A personal history: social medicine in a South African setting, 1952–5. Part 1: The shape of ideas forged in the second world war

Short abstract

The second part of this personal history focusing on the ups, downs, and politics of social medicine in Alexandra Township, South Africa, will be published in the August issue of the journal.

This is a convoluted tale. After an unlikely beginning in South Africa, it meanders with the best of intentions through misadventure, debacle, and inadvertent emigration. South Africa became a Dominion of the British Empire by the Act of Union in 1910. The act united several constituencies into four provinces. In 1939, Barry Hertzog was prime minister of the “Fusion” government, and Jan Smuts was deputy prime minister. This was an unusual arrangement, a compromise reached after a close election between Hertzog (leader of the unremittingly anti‐British Afrikaner Nationalist Party), and Smuts (leader of a broader, more catholic United Party). Both had been generals in the Boer war* (1899–1902) led by President Paul Kruger of the Transvaal Republic against Britain.

Thereafter, Smuts was a reliable British ally whom they held in great esteem (indicated after the second world war by his ceremonial position as chancellor of Oxford University). Although Smuts opted for a policy of reconciling the interests of English speaking with the Afrikaans speaking white population, in respect of the black population “his realpolitik” was scarcely enlightened. In the crucial vote in the 150 member parliament of whether to join Britain in the second world war, Smuts ousted the antiwar prime minister by a slim 13 vote margin.

In 1940 when this personal story begins, I was living with about 20 others in the small Men's Residence of the Teacher's Training College in Johannesburg. A youth of 18 interested mainly in studies of literature and history, this was my second year on a scholarship at Witwatersrand University (Wits). Even so my literary fare was limited. As a boy I had devoured Dickens, Thackeray, Victor Hugo, and the 19th century writers; now at university, my acquaintance had only begun with D H Lawrence, Aldous Huxley, Virginia Woolf, Tolstoy, the modern Americans like Dreiser, Steinbeck, and others of the 20th century.

On 1 September 1939, Adolph Hitler breached one more solemn treaty and invaded Poland. On 3 September Britain's reluctant Prime Minister Chamberlain had declared war. On the front between the Wehrmacht and the Allied forces, not much happened for the six months of the derisively named phony war. The story gathers pace in mid‐June, 1940. The supposedly impregnable Maginot line was simply bypassed by the Wehrmacht. The Allied Forces in disarray, the British evacuated their troops at Dunkirk and the French government retreated into the south of France. Upon the collapse of the French, Hitler entered Paris in a triumphant parade. Not only Europe, but the whole world seemed at risk from the forces of Hitler's militant Nazi Germany and his role model Mussolini's Italy. It was a desperate moment.

In the hall of the residence, together we listened in stunned silence to the shattering radio broadcast of the collapse before the German blitzkrieg of the Allied front in France and the British evacuation from Dunkirk that followed. It was several shocked moments before talk followed. I could not but agree with four of the seniors that the only course was to join the armed forces at once. Together, we signed up the next morning in the (South African) Irish Infantry, a battalion said to be recruiting and being readied for action (see fig 1). I was assigned to a Vickers machine gun crew, ignorant until much later of the inadequacy of our weapons and equipment. The machine guns, the rucksacks, and the .303 rifles we carried were all of first world war vintage (so we were informed by a member of the platoon who had served in that war).

Figure 1 The new recruit, June 1940. Private, South African Irish Infantry Battalion.

After a few months of basic training as part of the 5th Brigade, 1st Division, South African Defence Force, we sailed for Kenya. From its green highland forests and plains we headed north in 3‐ton trucks and primitive, improvised armoured cars (the latter converted from the chassis of Ford trucks). We bumped and ground through the fine grey dust of the sun baked, lava strewn, and volcano cratered desert of northern Kenya and broached the Southern Abyssinian border. Mussolini's reluctant soldiers, holed up in small fortresses, had neither the desire nor the means to resist effectively. In short order, the campaign in the south was over. Italian surrender before the onslaught of other brigades of the South African First Division soon followed in the coastal east and mountainous north of Abyssinia. The South African First and Fifth Brigades then embarked for Egypt. There, in the Western Desert of Egypt and Libya, we engaged again with the Italians and with Rommel's keen and more warlike Afrika Corps. A long and bitter campaign ensued. In the battle of Sidi Rezegh (on 22 November 1941) Rommel's tanks, armed with devastating 88 mm guns, virtually destroyed our infantry battalion and many were taken prisoner. Survivors comprised about 20% including myself, and were reassigned to other units.

