BACKGROUND AND THEORETICAL FRAMEWORK
3.7 LIMITATIONS OF DESIGN AND METHODOLOGY
In evaluating potential outcomes ofthe study, the researcher anticipated certain methodological limitations which could affect the validity or interpretation of results.
As a qualitative study, the data is more vulnerable to personal, intellectual, and cultural biases (Denzin and Lincoln, 2000), including observer bias and self-selection bias (e.g.
only those health educators who viewed their experiences positively may have responded to the original request for contact.) Similarly, the perceptions of the interview subjects are entirely subjective, and may misrepresent actual conditions at the IFCH. Interviewees spoke five decades after their IFCH experiences, and thus memory lapses or inaccuracies must be expected. These limitations will be discussed more fully in the study's
conclusion.
Finally, the study sample's composition reflects certain race and class elements that tilt the data in a particular direction. The absence of African male participants is a regrettable lacuna, and the small number of African female participants may lead to their voices being overshadowed. The relatively large number of white women in the sample corroborates a trend in exploratory studies employing volunteer subjects, which are more likely to elicit participation from white middle class women (Cannon, Higginbotham and Leung, 1988).
The study has low generalizability, due to the small sample size and convenience sampling methods. It is likely that the context-specific and interpretative nature of this study precludes the possibility of another researcher arriving at exactly the same results.
3.8 ETHICAL CONSIDERATIONS
3.8.1 Consent:
Before being interviewed, the retired HEs were notified that they would have an opportunity to participate in a study of IFCH HEs. Those who elected to be interviewed were mailed self-stamped envelopes containing informed consent forms. This study was approved by the Research and Ethics Committee of the Faculty of Health Sciences, University of KwaZulu-Natal; procedures for the protection of human subjects were followed.
3.8.2 Confidentiality:
HEs were assured of confidentiality before conducting interviews. Permission was
requested to identify interview subjects either through initials or full name (see check box on Informed Consent document). If permission was not granted, neither the subject's initials, name or any other personal identifiers would have been recorded: subjects would have been given an alias as a personal identifier. However, all subjects in this thesis formally indicated that they wished to be identified by full first and last name, as well as by a brief biographical description (See Appendix 7).
CHAPTER FOUR: HISTORICAL CONTEXT OF THE IFCH
As suggested in Section One of the Literature review, the early 1940s was a period of mounting tensions between segregationists and liberal reformers. Increasing African urbanisation and labour militancy, as well as growing impoverishment in both townships and African reserves, galvanised reformers to press for the extension of social services to Africans, Indians and Coloureds. The demands included better provision of housing, medical and sanitation services, welfare programmes such as school feeding schemes, and recognition of black workers' rights. To a limited extent, the Union government-particularly General Smuts' liberal-minded deputy Jan Hofmeyr- attempted to answer these needs, but reformist individuals and institutions insisted on greater interventions.67 For example, in 1942 the South African Trained Nurses'
Association passed a unanimous resolution deploring the inadequate provision of health services for non-Europeans and urging joint pressure on the government to rectify this immediately (Marks, 1996). Such calls consistently came from the Union Departments of Public Health and Native Affairs during the early 1940s as they endeavoured to publicise the severity of the crisis in African health and welfare (Jeeves, 2001b).
These protests and reforms did not occur within a vacuum, but were a reflection of international post-World War I trends that witnessed the creation of social welfare systems throughout western Europe, the United States and the USSR.68 The influential but doomed 1919 Dawson Report in Britain recommended a state-organised
67 The Union government during the 19305 and '405 was led by Prime Minister Hertzog, with General Smuts as Deputy Prime Minister. Jan Hofmeyr was appointed by Smuts to head the Ministries ofInterior Education and Public Health. In 1945, the Department of Public Health received full departmental status' and its own minister.
68 In contrast, most colonial governments retained a paternalistic model of health care (Vaughan, 1994).
rationalisation of health services based on primary health centres, a blueprint later evoked by the National Health Services Commission in South Africa.69 The Dawson Report viewed preventive and curative care as inextricably linked, exemplifying the "holistic"
trend that commenced in the early decades of the twentieth century. Medical holism countered the Kochian bacteriological paradigm that dominated medicine since the late nineteenth century. Advocates of medical holism such as Charles-Edward Winslow of the Yale School of Public Health, maintained that ill health could not simply be understood at the individual or c1inicallevel; rather, illness was an indicator of the well-being of a society (Porter ,1998; Fee and Porter, 1992). However, it must be emphasised that the holistic attempt to relate health to the larger social environment was a minority view, with far more doctors, epidemiologists and bacteriologists following Koch's injunction to concentrate on specific disease-causing organisms and the individuals who harboured them.
