Disadvantaged Backgrounds

‘We are from humble beginnings; disadvantaged and the odds heavily against us…. We came from very poor schooling’.Footnote ⁸ The very earliest black doctors had been comparatively well served by mission schools, but after the apartheid legislation of the Bantu Education Act of 1953 closed these establishments, African aspirants to a professional future were penalised. Schooling was frequently characterised by daily double sessions, overcrowded classes, high pupil–teacher ratios, low-paid and poorly qualified teachers and a dearth of scholarship opportunities, and so most schooling may ‘seriously handicap the African as a university student’.Footnote ⁹  Only a small number of outstanding high schools with dedicated teachers existed.Footnote ¹⁰ A few parents were sufficiently affluent to use good boarding schools in Swaziland or Lesotho and later differentials amongst black medical students resulted from these kind of class differences.Footnote ¹¹  The scientific and pre-clinical courses offered by Fort Hare (a tertiary institution set up in 1916 for black students) also enabled some students to bridge the gap between schooling and the clinical courses in medical school. However, many black students continued to suffer from a linguistic handicap because the language of instruction in medical schools was English or Afrikaans, which was a second or third language for many of them. Geographical inequity also impacted because many Africans had homes remote from the first black medical school in Natal. The creation of MEDUNSA lessened this geographical handicap and almost two-thirds of MEDUNSA’s students were drawn from neighbouring areas in the Transvaal or northern Bantustans.Footnote ¹²

Deans of medical schools stated that ‘We find ourselves fatally hampered by inadequate (primary and high) schools for Africans’, and that ‘the dropout rate among African medical students is alarming, and can be directly related to their school education’.Footnote ¹³  At the Natal Medical Faculty, Africans struggled more than Indians or Coloureds due to their limited schooling.Footnote ¹⁴  The training period at Natal was extended by a preliminary year but, despite this, little more than half were on schedule with their studies; many failed the second year after finding anatomy and physiology very challenging.Footnote ¹⁵ Overall, only forty-three per cent of students admitted from 1951 to 1970 graduated.Footnote ¹⁶

Improved schooling as well as more financial support was required if the number of medical students of colour was to expand.Footnote ¹⁷ Low entry standards meant high dropout rates later as they struggled to cope. Dr A. Aziz Aboo commented of his fellows at UCT that ‘Many of them came from schools that weren’t on a par with the white schools …fifty per cent of the class of black students, failed in the first year’.Footnote ¹⁸

MEDUNSA acknowledged that many of its African students came ‘from under-privileged communities, where their own education was lacking’.Footnote ¹⁹  Its rector conceded that ‘average standards are not yet on a par with those at white schools’.Footnote ²⁰  To counteract this, the institution later identified itself as ‘committed to training those previously disadvantaged by Bantu education’,Footnote ²¹ with remedial measures including outreach for matriculating school students, training orientation on campus, mentoring of junior by senior students, as well as supplementary instruction.Footnote ²²  As a result, a high initial failure rate did not lead to an excessive dropout rate.Footnote ²³ And the post-apartheid university promised that ‘the selection process shall focus on potential to succeed’,Footnote ²⁴ so that, whilst conceding that the entry level was lower than for historically white universities, the exit standard was not.Footnote ²⁵ In contrast, at the University of Transkei only eight to twelve per cent of intakes actually graduated in the apartheid and post-apartheid eras.Footnote ²⁶

As elsewhere in the African continent money was a central concern for black medical students.Footnote ²⁷ Wits students set up an African Medical Scholarship scheme to replace a short-lived government bursary schemeFootnote ²⁸ And at Natal, fifteen government bursaries were created in 1951, gradually increasing to 143 by 1971, when as many as eighty-five per cent of African students held them.Footnote ²⁹ Under these bursaries half the loan was remitted if the student successfully finished the course and, until 1961, the remainder was conditional on service in the public health system. A few provincial bursaries existed,Footnote ³⁰ but these had to be repaid or, as one recollected, you had to enter public service in a remote hospital.Footnote ³¹

The professional labour market remained skewed with a gross maldistribution of doctors and a conspicuous rural/urban divide. During the eighties and early nineties newly established Bantustans hoped to grow their own supply of doctors and so help alleviate the shortage of rural public sector doctors. As we have seen, the Transkei Bantustan even set up its own medical school. The Bantustans gave bursaries to medical students, with Lebowa giving monthly salaries to ease hardship.Footnote ³² After graduation several Bantustan bursary holders returned to become hospital interns,Footnote ³³  but many did not, thus contributing to disillusionment about solving a chronic medical shortage through training.Footnote ³⁴ More generally, a makeshift student economy was strengthened by American organisations such as Medical Education for South African Blacks (MESAB) giving bursaries from 1985, whilst the Mellon Foundation provided black doctoral fellowships.Footnote ³⁵ In addition, piecemeal help might come from a teacher, the local community, or an employer or local professional chipping in with funds.