Do not fear that this is another old codger's war story, although I cannot deny that I qualify for the role. The point of this introduction is that, despite diversions and the mutual destruction of warfare during three desert years, both my political understanding and my social commitment matured. The sergeant in charge of my machinegun section, Arthur Rowney, was a quiet, cultivated Englishman, a socialist, and an intellectual. Among other things, he received a regular supply of literature: the weekly New Statesman edited by the fiery Kingsley Martin arrived in bundles of copies for several weeks together. Once read, Sergeant Rowney routinely passed them on to me. Also, among the so called home comforts for our “boys up north” so diligently and kindly put together on the home front—in the main knitted socks, sweaters, sweets, and a box of 100 cigarettes each—was a supply of somewhat battered books. War is a waiting game, and there was always time to read.

After the decisive victory of the third battle of Alamein in 1943,¹,² and three years of campaigns in Abyssinia and the Western Desert, the First Division of the S A Defence Force (SADF) was recalled. Arrived in South Africa, we were given three options: a choice of remaining with the battalion, taking a discharge, or transferring to any other branch of the fighting forces. The outcome of the war still in question, the original reasons for my having enlisted were unchanged. Yet I had wearied of the life of a private soldier always at the beck and call of authority. Hardened by three long years of bush and desert and all of 21 years old, with a growing antiauthoritarian streak, I first engendered by boarding school was responding less and less well to the ever present demands of military bureaucrats. I chose to transfer to the South African Air Force (SAAF) as aircrew.

The transfer process began at an Air Force training base at Waterkloof not far from Johannesburg. There David Tabatznik, whom I had known as a member of my first year English seminar class in 1939, was assigned to test my aptitude for aircrew. He was in the same unit as Zena Stein and told her about me (presumably because of the bits of previous history they each shared with me). Now she, like him, was a member of a unique Aptitude Test Section directed by Simon Biesheuvel, a Wits Professor of Psychology transformed into colonel. He was given a lien to recruit to his unit any bright academically qualified recruit he could find among those who volunteered for the SADF. This section evaluated all new volunteers for aircrew for their suitability by putting them through a battery of psychological tests and interviews.

I was happy to meet Zena, someone I had known in my schooldays. Ever since I was sent to Durban in January 1931 to attend primary school, her elder brother Sylvester Stein had been a close friend. My home was some 600 miles away in the Northern Transvaal bushveld; the area was bare of schools, excepting a one room school house converted from a bywooners (or squatters) cottage, where at age 6 years I was through the syllabus in less than a year. If I was to be properly schooled, some kind of translocation was inevitable. My widowed father had then sent me to Durban where an aunt undertook to care for me without discrimination among her family of six.

Sylvester was the wit and lively spirit of the small childhood playgroup of three that at once adopted me and so became a gang of four. Remarkably in the culture of young schoolboys, Zena was nearly always included in our hikes into the countryside and in many games. We were close enough that Sylvester and she even organised for me the then routine Barmitzvah party. Instead of the signature Saturday night of new tailored blue suits, party dresses, and parlour games, they turned it into an unorthodox and riotously jolly affair in my aunt's quite spacious garden.

Back to Waterkloof: all potential flying crew—first before being accepted and assigned a function, and then again before discharge—were required to undergo the process of aptitude testing. Now, as I can and do always tease Zena, she was in the powerful position of having inside knowledge—never divulged to me—of my psyche and my wits. She knew the scores on all the aptitude tests to which I was subjected. In truth, I confess I was already in awe of her academic record. History was her major at UCT; in 1943 she graduated and won the prime Queen Victoria scholarship to Cambridge for her MA thesis.

I was selected for aircrew training as an observer—that is, a role combining the functions of navigator and bomb aimer. Zena explained that the strike against me for pilot training was my advanced age of 21 going on 22. During the training process, in the relative luxury of airfield barracks for the better part of a year, one learned the genuine skills of navigation and aiming bombs with precision at practice targets. Also, out of camp over weekends we tasted some of the jollity and social grace of the everyday normal life of students and civilian youth. In the last phase at base at Oudtshoorn in the semi‐desert of the Small Karoo, the theoretical navigational lore we had learned on the ground was put to the test. We flew in small, ancient Anson training aircraft, with front seats for pilot and copilot, and one in a mid‐position for the navigator. For a young earthbound veteran, to fly for the first time was itself exciting. More than that, when the plane had struggled through the downward air currents between the canyon walls of the Swartberg Mountain range, to rise above enveloping grey clouds into the sunlight, it was pure wonderment to look down on the unanticipated beauty of a brilliant white expanse of cloud obscuring the world below.