In the 1930s, as the field of health education solidified, it adopted various
strategies to prevent disease and promote health. Many of these initiatives were aimed at women and children, instructing them in the principles of hygiene, nutrition and
"domestic science" (Aita and Crabtree, 2000; Lupton, 1995). Other programmes were tailored to the needs of workers; health education was one of the roster of services delivered by the Peckham Health Centre in London, an institution that embodied the
69 Report of the National Health Services Commission 1942-44 (Pretoria, Government Printer, 1944, U.G.30-1~44), 66. See al~o Kark and Kark, 1999:88. In tum, the NHSC plan served as the inspiration for the Bevendge Report whIch established the NHS in Britain (Gluckman, 1970; Marks, 1997).
1930s ideal of democratic health care by providing free clinical care along with leisure and educational facilities to a working-class community.70
Divided into five sections, this chapter explores how these international models and their underlying concepts inspired the originators of the National Health Services Commission and the IFCH.
Section 4.1 defines social medicine, one of the pillars of the IFCH approach. It traces how social medicine functioned in the South African context.
Section 4.2 outlines the objectives and outcomes of the 1942 - 44 National Health Services Commission (NHSC).
Section 4.3 provides a brief history of the IFCH, its relation to the health centre plan and its affiliation with the Durban Medical School.
Section 4.4 summarises the role of health educators within the IFCH structure and compares them to other historical South African and international examples.
Section 4.5 sketches the history of international health education.
4.1 Social Medicine
Social medicine refers broadly to a model that views sickness as the product of a complex web of interactions--economic, social, environmental, and political and biological. The model's nineteenth-century founders, RudolfVirchow and Frederick Engels, analysed the distribution of illness, linking it to social and political forces.
70 In various publications, Sidney Kark cited the Peckham Health centre and similar initiatives in the USSR as historical predecessors (Kark, 1951:662). See also TES 56/157 Department of Public Health. 1) Institute of Hygiene.
Although the revolutionary changes in political economy advocated by Virchow and Engels were later diluted by followers into "reform" of existing structures, what remained was the correlation of morbidity and mortality statistics with variables such as income, education, class, diet and housing (Porter and Porter, 1988; Porter, 1997; Trostle, 1986).71 Twentieth century champions of social medicine such as Sidney and Beatrice Webb in England, Henry Sigerist in the United States and Salvador Allende in Chile, urged the widest possible dissemination of health-promoting knowledge, services, and resources.72
Another important figure in social medicine is John Ryle, the first professor of social medicine at Oxford, who urged the extension of public health's traditional concerns-issues such as drainage and water supply-to encompass the economic, nutritional, occupational, educational, and psychological needs of the individual and the community (Porter, 1992). Ryle played a significant, if ultimately, damaging role in social medicine in South Africa when he released a disparaging assessment of South Africa's nascent health centres in 1948.73
71 Other nineteenth-century pioneers included Jules Guerin (who coined the tenn "social medicine") and Rene Villanne in France; William Farr in England, and Neumann and Leubusche in Gennany (Hamlin, 1992; Waitzkin, 1981). These figures represent a wide range of attitudes towards the social detenninants of disease. Villenne and Farr, for example, advocated the moral regeneration of the poor as opposed to state intervention which might, as Farr wrote, "be expended indiscriminately upon the idle, reckless, vicious as well as the good but unfortunate" (cited Porter, 1997:408).
72 These figures' understanding of "health-promoting factors" encompassed nutrition, housing, sanitation, and environmental safety. The American social medicine doyen Henry Sigerist was particularly influential in South Africa through his 1930s seminars at Wits which the Karks attended and cited as a lasting influence (Marks 1997 quoting 1992 interview with Sidney Kark). Salvador Allende's work in social medicine offers a relevant parallel because he specifically addressed the role of underdevelopment in health problems. For a review of social medicine in South America, including the key role played by Allende between the 1930s to his death in 1973, see Waitzkin et aI, 2001).