Although structurally disadvantaged by an inadequate grants system and inferior schooling, hardship was held to be a bracing incentive. One UCT medical student of colour recollected that:

Indeed, MEDUNSA recognised that its students had ‘to develop a greater than usual amount of self-discipline and capacity for hard work, and thus initial disadvantages are converted into valuable personal assets’.Footnote ³⁷ Although some black doctors came from professional homes, others were from impoverished backgrounds where fathers were miners or labourers, and mothers were domestic workers or street traders. However, a poverty-stricken beginning might give personal momentum because, as one remarked, a future as a doctor was ‘a dream out of poverty…a way to get oneself out of poverty’.Footnote ³⁸

Numbers and Institutions

The two English-speaking historically white universities of UCT and Wits made an early contribution to expanding the number of black doctors.Footnote ³⁹ UCT graduated its first black doctors in 1945; subsequently the vast majority of Coloured doctors trained there, with ninety Coloured medical students registered by the 1970s.Footnote ⁴⁰ Wits graduated its first black medical students in 1946 with, by 1959, a total of eighty-four black graduates – mainly Africans and Indians. From 1959 to 1984 the apartheid state required black individuals to seek ministerial permission to study at Wits or UCT together with a permit to travel. The Dean of UCT Medical School made a point of underlining the provisional status of Coloured students under permit during the 1960s.Footnote ⁴¹ One demeaned UCT student recollected that ‘as a black student on permit, you felt like a migrant worker’.Footnote ⁴² Although permits were granted to most ‘Asian’ or Coloured applicants, less than one in three African applicants were successful.Footnote ⁴³ As a result, between the 1960s and 1970s from one in six to one in seven at Wits, and from one in five to one in eight at UCT were black medical graduates.Footnote ⁴⁴

In terms of apartheid the University of Natal was anomalous in having a white faculty and students but opening a medical faculty (UNB) for black students in 1951. Its first medical faculty staff included notable progressives such as Sidney and Emily Kark and George Gale, who hoped to implement aspirations to improve the healthcare of the black population developed in the National Health Services Commission of 1942–4. The apartheid government’s election in 1948 had stalled the commission’s implementation whilst financial stringency by the apartheid state undercut attempts to fund the Durban faculty at a level ensuring equivalent standards to white medical faculties.Footnote ⁴⁵ That apartheid had blighted early utopian aspirations for UNB was indicated by the emigration of the Karks and Gale before the end of the fifties.

In 1957 the state attempted to downgrade UNB status by removing it from university control, but this was unsuccessful.Footnote ⁴⁶ A later government attempt to close this medical faculty was blocked by student opposition, the policy rationale having been that all black medics should graduate from MEDUNSA.Footnote ⁴⁷ By 1991 UNB had produced more than 300 specialists, whilst by 1995 (when its first white undergraduates were admitted), it had graduated 2,700 black doctors. The racial composition of Natal’s medical graduates was remarkably uneven in comprising sixty-two per cent Indians, thirty-three per cent Africans, and five per cent Coloureds,Footnote ⁴⁸ despite the faculty’s continuing efforts to prioritise African admissions.Footnote ⁴⁹

Critics perceived MEDUNSA’s creation in 1976−7 as an extension of the ethnic universities concept, although its white rector justified it as ‘optimizing opportunities for [all] black applicants’ in a situation of ‘a dire need’ for trained black healthcare workers.Footnote ⁵⁰ Initial fears that MEDUNSA’s location thirty miles north of Pretoria meant that it would become an ethnically Tswana university were allayed both by early enrolments (showing less than one-fifth of the students were Tswana) and by the expropriation of its teaching hospital of Ga-Rankuwa from Bophuthatswana, the Tswana ‘homeland’.Footnote ⁵¹

MEDUNSA trained almost exclusively African undergraduates, although in 1989 it graduated its first Indian doctor. Graduating its first thirty-four doctors in 1982, the total had grown to 903 by 1996, of whom as many as two-thirds had qualified between 1990 and 1995.Footnote ⁵² (This single-handed achievement compared well with a South African total of only about 1,000 black lawyers who had qualified from all training institutions by 1994.Footnote ⁵³) At post-graduate level white numbers at MEDUNSA were larger than those of Africans, Indians and Coloureds. By 1994 MEDUNSA claimed to have produced ‘nearly half of all the black doctors registered with the South African Medical and Dental Council’ (SAMDC), with half its graduates working in ‘the under-served non-metropolitan areas of the country’.Footnote ⁵⁴ MEDUNSA and Natal thus had a similar track record to the principal black medical schools in the Unites States of America (USA; Howard, Meharry and Morehouse) in being the main training grounds for black doctors.Footnote ⁵⁵ In 1985 the University of Transkei Medical School was set up within the Bantustan of Transkei to address the shortage of public sector doctors in rural areas. The school had a low entrance requirement and an accompanying very high dropout rate, but grew rapidly to reach an annual intake of about one hundred students. These were overwhelmingly African students.Footnote ⁵⁶

Until 1982, when MEDUNSA’s first graduations came on-stream, the national output of African doctors compared poorly with that of graduating Indian/‘Asian’ doctors, as Table 1 indicates.

Table 1: Graduating black doctors, 1966–86. Source: Annual Reports of South African Institute of Race Relations (SAIRR), supplemented by data in. Tobias, op. cit. (note 13), Table 2.

The production of doctors was inversely correlated to population groups in South Africa, as Table 2 indicates.Footnote ⁵⁷ During the first quarter of a century of apartheid the ratios of white and Asian doctors per million white or Asian people grew, whilst those of Coloured and African doctors declined.Footnote ⁵⁸ An official inquiry in 1976 drew attention to ‘an almost incalculable need for more Coloured doctors’. Nevertheless, the ratio of Coloured doctors to population was 1:6,200 and thus much better than the 1:44,400 for Africans. In a more privileged position were ‘Asians’ (mainly Indians) with 1:900, and whites with 1:400.Footnote ⁵⁹

Table 2: Graduating doctors belonging to each population group (per 100,000), 1968–77. Source: Tobias, op. cit. (note 13), 399.

