Expertise, ethnicity and equity
Growth points in healthcare in apartheid South Africa – by Anne Digby
Urban developments in South African healthcare, both past and present, have received more attention than rural ones. I am recalibrating this focus by giving importance to non-urban areas, not least because Africans – the demographic majority of South Africa – live there in huge numbers. I have been fortunate in discovering very good sources on rural healthcare, and I shall briefly discuss three examples here: the Valley Trust in KwaZulu-Natal, the mission-run All Saints Hospital in the Eastern Cape, and the little-known outreach activities of academic hospitals, which, from their urban location, extended expert help into rural areas.
The Valley Trust made available its extensive, continuous documentation on its history and also facilitated interviews with its staff and with local traditional healers. The Trust was an independent voluntary organisation set up by Dr Halley Stott during the late 1940s, in order to encourage holistic health within the evocatively named Valley of a Thousand Hills. The Trust encouraged promotive and preventive healthcare for Zulus living on its extensive site through good nutrition, fostering the development of individual and communal vegetable plots as well as fish ponds, and with support given by an agricultural demonstrator and by dietetic classes. Importantly, Zulu customs and traditions were respected, including the work of traditional healers with local people. The Trust’s nutritionally focused programme developed side-by-side with the government-financed Botha’s Hill Health Centre, which brought modern scientific medicine to local people. Unusually amicable relationships existed between the Centre’s staff and traditional healers. Within the Trust, healers were recruited as community health workers; they promoted the virtues of good nutrition among their clients, were assisted in growing medicinal plants in their own gardens and also attended workshops.
The Trust’s reforming promotive and preventive health methods were disseminated to visiting medical and nursing students, while residential courses on nutrition as the path to better health were organised for healthcare personnel from all over southern Africa. Among those attending were nurses from mission hospitals in the Transkei. Beginning in the 1970s, however, South Africa’s extensive network of mission hospitals was nationalised by the apartheid government, preparatory to handing the institutions over to nine newly created ‘homelands’ or ‘Bantustans’, where they were intended to act as the linchpins of hospital-centred district health systems for the local African population. Mission hospitals in South Africa have not been the subject of detailed historical analysis, despite the fact that they – alongside government district surgeons – were the backbone of healthcare in many rural areas.
Extensive papers on the later years of one Transkeian mission hospital – All Saints Hospital – were collected by a former medical superintendent, Dr Ronald Ingle, and I am fortunate in having been given access to them. All Saints was in the Engcobo district and served about 140 000 Africans in 1970. The local population’s demand for the hospital’s services continuously increased, so that facilities might be over-stretched. The hospital provides an interesting case study of how a well-run rural hospital developed a prototype district health service with a network of stationary and mobile clinics bringing medical care to traditional communities, particularly to mothers and babies. Given extensive local malnutrition in this rural area, African health educators were employed as mid-level health workers in order to promote the Valley Trust’s ideas of good nutrition.
A third area of interest is academic teaching hospitals such as Groote Schuur in Cape Town or Ga-Rankuwa in Pretoria and the way in which they tried to support under-resourced rural areas. Groote Schuur Hospital periodically sent out consultants to a variety of hospitals in the Eastern Cape in order to help provide some in-service training for staff, and to see complex cases before referring selected patients back to Cape Town for specialist treatment. Ga-Rankuwa’s Department of Family Medicine provided weekly supportive visits to understaffed clinics in the neighbouring ‘homeland’ of Bophuthatswana.
These three case studies are located within the wider context of health policy and provision, and illustrate how the progressive ideas contained in the Gluckman Report of 1944 (which had recommended a national health service of promotive, preventative and curative medicine) were not altogether lost in apartheid South Africa, as is usually depicted. Remarkably, some of these ideas – including district health services, networks of rural/urban health services, a strategic place for mid-level health workers, and a recognition of a legitimate place for traditional healers – had a more continuous history and were to find their place in the transformative health policies of the newly elected democratic government after 1994.
Anne Digby is Research Professor in History, Oxford Brookes University.