73 There are many similarities between the respective views of social medicine held by John Ryle, on the one hand, and Sidney and Emily Kark on the other. For example, they all insisted on the integration of medical and social science; called for research that examined how social change affected health; and emphasised that epidemiological data provided the necessary foundation on which to build and monitor a health service. The Karks and Ryle also shared a desire to combine preventive and clinical practice, and abhorred the increasing specialisation of medicine (Jeeves, 2000; Porter, 1992). Given these parallels, it is
Through advocates such as Ryle and Sigerist, the 1940s saw a renewed interest in social medicine. The Cold War was just brewing and the paranoia that would demonise
"social medicine" as "socialized medicine" was not yet dominant. Writing in 1947 and
1952 respectively, George Rosen and Rene Sand chronicled the history of social medicine and sanguinely predicted its ascendancy in the future (Rosen, 1947; Sand, 1952). Furthermore, philanthropic institutions such as the Rockefeller Foundation and its programme officer John Grant funded international projects that unabashedly drew on precepts of social medicine, including the IFCH (Grant, 1963).74 Grant visited Pholela in
1947 when the Rockefeller Foundation was considering offering a grant to the IFCH. The Karks and George Gale acknowledged Grant's pioneering efforts to integrate preventive and curative health care in China and India.75
surprising that Ryle so disapproved of the ways in which South African health centres attempted to practice social medicine: GES 2958, PN6/2, John A. Ryle, "A Report on the Health Centres Service of the Union Department of Health", p . .3. His tour of these centres in late 1947 was cursory: of20 extant sites, he visited only ten (Grassy Park, Knysna, Walmer, Thaba 'Nchu, Alexandra Township, Lady Selboume, Springfield, Polela and Tongaat). At Springfield, then the IFCH headquarters, he spent only two hours on site, and met very briefly with Secretary of Health George Gale, Minister of Health Henry Gluckman, and David Landau, head of the IFCH while Sidney and Emily Kark were abroad, studying at Ryle's Oxford-based Institute of Social Medicine: GES 2958 PN6/2, Confidential Memo by George Gale, 24 Dec 1948. In his report, Ryle asserted that the health centres attempted "to cover far too wide a range of interests-
particularly on the investigatory side-having regard for the relatively primitive conditions under which the centres have at first been compelled to work .... " Ryle lamented the paucity ofpubJic health services and inadequate government support for a national health service, which prevented the centres from truly fulfilling their mission. In raising these issues, he seemed oblivious of how familiar they would seem to beleaguered defenders of the health centre movement such as Gale. A strict idealist, Ryle contended that practice and research should remain separate and unadulterated, the latter ensconced within an independent academic institution. Similarly, he argued, no attempt could be made to implement social medicine without poverty-reduction policies as well as functional environmental and welfare services. Such concerns, however well-conceived, belied an "all-or-nothing" approach. Ryle appeared unwilling or unable to fully appreciate the actual political, economic and racial order of South Africa. For more on Ryle's criticisms of health educators, see Chapter 4.4.
74 The Rockefeller Foundation's mandate and methods have generated a number of critiques, including those by Brown (1979) and Solorzano (1992). These scholars argue that the Rockefeller Foundation's agenda supported capitalist designs, and its association with social medicine was superficial at best.
75 During Grant's 1921- 23 tenure as director of the department of hygiene at the Peking Union Medical College in China (a Rockefeller-funded institution), Grant had developed a "demonstration health station"
which taught the principles of health promotion, prevention and curative care to medical school students
Social medicine was integral to the 1942-44 NHSC and remained sufficiently acceptable that in 1946 the Department of Health (DOH) formed a Division of Social Medicine, headed by Dr. David Landau. However, after the 1948 Nationalist Party victory, "social medicine" became such a term of opprobrium that Secretary of Health George Gale was forced to disavow its influence:
In.view ofthe ambiguities, misunderstanding and controversies which have arisen from the use of the term social medicine, it has been decided, by the present Minister of Health himself, to discontinue its use in connection with Government Health Centres. Henceforth, therefore, the term used will be simply 'Health Centre practice'(Gale, 1949).76
Despite such perfunctory recantations, the idiom of social medicine lingered for several years in departmental correspondence and publications written by a dwindling group of stalwarts that included Gale, the Karks and former Secretary of Health E.H.
Cluver, who in 1951 defiantly titled his edited volume Social Medicine.77 However, by 1962, when Kark and Steuart published A Practice of Social Medicine, they, like most of its contributors, had emigrated in response to the apartheid state's increasing hostility to their reformative vision. Set in various IFCH centres, the book vividly illustrates many of
and public health nurses. In 1944, Grant had established a similar health centre in Bengal, the All-India Institute of Hygiene and Public Health. The sphere of influence between the Karks, Gale and Grant was reciprocal; in 1947, when Grant was advising the Bhore Commission in India about setting up health centres in India, he drew inspiration from the NHSC report, and subsequently reported to Gale that ''"the members of the Bhore Commission had been greatly stimulated by the recommendations of the Gluckman Commission" (Kark and Kark, 1999: 179). Grant facilitated Sidney Kark's first visit to the USA in 1947, and through Gale, arranged the Foundation's 5-year joint sponsorship with the Durban Medical School for an IFCH-based teaching program in family practice and community medicine. UKP H6/1Il George Gale.
