’, American Journal of Public Health, 94, 11 (2004), 1884–1893.
91. The euphoria did not last long: within a year, the bottom-up approach was denounced as utopian, too labour intensive and too expensive by medical sceptics and the pharmaceutical industry, and by the early 1980s was replaced by ‘selective primary health care’ which was once again top-down, and disease-focused. The struggle between comprehensive and selective primary care which ensued is the subject of a considerable literature which cannot be addressed here.
92. M. Susser, ‘What is Community Oriented Family Care?’, talk at the Jerusalem Memorial for Sidney Kark, January, 1999; see also for example, S. Litsios, ‘The Christian Medical Commission’, Footnotefn 90 cited above.