Medical Training

‘We silently tolerated the discrimination, indignity and arrogance we confronted in the university, hoping that one day it would change!’ recollected one Indian medical graduate from Wits.Footnote ⁶⁰ Some individuals were handicapped by the psychological strain of being in a very small minority in a white university whilst others suffered from material adversity. Off-campus studying was difficult, as in the case of an Indian student at Wits who recollected, ‘my awful living conditions, a cramped house $\ldots $ shared by three families comprising seven adults and nine children, with no bathroom and sharing one toilet’.Footnote ⁶¹ Another instance was that of a UCT student living in a crowded backyard dwelling who ‘used to study in the car, in the driveway, to get some peace and quiet’.Footnote ⁶² And even Natal’s Alan Taylor Residence for black medical students was situated in a polluted industrial area, had bleak, barrack-like buildings and, until the 1980s, inadequate public transport to the medical school.Footnote ⁶³

Institutionalised apartheid discriminated against black students, interns and registrars. MEDUNSA internships took place at Ga-Rankuwa Hospital, designed as a secondary institution without tertiary specialist facilities so that it ‘never was quite equal when it came to funds or facilities’, and where until 1993 there was never money to replace out-dated equipment.Footnote ⁶⁴  An even more important issue on  all campuses was the limited range of clinical material and pattern of diseases that black medical students were exposed to in segregated, crowded wards where they saw only black patients, whilst also working solely on black bodies in anatomy and pathology. Students were forced to operate a ‘self-policing’ racial exclusion,Footnote ⁶⁵ and one African student at Wits considered that ‘this is, was, humiliation’.Footnote ⁶⁶ The range and frequency of pathologies varied according to race so that, as a black UCT student stated, ‘keeping one away from white patients, took a chunk out of one’s development and self-confidence; [I] couldn’t see the [clinical] spectrum’.Footnote ⁶⁷  Another remembered that ‘coronary heart disease was, at the time, seen in white people, and we never saw it, we never knew anything about ECGs [electrocardiography]’.Footnote ⁶⁸ To try to offset this, a mentoring system was organised in which UCT seniors would report that ‘there’s a very interesting patient, come and have a look’.Footnote ⁶⁹ Informally, sympathetic tutors might offset black students’ one-sided exposure, as when at Wits ‘Dr Chatgidakis would bring back specimens to the lunch hour tutorial in the pathology department to demonstrate and discuss findings’.Footnote ⁷⁰ In contrast, the need for inclusive clinical experience for whites was acknowledged, as when Cape Town and Stellenbosch Medical Schools agreed that ‘the essence of good teaching …is that there should be available adequate clinical material …drawn from the various racial groups comprising the South African complex’.Footnote ⁷¹

The issue of professional standards was raised as soon as the segregated, medical training of black students developed. The initial fundraising appeal for the new Durban Medical School was insistent on the need for high standards and thus of meeting the single standard of qualification of the SAMDC. J.E. Viljoen, Minister of Education, therefore asserted that schooling at Durban was ‘in no way inferior to that at other schools’.Footnote ⁷²  Training programmes elsewhere on the continent (at Yaba, Kano, Khartoum, or Makerere) were consciously distanced from the planned experience at Natal because of what were referred to as their early ‘substandard’ courses training medical auxiliaries, general doctors and assistant medical officers.Footnote ⁷³

Natal’s Department of Family Practice provided a rare but short-lived instance of comparative advantage for black students where practical experience could be gained in community-oriented primary healthcare at the Institute of Family and Community Health (IFCH) run by the Karks.Footnote ⁷⁴ From its inception Natal had recognised that the majority of black students would go into general practice, so needed to have exposure to social, preventive and family medicine.Footnote ⁷⁵ Indeed, the first Dean, George Gale, considered Durban’s family practice courses superior to that in any other South African medical school.Footnote ⁷⁶ But state refusal to continue funding an institution thought to harbour communist tendencies – because of the apartheid government’s ideological conflation of social with socialised medicine – led to the closure of the IFCH in 1961.Footnote ⁷⁷ Within a fragmented and profoundly inequitable healthcare system, Natal medical students used their own initiative to work in local clinics,Footnote ⁷⁸  and participated in research projects linked to diseases rife in the area, including malnutrition and chronic infections.Footnote ⁷⁹ At MEDUNSA too there was involvement in health work in the nearby Soshanuve Township as well as in mobile clinics and rural hospitals.Footnote ⁸⁰  MEDUNSA’s  research agenda was shaped by the need to investigate health problems such as low birth rates experienced in local communities.Footnote ⁸¹  The Transkei Medical School adopted problem-based learning within a community-based curriculum as a means to train doctors for poverty-stricken, rural conditions.Footnote ⁸²

Career Development

After six years of medical training a one-year hospital internship was compulsory for South African doctors.Footnote ⁸³ Internships were in such short supply that some Indians in the Transvaal were refused permission to take them in African hospitals, serving one with a general practitioner instead.Footnote ⁸⁴  In the Cape black internships were located only at Somerset, Victoria and Livingstone Hospitals.Footnote ⁸⁵ For white junior doctors aspiring to be a specialist, internship was followed by three years as a registrar, and a further year in senior house posts, before peer evaluation to determine entry to a consultancy track. For blacks the interim period was usually longer, with openings pursued at King Edward VIII, McCord Zulu, Baragwanath and Kimberley Hospitals or overseas in Cairo or Dublin. In most cases this gave a narrower clinical experience focused on black patients and their common diseases so that a specialist career was then harder to develop.Footnote ⁸⁶ Indeed, the Theron Inquiry had concluded that ‘Coloured graduates cannot compete on an equal footing for posts as resident doctors in teaching hospitals’.Footnote ⁸⁷ This was not only because of institutional barriers but because black doctors lacked role models and mentors to ease prolonged rites of passage. Whereas elite white graduates were perceived (perhaps erroneously) as having connections, money and self-confidence to realise their ambitions, able black graduates might be rebuffed by their seniors. One UCT doctor of colour recollected ‘taking his life downstairs’ following a year as a junior registrar because in 1963 the Professor of Pathology told him ‘for you blacks there is no post’. As a result he sought post-graduate specialist experience in Canada.Footnote ⁸⁸ It was a decade later before UCT agreed that coloured graduates should compete for posts on equal terms.Footnote ⁸⁹ And even at MEDUNSA there was reluctance to train African registrars to become specialists.Footnote ⁹⁰