"The Story of the Durban Medical School", 25 Jan. 1976, p.6.
76 In a later document, Gale was openly sarcastic about the diluted language: " ... the teaching of social medicine-or, to use tenninology which they favour, teaching in health centre practice ... ": UKP H6/2/3, Durban Medical School Project for a Department ofFamily Medicine, p. 6.
77 See also a 1951 report compiled for the Dept. of Health on "Social Medicine in South Africa": GES 2704 1162 Medical and Health Services for the Union.
social medicine's fundamental premises: poverty and class are important determinants of health; cultural change affects transmission of illness; and collective interventions are as critical as individual actions in preventing disease.
The emphasis of social medicine on the group was also a feature of African concepts of vitality and morbidity, a congruence noted by the Karks and their associate, anthropologist Hilda Kuper. In a 1947 article exploring the applicability of social medicine to a "Bantu" context, Kuper contended that African interpretations of disease share with social medicine a belief that sickness could be attributed to myriad "indirect"
factors ranging from the natural to the man-made, rather than merely biological causes.78 Yet this common focus on the environmental and social setting existed alongside a major difference: African notions of etiology included "such mystical notions as witchcraft and pollution", which were "rooted in the pattern of Bantu tribal society, the political and kinship structure, the legal code and the religious beliefs"(Kuper, 1947:66}. Kuper urged the Karks and their colleagues not to impose "the European concept of social medicine"
which was, after all, "a historical development in a particular sociological setting". Any attempt to fuse African and scientific approaches must first accept that "notions of witchcraft-intellectually a perfectly coherent system ... [are not due to] any innate differences of mentality, but because of different social conditioning".79 Persuaded, Sidney Kark argued that "witchcraft thinking is social thinking: a man examines his relationships with other people: and the diagnosis and treatment are also in social
78 Kuper used particular examples from Swazi concepts and social structure to illustrate her points, but extrapolated from the Swazi to other Bantu-language groups such as the Zulu.
79 Kuper's willingness to regard witchcraft beliefs as a legitimate expression of "African institutions"
(Kuper, 1947:66) was shared by the Karks and other anthropologically-minded IFCH staff, a point which will be developed in Chapter Five. See also chapters by Chesler and Cassel in Kark and Stueart (eds.) 1962.
terms ... such an attitude to ill-health comes very close to our Western concept of social medicine" (Kark,1957:11).
In one of his many definitions of social medicine, Sidney Kark cast a wide net:
"Social Medicine means the practice of medicine which, both in diagnosis and therapy,
takes into account all the factors extrinsic (including social and environmental) as well as intrinsic that make for the health or ill-health of the individual. It is holism applied to health services" [emphasis original].8o Although Kark alluded to the structural nature of
"extrinsic" factors, such as the migrant labour system which spawned the "social pathology" of syphilis (Kark, 1949), the Karkian model as it was implemented in South Africa remained resolutely embedded in quotidian relationships rather than the political and macro-economic analyses that underpinned revolutionary strands of social medicine.
4.2 National Health Services Commission (NHSC)
Debates over health care and medical personnel in under-served populations took diverse expressions throughout the 1920s to the 1940s.81
Many voices chimed in-
80 TES 6902 561157 Dept. of Public Health. 1) Institute of Hygiene. 2) Family and Community Health.
81 See Chapter 1.3 of the literature review for scholarship about the NHSC.lmportant milestones in debates about health services for Africans include the 1928 "Loram" Committee: Report of the Committee
Appointed to Inquire into the Training of Natives in Medicine and Public Health (Pretoria, Government Printer 1928, V.G. 35-1928 and the 1933 'Thornton Committee": Report of the Interdepartmental
Committee on 'Native Medical Education' 1933 (unpublished, cited Shapiro 1987:251). Whereas Thornton adamantly opposed the concept of identical medical training for black and white students and proposed a category of black medical auxiliaries (along lines developed in colonial West Africa), the Loram
Committee instead counselled against a dual standard in which blacks would receive inferior qualifications.
Yet Loram did insist on separate training facilities for blacks through in a segregated division of the Wits medical school. Like the NHSC later, the Loram Commission concluded that that the best way to combat disease in the "native territories" was to establish a government medical service featuring team of doctors, nurses, and particularly "health assistants", skilled in preventive work and hygiene. See also GES Vol.
2957 Ref. PN 5, Native Medical Aids. Report of the Committee of Enquiry on the Medical Training of Natives to the Minister of Public Health, 15 June 1942). In the end, it was Thornton's conception of Medical Aids which won the support of Minister of Education and Public Health Jan Hofineyr and thus became government policy, implemented through the Fort Hare training programme.