Early in 1944, with my observer's half‐wing on the breast of my uniform and a lieutenant's pip on the epaulettes, I was assigned to Italy to join 24 squadron of Three Wing of the SAAF at Iesi near Ancona (see fig 2). After the rawness of Africa, this first encounter with a cultivated and cultured civilisation mellowed by two millenniums was enough to move one to poetry (as in fact it did). The squadron flew new American made B26 Marauders. These fast, short winged “bombers were incapable of descending in a gentle glide on landing, a feature that earned the appellation the ‘flying brick”. As observer, one sat in the glass nose and hurtled toward the ground like a hawk spotting prey. Not without some thrill, the squadron targeted bridges and marshalling yards of the towns of north Italy, the Austrian Tyrol, and the Balkans. As we released our bombs over the rail yards of heavily fortified towns and cities like Rovigo and the bridges across the river Po, one had a strange sense of detachment, even of inviolability, as the white puffs of antiaircraft fire burst around and below us. Fortunately, big hits that downed our planes were comparatively rare. Occasionally shrapnel from antiaircraft fire left some holes in the fuselage.

Figure 2 The newly graduated observer, South African Air Force.

Soon after being briefly hospitalised in Bari at the southern tip of Italy for a herniorrhaphy, however, the drive back up the shattered east coast could arouse only unease and disquiet at the devastation wrought by our forces both on the ground and from the air. By early April 1945, our ground forces were at the River Po and Italy was close to surrender. One day, upon the return of our squadron from a sortie across the Adriatic our commander, looking very serious, called me into his quarters. It was no matter of discipline or error as I supposed and feared. My father was not well, he said solemnly, and I was to fly back to Johannesburg at once. There I found my widowed father struggling to breathe in a nursing home, and was able to sit with him each day for the two or three weeks before he died. In a city aquare in Milan, a mob hanged Mussolini! On 2 May, Italy surrendered. It was not long before the Russians advanced into Germany and Hitler committed suicide in his thoroughly fortified bunker.

On leaving Italy one had known that the end of the war in Europe was near. I had begun to think a little of what I might do in civilian life. The horrific Nazi ideology had provided the personal impetus for entering the struggle five years before. Thereafter, my main criterion for postwar life slowly evolved into a sense that whatever I undertook, it should be not only benign but socially and politically useful. I had always assured myself, however, against the hopes of two fashionable aunts (both had been sent to finishing school in England), that I would never be the fortune making city doctor.

As I discussed the matter with my best friend while I prepared to leave the squadron for home (see fig 1)—he was a law graduate—he countered my assumptions: “Think again”, he said. “Medicine can make large socially useful contributions. It does not have to confine you to the sterilities you fear of fashionable bourgeois Johannesburg.” He persuaded me at the least to think about medicine as a possibility.

Not long after, back at Waterkloof to undergo the process of discharge, I was again tested by an obviously bright but somewhat taciturn fellow. This second tester of my aptitudes, I learned only later, was courting Zena. Unknowing, I looked her up. Appropriately, as a historian she had been transferred from the testing unit to address the history of the Medical corps in the war. Now twice weekly, with routine duties done she was able to join a special premedical night course designed by Wits professors for service people who on discharge would pursue medical studies. She was already near to completing the first year of the six year programme. I learned from her also that an accelerated first year course for former volunteers would begin in August 1945 to be completed in six months. With no further doubts, I registered at once.

Together, as we neared the completion of first year studies, we hatched a plan to allow Zena to take up her Queen Victoria scholarship at Cambridge. My part in the plan was to apply for a Rhodes scholarship at Oxford, near enough to Cambridge to keep in touch. I was well positioned, with firsts in all four subjects (a level, one should emphasise, I was never to repeat). Together with a friend who owned a car—a two seater with an open “dicky‐seat” behind the front cabin—we happily drove the 1000 miles to Cape Town for the summer vacation (six relaxing weeks from December through January). It was a city I knew only from a weekend landing on a training flight artfully combined with a rugby match against the local SAAF training camp. Zena having earned her MA there, a multiplicity of relatives and friends were ready to welcome her and me as well. I was duly spellbound by the unexcelled beauties of the city. In my many and often inadvertent travels over more than 60 subsequent years, I have seen no city more beautiful, not in Egypt (Alexandria); Israel (Jerusalem); Italy (Rome, Florence, Pisa, Perugia, Naples, Venice, etc); Australia (Brisbane, Sydney, Melbourne, Adelaide, Perth); Latin America (Buenos Aires, Salvador, Rio de Janeiro, Lima, Mexico City); Durban in South Africa. I desist—the list could go on.

Zena guided me also beyond the city to all the delights of the Cape Peninsula—the spectacular coast lines, the mountain looming behind the city and overlooking the harbour, with the university endowed by Cecil Rhodes nestling in its side; the vineyards with their old gabled Cape Houses, the roads shaded by 17th century oaks planted by Simon van der Stel (the first governor appointed at the Cape by the Dutch East Indies Company); the Peninsula and the winding drive along its rockbound edge to its tip at Cape Point, the Atlantic Ocean crashing against its sides. She had not neglected also to fix an appointment with Ann Fisher, reputedly the best portrait photographer in Cape Town for the portrait the Rhodes Committee required (fig 3). The long vacation ended, back in Johannesburg I sorted my mail. There, excitedly I found an invitation to meet the Selection Committee for the Rhodes Scholarship. But there was a hitch. The date for the interview was two weeks previous to our return. I did not have the wit to think of explaining and asking to meet the committee at a later date. (In a further unhappy twist of circumstance, within a short time thereafter the successful applicant had a schizophrenic breakdown). In the light of our subsequent experience, neither Zena nor I has ever had occasion to regret my naivete.