A fortunate few gained hospital posts: Baragwanath offered houseman posts to African doctors as early as 1952-3; a decade later eight per cent of its full-time doctors were African, but by the end of the seventies this was only five per cent. Livingstone appointed its first black paediatrician in 1967.Footnote ⁹¹ Despite some advances, however, one doctor of colour recollected the continuing micro dynamics of UCT culture during the early seventies, where coloured individuals had a ‘status as second-class medical students’.Footnote ⁹² There was ‘unspoken differentiation’ over access to extra tutorials, and a grooming process that ‘wasn’t shared’, including extra tutorials, post-graduate training abroad and entry to a specialist track. Black students were denied the ‘pathway to becoming an academic leader’ through a ‘subtle process’ in which race, religion, class and language served as filters. A turning point at UCT came in 1971 when Bryan Kies was chosen as a registrar but recollected that UCT’s Professor of Medicine, Stuart Saunders, asked him not to talk to the newspapers, as this kind of career advancement for Coloureds wasn’t apartheid government policy.Footnote ⁹³

Conditions of service were discriminatory. Accommodation and facilities for black staff in hospitals was inferior, as at Groote Schuur Hospital in Cape Town,Footnote ⁹⁴ whilst in the country more generally few changing and shower rooms were attached to hospital theatres for the use of black surgeons.Footnote ⁹⁵ Black hospital doctors experienced discriminatory leave periods, housing subsidies and pension schemes.Footnote ⁹⁶ There were differential salaries for interns, registrars and medical officers with such low salaries for the latter that posts were difficult to fill during the early sixties in the Cape, whilst in the Transvaal African doctors threatened to resign over the issue.Footnote ⁹⁷  The situation  was still inequitable during the early seventies: as interns, Coloureds and Indians earned seventy per cent and Africans sixty-three per cent of white salaries. After becoming medical officers, Africans found their final salary was less than the starting salary of whites.Footnote ⁹⁸ In state employment, too, Coloureds or ‘Asians’, earned seventy to eighty-one per cent and Africans sixty-five to seventy-six per cent of the salary of white colleagues.Footnote ⁹⁹ Belatedly in 1974, the Council of the Medical Association of South Africa stated that the South African Medical Journal would not accept advertisements of posts with discriminatory conditions.Footnote ¹⁰⁰

During the late sixties and early seventies there was publicity on African doctors taking up senior posts abroad because their promotion in South Africa was blocked because of the racially charged issue of senior black doctors giving instructions to white staff.Footnote ¹⁰¹ However, without public awareness the medical brain drain had begun earlier: amongst the dozen black doctors graduating at Wits in 1949, for example, two-thirds left South Africa.Footnote ¹⁰² One black UCT graduate later expressed the rationale for his emigration: ‘I was never made to feel I had potential. I only discovered I had potential when I went to another country’.Footnote ¹⁰³ This leakage of talent was one reason adduced for a low black fellowship in the South African College of Medicine.Footnote ¹⁰⁴

The emigration issue has continued to have huge relevance, although South African evidence suggests lower rates of emigration for young black doctors than for white.Footnote ¹⁰⁵ In the African continent more generally, whether to emigrate or not has loomed large amongst recent medical graduates, as in the central African state of Malawi.Footnote ¹⁰⁶ Global concern continues over an ongoing medical brain drain from sub-Saharan Africa and focuses on the consequent detriment to the healthcare of source countries.Footnote ¹⁰⁷ Although South Africa has been less hard hit than many countries, the Minister of Health has lamented the outflow of scarce medical skills.Footnote ¹⁰⁸

Serving ‘Their Own People’

An apartheid geography of defined racial residential zones had been created under the Group Areas Act (1950). Public bursaries to black medical students were conditional on graduating doctors setting up in racially defined areas approved by the state, thus confining private practice to ethnic communities.Footnote ¹⁰⁹ One African doctor aptly expressed this as ‘service was to be remote in own areas – rural/homelands – to pay back in service’.Footnote ¹¹⁰ Already by 1962 the distribution of black doctors broadly reflected that of the black population.Footnote ¹¹¹ A quarter of a century later the official Browne Commission still put forward the need for ‘Asian’, Coloured and black health personnel ‘to serve their communities’ because of ‘differences in cultural, social and linguistic background’.Footnote ¹¹² That black doctors treated black patients was evident in careers. For example, Yosuf Veriava revealed that it was almost a quarter of a century after his qualification at Wits in 1968 that he was first able to treat a white patient.Footnote ¹¹³

On opening the Durban Medical Faculty Dr Karl Bremer, Minister of Health, had articulated apartheid ideology in stating that ‘This medical school has a great opportunity to evolve a training which will specially fit its graduates to serve the needs of its own people’.Footnote ¹¹⁴ Even progressives such as Dr Henry Gluckman also envisaged ‘non-European’ doctors ‘serving the health needs of their own people’ or serving ‘their own people in various ways’,Footnote ¹¹⁵  whilst the National Health Services Commission Report of 1944 foresaw a new medical school for blacks producing doctors to staff health centres whose patients would largely be Africans and Coloureds.Footnote ¹¹⁶  Some individuals, like Jeanette Morupi who studied at MEDUNSA, shared this mind set, stating that she was ‘motivated to choose a career where I could do something to help my black brothers and sisters’.Footnote ¹¹⁷  But less than one-third amongst a sample of UNB students referred to opportunities to serve their own people (and/or of serving humanity) as their original career motivation.Footnote ¹¹⁸ Early UNB students had a distinctive training in social medicine but were suspicious of this, fearing second-rate status because it set their training apart from the white model.Footnote ¹¹⁹ Both MEDUNSA’s medical training and that at the University of Transkei emphasised rural community health care.Footnote ¹²⁰

Government medical posts reinforced separate development in being located in densely populated black areas. In 1962 Dr M.V. Gumede was made Zululand District Surgeon;Footnote ¹²¹ two years later five such part-time posts were located in the Transkei and Ciskei, whilst by 1967 four out of the seven posts were still in the Transkei.Footnote ¹²² A Department of Bantu Administration and Development circular in 1969 directed graduating African doctors to the ‘homelands’ then being created, which allegedly offered ‘excellent opportunities for Bantu medical practitioners’. A UNB medical student confirmed that ‘most doctors from here go to the homelands’.Footnote ¹²³  Indeed, there were seventy African doctors there in 1969, growing to eighty-four by 1975.Footnote ¹²⁴ The newly created Bantustan health services had many problems for practitioners including those of language,Footnote ¹²⁵  but also offered  opportunities to become part of a new administrative elite, as when the first African specialist physician, Dr K.P. Mokhobo, became Bophuthatswana’s ‘energetic and visionary’ Minister of Health.Footnote ¹²⁶

Virtually all the earliest Wits black medical graduates went into general practice, setting up in townships such as Duncan Village, New Brighton, Galeshewe, or Lady Selborne.Footnote ¹²⁷ One African doctor expressed the rationale as ‘Private practice $= $ more freedom and better income’.Footnote ¹²⁸ This was similar to the motivation and career path of East African doctors at the time.Footnote ¹²⁹ Amongst a sample of Natal graduates, private practice was viewed both as a positive alternative to the racially discriminatory pay of a hospital post and as a means ‘to earn more money’.Footnote ¹³⁰ Hidden financial pressures dictating career choice originated in the bursary loan that had financed medical school, which meant black doctors became obligated to repay money.Footnote ¹³¹

George Gale had warned that ‘it is a temptation …to assume That …there are tremendous opportunities for African doctors among their own people’. Footnote ¹³² Indeed, a study found that the typical township general practitioner (GP) suffered from overwork, lack of professional access to hospitals, and frustrating restrictions in treating patients, whose loyalty to alternatives (notably indigenous medicine) delayed therapy, whilst their impoverishment limited drug prescription.Footnote ¹³³ William Pick, a doctor of colour, set up a family practice in a designated group area – Tervlei – where the hours were ‘long’ and the workload ‘enormous’, with only one day taken off during the first two years of practice.Footnote ¹³⁴ In this kind of high-traffic practice in the working-class sector of the medical market there were clear parallels with earlier black doctoring in the American South during the depressed 1930s, where the doctor also had ‘a time-consuming, demanding job’.Footnote ¹³⁵

Continuing shortages of African practitioners tempted the more numerous Indian practitioners into African township practices despite its illegality under the Group Areas Act. Official action threatened prosecution and notice to leave, although official second thoughts permitted such practice if doctors from the community were unavailable.Footnote ¹³⁶ Many Indian doctors were advantaged by their family’s commercial background, with connections to local businesses as well as knowledge of accounting and debt collection. But conditions for practice in a very unequal and impoverished society were difficult, as Dr Anvir Adam recollected:

For Indian medical women there was the possibility of occupying a market niche in offering a distinctive all-female practice, as did Dr Moseda Ismail in Durban.Footnote ¹³⁸ Nevertheless, Indian practitioners felt apartheid restricted them. ‘Because of the Group Areas Act we could not live or practice where we wanted to – everything was governed by permits’.Footnote ¹³⁹ And ‘we had no alternative but to start a private practice of some sort. Ill equipped and dark and dingy premises. No help from banks to finance our practices’.Footnote ¹⁴⁰ In her Durban practice Dr Gonarathnam Goonam described the frequency with which a general practitioner dealt with patients whose illnesses were derived from personal trauma resulting from apartheid group areas and population registration legislation.Footnote ¹⁴¹

Black general practitioners’ access to their patients in hospitals was problematic. ‘Native Doctor Set Hospital Board a Problem’ read a newspaper headline in 1948 in prefacing discussion of anxieties provoked at Grey Hospital in King William’s Town, where one of Wits’ first African medical graduates had applied to be an honorary surgical staff member.Footnote ¹⁴²  The Cape Provincial Administration later clarified its policy by stating that, although it did not exclude ‘non-European’ doctors, hospital medical superintendents could still bar individuals.Footnote ¹⁴³ Responses to its ensuing hospital circular revealed discriminatory practices with conditional access imposed on black doctors, and prejudicial attitudes including one superintendent who viewed an African doctor as a ‘troublemaker’.Footnote ¹⁴⁴ Continuing anxiety about black doctors issuing instructions to white nurses and/or white junior medics, thereby subverting the established racial hierarchy of apartheid South Africa, resulted in black practitioners being pressurised to hand over patients to white colleagues in smaller, country or suburban hospitals.Footnote ¹⁴⁵

Trajectories For Medical Women

Early graduation returns from medical schools seldom had a gendered breakdown. Yet women were amongst the first black doctors: Mary Susan Malahelela (later Xakana) graduated at Wits in 1947 and Rawa Patel at UCT in the following year.Footnote ¹⁴⁶  However, Wits remained  overwhelmingly male, with only one in five female medical students by 1959.Footnote ¹⁴⁷  UNB  also had few women, with thirty out of 161 admissions between 1951 and 1955,Footnote ¹⁴⁸ whilst between 1957 and 1973 only one in seven of its graduates were women. Amongst this small minority Indians greatly outnumbered Africans.Footnote ¹⁴⁹ Over the longer term (1957–94), the Natal Medical Faculty had less than one in four women (twenty-three per cent) amongst its graduates,Footnote ¹⁵⁰ although MEDUNSA did rather better with thirty-six per cent.Footnote ¹⁵¹