Figure 3 Cape Town, 1946. The medical student.

For the five remaining years at medical school we both slogged on, studying and holidaying together. The programme was demanding but nearly always interesting. We married early in 1949, during the fifth year of study. In the middle of the next and critical final year, Zena gave birth to our oldest child. Some three months later, we underwent the always stressful final clinical examinations in the three major disciplines of medicine, surgery, and obstetrics/gynaecology. Each of these comprised three elements: full scale written examinations; the rapid examination, diagnosis and care of a series of “short cases” each with some or other typical diagnostic feature; and one “long case” to be fully examined clinically, described, and diagnosed. Like most of the minority in the class who were women, Zena suffered to a degree from the hostility of the unredeemed antifeminist diehards among the then senior faculty.

A typically stressful and humiliating encounter transpired in her final obstetrics examination. The viva voce was conducted by Professor Creighton, a senior and notoriously irascible visiting examiner from the University of Cape Town, together with Oswald (known as Ossie) Heyns, in contrast the distinctly benign chair of the Wits Department. Creighton asked what she would do if a delivery was delayed well beyond the due date. It was only three months since Zena had herself given birth more than two weeks beyond the expected date to our first child. Of course, her answer could and did draw exactly on her own delivery, conducted by a senior member of the obstetrics department at the university affiliated teaching hospital (the Queen Vic). In a distressing irony, the idiosyncratic Professor Creighton was little in agreement with the procedure she outlined. Angrily he dressed her down and seemed ready to fail her. Ossie Heyns had the good judgment and decency to defend her, and she left the ordeal unscathed.

As early as the second year in medical school, we had begun to formulate ideas about social medicine. Such a leaning was natural to enlightened postwar ideology, and further stimulated by both Joseph (Joe) and Theodore (Teddy) Gillman. These two brilliant brothers, both in the anatomy department, were inspiring and humanely leftwing. Given our social bent, we had early on read the book on the famous Peckham Experiment in London.³ More important, early in Zena's part time first year course, Isaac Kaplan (a fellow former volunteer student) and his newly graduated wife Charlotte (then an intern), had become her close friends. Charlotte was a cousin of Sidney Kark. It was from her that we first learned of his ideas on social medicine and of his work in the field with his wife Emily (nee Jaspan), a history that had begun while they too were students at Wits medical school in the mid‐1930s. While still a student, Sidney and fellow student Harding Le Riche had conducted a unique survey of growth and development in a population sample of the black township of Alexandra.

Soon after graduating, they had joined the national Department of Health, and persuaded the director to allow them to build a rural health centre to implement and demonstrate the ideas and the practice of social medicine. For this, they chose Pholela, a rural site deep within an “African reserve” in the province of Natal. The core of those ideas rests on approaching health states as a characteristic of communities, and in addressing such characteristic problems at the community level. That address, in sum, is to provide comprehensive health care for communities: primary care in the first instance, followed by evaluation of the health states of the community, education in preventive measures for healthy living among individuals and communities, and the imaginative promotion of a healthy local environment.⁴,⁵,⁶,⁷ It became obvious that we must seek out the Karks. By that time, in the late 1940s, they had left their first practice base at Pholela to others they had trained and moved to Durban. There they were absorbed in the major venture of developing a national training base for social medicine. They set about creating a cast of medical, nursing, and community staff to serve the whole country.

The Minister of Health in the wartime Smuts government, Dr Henry Gluckman, had sponsored a national commission to examine the health needs of the country. A liberal postwar swing of ideology among the allied victors was expressed in the Gluckman Report. Much impressed by the work of the Kark's at Pholela, the Gluckman commission's report of 1946 was imbued by Karkian ideas. Gluckman had at once approved and funded the new training centre that was to produce a staff with the requisite training to sustain a new ambitious national health plan for all races equally.

It recommended a National Health Service that would provide for all sections of the population.⁸ The report gave the postwar Department of Health licence to allow the Karks to implement their ideas on a larger scale.

Sidney was a man of noble aspirations and practical imagination. He had founded the Socialist Society, and served on the Student's Medical Council, the University‐wide Student's Representative Council, and also as university delegate to the liberal National Union of South African Students (NUSAS). In his works and in his writings, he expressed a coherent philosophy and practice of social medicine. We had found a guide to our future course.

The South African academic year runs concurrently with the calendar year. At the first opportunity—the Easter break of our second year in medicine in 1946—we drove the 400 miles to Durban and sought out the Karks.