A female student might feel double pressure from her gender and her race, and one UCT graduate woman commented ‘I had not just to be good, I had to be better than good – I wanted to show them that I was equal or better’.Footnote ¹⁵²  Despite this kind of ambition, in Natal cohorts between 1951 and 1970 only thirty-one per cent of females graduated compared to forty-six per cent of males.Footnote ¹⁵³ Vanessa Noble has argued that gender inequalities at the Natal Medical Faculty ‘greatly influenced’ women’s lives and choices.Footnote ¹⁵⁴ Mamphele Ramphele described how she and other politicised UNB women ‘learnt to be tough, insistent, persistent and to hold our own in public and private debates’.Footnote ¹⁵⁵

Black women were in a small a minority amongst black doctors, as were all medical women in the South African medical profession where, by 1960, only ten per cent was female.Footnote ¹⁵⁶ Between 1947 – when the first black medical woman graduated – and 1981, fifty-three such women had graduated at Natal and fifteen at Wits. (This total was higher than in the competing profession of law where only thirty-three females had qualified nationwide by 1982.) Career progression of medical women was broadly similar to men: they did their internships at black hospitals and most went into township practice. For example, Mary Xakana practised as a township GP with a special interest in tuberculosis (TB) sufferers and later became a community activist.Footnote ¹⁵⁷ Despite the stereotype being of a small female minority opting for a hospital career,Footnote ¹⁵⁸ amongst a self-selected sample of UNB women almost as many opted for a specialism as for general practice.Footnote ¹⁵⁹

One early black medical woman alleged that gender stereotyping was so ‘deeply entrenched’ that girls were expected to teach or nurse but not to doctor.Footnote ¹⁶⁰ Such external expectations might be internalised.Footnote ¹⁶¹ Some overcame this: Rawa Patel stated that ‘Ever since I was a little girl I wanted to be a doctor’,Footnote ¹⁶²  whilst Ozma Mbombo reflected that ‘It’s a good, good feeling to have achieved something you’ve wanted to do so long!’ after her tenacious progression through nursing and teaching to graduate as a medic.Footnote ¹⁶³  Such ambition helped withstand what Bozzoli has termed a ‘patchwork quilt of patriarchies’,Footnote ¹⁶⁴ and for medical women these involved the institutionalised sexism of the medical school with demeaning comments by lecturers, and a later discriminatory hospital environment, as at King Edward VIII Hospital with its sexist harassment, female professional invisibility and unequal salaries and benefits.Footnote ¹⁶⁵ Women also encountered the wider power differentials of patriarchal African and Indian cultures involving practical and psychological barriers to professional success.Footnote ¹⁶⁶ Indeed, elsewhere on the continent only a handful of African women qualified because of early gendered restrictions on school science lessons leading to low recruitment to medical school.Footnote ¹⁶⁷ Within a socially conservative medical profession in South Africa, young medical women discovered male power to be entrenched and institutionalised,Footnote ¹⁶⁸ so that a sample survey of registered medical women of all races in 1983 found that, because they were women, half had encountered gender discrimination and four-fifths had experienced career difficulties.Footnote ¹⁶⁹  Unfortunately, the South African Society of Medical Women – a professional organisation set up to advance and improve medical women’s position through confronting professional discrimination and inequality – was perceived by black female doctors to be ‘white, elitist and apolitical and consequently unable to meet the needs of black women’.Footnote ¹⁷⁰

Amongst a sample of UNB female graduates, most stated they would recommend medicine as a career for ‘intelligent and ambitious young women’ although a minority disagreed, citing problems in combining a medical career with marriage.Footnote ¹⁷¹ Given these difficulties, black medical women might turn to familial networks for support. For example, Dr Beryl Peters was the sister of the first Indian doctor in Pietermaritzburg, Maurice Peters, and worked closely with him, whilst Padmini Peters, one of his two medically qualified daughters, ran her practice from her late father’s medical rooms.Footnote ¹⁷²

Political Activism

Institutionalised racism resulted in some political activism, despite Kuper’s comment that ‘The African doctor, of all professionals, is probably in the best position to avoid political involvement’.Footnote ¹⁷³ At the beginning of the apartheid era older moderate medical leaders had withdrawn from the political frontline to devote themselves to their medical practices, although amongst a younger generation some pursued radical activism.Footnote ¹⁷⁴ Their highly politicised attitudes were reported in 1955 at Victoria Hospital, Lovedale where Dr Cooper, as medical superintendent, disapproved of ‘the very great activity shown by African medical practitioners especially in undesirable political movements’ such as the African National Congress (ANC). Cooper foresaw that ‘our hospitals [will] develop into breeding grounds for racial strife’. Even worse, in his opinion, was that ‘two or three African interns had a definitely unfavourable influence on student nurses’. Cooper insisted on black candidates for junior hospital posts providing a written undertaking to take no active part in politics, thereby causing their numbers to plummet.Footnote ¹⁷⁵

Repression by the early apartheid state resulted in the loss of scarce medical skills as politicised black doctors were tried, banned or went into exile.Footnote ¹⁷⁶ Following the banning of the ANC and the Pan African Congress in 1960, political activity slumped, before renewed activism occurred in 1969 with the creation of a South African Students Organisation (SASO) informed by Black Consciousness Movement (BCM) ideology. The universalist, humanist values of BCM synchronised with black students’ medical aspirations. For many, but not all black medical students, a culture of opposition became inseparable from medicine, with widespread political activism evident especially amongst Africans at UNB by the 1970s (with support for SASO) and in the 1980s (with support for the United Democratic Front and the ANC.Footnote ¹⁷⁷ This was enabled by a comparatively liberal campus,Footnote ¹⁷⁸  and by the fact that Indian, African and Coloured students had been brought together in a way that negated apartheid separatism.Footnote ¹⁷⁹ SASO’s first office at UNB was situated in the medical hall of residence because its first president, Steve Biko, was enrolled in the medical faculty. Biko was dismissed in 1972 after privileging the political struggle over his medical career, as indeed had the first cohorts of South African educated black doctors.Footnote ¹⁸⁰ But a fellow activist recollected the importance of the SASO subculture, and how Biko and fellow SASO leaders provided ‘pride, hope and things to aspire towards’.Footnote ¹⁸¹ After SASO was banned in 1977, Natal’s Medical Students Representative Council published the radical UNB News, which revealed simmering discontent over exclusions as well as high failure rates, and with student boycotts occurring in 1977, 1980, 1982, 1984 and 1986.Footnote ¹⁸²  The News (itself later banned), commented that ‘remarks passed by some staff instil fear and uncertainty’.Footnote ¹⁸³ Indeed, an earlier inquiry in 1975 had found a politicised student body wary of the white staff, viewing their perceived paternalism as unacceptable, and ‘suspicious of motives’.Footnote ¹⁸⁴ At MEDUNSA the students accused the largely Afrikaner staff of racism, even of terrorising them,Footnote ¹⁸⁵  with unexpected elements in examinations viewed as those of an ‘enemy who is out to sabotage’.Footnote ¹⁸⁶  The MEDUNSA campus was disrupted by  boycotts during 1983 and 1989,Footnote ¹⁸⁷ and any easing of racial tension had to await the post-apartheid appointment of the first black vice-chancellor.Footnote ¹⁸⁸

SASO was male-dominated; its female members on the Durban campus left its patriarchal assumptions unquestioned, although they shared its opposition to racial domination.Footnote ¹⁸⁹ In contrast, at MEDUNSA there was an active women’s group in the black consciousness-informed Azanian People’s Organisation.Footnote ¹⁹⁰ Amongst politically active medical women more generally were Gonarathnam Goonam (active in the Indian Congress of Natal), Ansuya Singh of the King Edward VIII Hospital, Margaret Chuene Mncadi (an ANC activist who served a prison sentence before going into exile), and Pascal Ngakane who was imprisoned on Robben Island from 1964 to 1967. Studying at UNB, Mamphela Ramphele was one of the BCM founders, and suffered internal banishment in Tzaneen from 1977 to 1984. Another at Natal was the later ANC Minister of Health, Nkosazana Dlamini-Zuma, a member of the banned ANC who fled in 1976 and qualified in exile. Amongst male medical activists were Sibongiseni Dhlomo (imprisoned on Robben Island for terrorism during 1987–91), Footnote ¹⁹¹ and ‘Chota’ Motala (an accused in the ‘Treason Trial’ of 1956–60, later banned during 1963–8)

Apartheid might radicalise even the apolitical. Dr Anvir Adam stated that he ‘was detained for the stance I took against human rights abuses’ and that ‘this was all to do with the disadvantaged state and glaring imbalances between white and non-whites. I am not a politician’.Footnote ¹⁹² Unlike black lawyers – with their highly visible human rights actions in court – many doctors were valuable precisely because they operated below the horizon of public visibility. Communities co-opted selected GPs to look after individuals injured in ‘the struggle’; most gave free treatment whilst keeping minimal documentation, thus avoiding admission to a hospital where security services would pursue injured activists.Footnote ¹⁹³ In Pietermaritzburg Drs Chota Motala and Maurice Peters treated without charge the Indian women injured during passive resistance campaigns.Footnote ¹⁹⁴ In later apartheid years the struggle also encompassed labour activism, with MEDUNSA medical students boycotting classes in solidarity with striking hospital workers.Footnote ¹⁹⁵  In Cape Town Dr Norman Maharaj described himself acting as ‘a political being, as an agitator, as a militant’ in organising general hospital workers into an independent trade union.Footnote ¹⁹⁶

The activism of white medical students had limited success in improving the situation of black colleagues. Wits students created scholarships, raised the issue of funding internships for Indians with provincial administrationsFootnote ¹⁹⁷ and protested against the prohibition of black students rotating to the J.G. Strijdom or Johannesburg Hospitals, showing solidarity in refusing to be placed there.Footnote ¹⁹⁸ In earlier years the UCT Medical Student Council made only ineffectual efforts to ameliorate black students’ problems by raising issues involving discrimination, but then accepting that apartheid policies prevented their resolution.Footnote ¹⁹⁹  Later, UCT medical students took a more active role in moves towards desegregation, focusing on changing the segregated arrangements at the training hospital of Groote Schuur.Footnote ²⁰⁰

Reconciliation and Transformation

From the 1980s institutions showed signs of change in their attitudes towards the training of black health professionals. In 1980 the Dean of Wits Medical School demanded a radical equalisation programme together with affirmative action to bridge gaps in medical training,Footnote ²⁰¹ whilst a few years later Dr Marian Jacobs, a later Dean of the UCT Health Sciences Faculty, indicted the apartheid training system for producing ‘rich white doctors’ for the white urban sector.Footnote ²⁰²

Each of the two historically white training institutions later held formal internal reconciliation processes to acknowledge institutional collusion with apartheid and failure to challenge discriminatory policies, or address unequal opportunities. Wits noted that senior staff acquiesced in silence over institutionalised discrimination, that black medical students and staff had been humiliated, made to feel inferior and inadequate, treated insensitively, denied advancement, generally neglected and made to feel either ‘incidental and peripheral’ or ‘outsiders in a hostile environment’. Whilst acknowledging individual and collective protests it judged that the faculty as a whole had ‘colluded with racial apartheid and enforced racial discrimination’.Footnote ²⁰³  And at UCT individual submissions from past black medical students were eloquent about what one termed ‘a culture of abuse’ and another ‘a daily feeling of humiliation’ in their training.Footnote ²⁰⁴  Others testified to their training as involving being ‘cheated’, made to ‘feel inferior’, or being part of an ‘invisible group’, with too many staff seen as patronising, paternalistic, insensitive or condescending. One encapsulated the impact of UCT’s permit system as having been that ‘you never felt accepted, or that you belonged there’.Footnote ²⁰⁵

After the apartheid government lifted its severe restrictions on black students’ ability to train at these two historically white universities in 1986, their applications increased,Footnote ²⁰⁶ and by 1999 black medical students outnumbered white students at Wits and UCT. Footnote ²⁰⁷ The historian is able to track the transformation of UCT’s demographic profile: from 1986 to 1991 African and Indian applications grew significantly, with the first African medical graduate in 1990. Increasingly, African applicants had experienced tertiary education before UCT, so nearly all graduated successfully, although those entering directly from school fared more poorly.Footnote ²⁰⁸ UCT affirmative action assisted black students who had had inferior school education. In 1993 African students were admitted under a Medical Academic Support Programme and completed three pre-clinical years in four, whilst benefiting from additional tutorials and non-academic mentoring and bursaries.Footnote ²⁰⁹

The female entry steadily increased so that, by 1993, women from all races made up fifty-six per cent of the first year and in the following year thirty per cent of black admissions were female.Footnote ²¹⁰  Less positively, however, after 1999 black women formed a lower proportion of graduations than enrolments, indicating poorer comparative performance than black men.Footnote ²¹¹ This contrasted with the USA experience where, from the seventies to nineties, female black medical students had a faster growth than black males in graduating physicians and in the award of MD degrees.Footnote ²¹²

The post-apartheid period stimulated institutions and individuals to make sense of their past identities. There were broadly comparable experiences for black medical students, whether studying at black or historically white institutions.Footnote ²¹³ Whilst the latter establishments made symbolic acts of restitution, the former grappled with the need to find a satisfactory post-apartheid identity. That of UNB became an apartheid survivor,Footnote ²¹⁴  triumphing over unhappy memories of conflicts between a white administration and a black undergraduate body.Footnote ²¹⁵ MEDUNSA’s earlier functional identity of servicing the ‘homeland’ populations with health workers was replaced by a new self-identity as ‘a pioneer of community-based tertiary education’.Footnote ²¹⁶

Reflections

In 1980 Philip Tobias laid the blame for a ‘scandalously low percentage of new doctors in the majority sector of the population’ squarely on the apartheid state.Footnote ²¹⁷ However, the received record of the apartheid years frequently ignored racial differences, so that a glaring shortfall in African doctors obscured the pressing need for more doctors of colour. One of the more beneficial ironies of apartheid policy was a substantial growth of Indian doctors. This was a group inadvertently benefiting from an inequitable system, as had black nurses.Footnote ²¹⁸ Within a central apartheid policy of separate group development, placing black medical students of different ethnicities side by side on campus was anomalous but was an effective strategy of divide and rule. Racist medical training with its abuse of human rights thus fractured a common sense of identity and status. Racial tensions between black doctors on campus have seldom been discussed in post-colonial and post-apartheid discourse so that a default view of solidarity has prevailed. Recently both A. Burton and V. Noble have emphasised the need for complex analyses focusing on alternative and selective memory production.Footnote ²¹⁹ Certainly, stressed relationships between African and Indian students existed at UNB over issues such as differential failure rates,Footnote ²²⁰ whilst confrontation at MEDUNSA involved African accusations of anti-social Indian cliques.Footnote ²²¹  Admission of a few white undergraduates at  MEDUNSA in 1995 also led to anxieties amongst black students that they would be deprived of what limited opportunities existed.Footnote ²²² For black women patriarchal prejudice reinforced racialism and was a major factor in the considerable difference between women’s and men’s progress in translating enrolments into graduations.

This article has explored reasons for professional marginality in experiences of class and geographical inequity (in training provision), inadequacy (in student finance), incompleteness (in clinical experience), and distortion (in career path.) Although shaped within a common discriminatory framework, the collective term of ‘black doctor’ has obscured diversity in experience and, for many, under-achievement in professional outcomes. Within segregated structures separate was far from equal. Burdens of isolation, alienation and humiliation had a profound psychic impact, such that one of the first African graduates at UCT reflected on his damaged self-confidence in being ‘spoke down’ to, concluding dramatically that ‘I think my soul has been damaged’.Footnote ²²³ Despite the potential for membership of an elite group within the black community and of a privileged professional group in wider society, most black doctors under apartheid achieved second-class or subaltern status. They were ‘marginal men and women’.Footnote ²²⁴ The demeaning impact of institutionalised racial discrimination in South Africa was thus far worse than in the USA where African American physicians also faced under-representation, bias and exclusion.Footnote ²²⁵ Overall the personal and professional experience of black doctors under apartheid showed a profound disconnect from the universalistic professional ideal for South Africa envisaged for black doctors by an earlier African role model, Dr A.B. Xuma. He had stated that ‘Disease knows neither class nor colour …the same knowledge and the same skill in the treatment is required’.Footnote ²²⁶