Doctors beyond Borders: The Transnational Migration of Physicians in the Twentieth Century 9781442629622

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DOCTORS BEYOND BORDERS The Transnational Migration of Physicians in the Twentieth Century

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Doctors beyond Borders The Transnational Migration of Physicians in the Twentieth Century

EDITED BY Laurence Monnais and David Wright

University of Toronto Press Toronto Buffalo London

© University of Toronto Press 2016 Toronto Buffalo London www.utppublishing.com Printed in Canada ISBN 978-1-4426-2961-5 Printed on acid-free, 100% post-consumer recycled paper with vegetablebased inks. ______________________________________________________________________ Library and Archives Canada Cataloguing in Publication Doctors beyond borders : the transnational migration of physicians in the twentieth century / edited by Laurence Monnais and David Wright. Includes bibliographical references and index. ISBN 978-1-4426-2961-5 (cloth) 1. Medicine – History – 20th century. 2. Physicians – History – 20th century. 3. Emigration and immigration – History – 20th century. 4. Transnationalism – History – 20th century. I. Monnais-Rousselot, Laurence, editor II. Wright, David, 1965–, author, editor R133.D62 2016 610.9 C2015-907582-3 ______________________________________________________________________ University of Toronto Press acknowledges the financial assistance to its publishing program of the Canada Council for the Arts and the Ontario Arts Council, an agency of the Government of Ontario.

    Funded by the Financé par le Government gouvernement du Canada of Canada

an Ontario government agency un organisme du gouvernement de l’Ontario

Contents

Acknowledgments  vii Introduction – Doctors beyond Borders: Entanglements and Intersections in the Modern History of Medical Migration  3 laurence monnais and david wright 1  Imperial Connections and Caribbean Medicine, 1900–1938  20 juanita de barros 2 Pathways of Perseverance: Medical Refugee Flights to Australia and New Zealand, 1933–1945  42 john weaver 3 Public Health and Persecution: Debates on the Possible Migration of Jewish Physicians to Sweden from Nazi Germany  73 annika berg 4 “A mysterious discrimination”: Irish Medical Emigration to the United States in the 1950s  96 greta jones 5 A System of Exclusion: New Zealand Women Medical Specialists in International Medical Networks, 1945–1975  118 john armstrong 6 From Zebra to Motorbike: Transnational Trajectories of South Asian Doctors in East Africa, ca 1870–1970  142 margret frenz

vi Contents

  7 Draft Doctors: The Impact of the Vietnam War on the Migration of Foreign Doctors to Canada  166 david wright, alex ketchum, and gregory marks   8 “Without racism there would be no geriatrics”: South Asian Overseas-Trained Doctors and the Development of Geriatric Medicine in the United Kingdom, 1950–2000  185 joanna bornat, parvati raghuram, and leroi henry   9 Providing “Special” Types of Labour and Exerting Agency: How Migrant Doctors Have Shaped the United Kingdom’s National Health Service  208 julian m. simpson, stephanie j. snow, and aneez esmail 10 Connecting to Canada: Experiences of the South Asian Medical Diaspora during the 1960s and 1970s  230 sasha mullally and david wright Contributors  257 Index  261

Acknowledgments

The editors and authors would like to thank several individuals and funding agencies that made this edited volume possible. The book arose from a conference on the transnational migration of physicians in the twentieth century, held at McGill University in September 2012. The conference was generously funded by a Social Sciences and Humanities Research Council of Canada Aid to Research Workshops grant, which also included a subvention for the publication of this collection of selected papers. We would be remiss not to also mention the Canada Research Chairs program, which has provided both of the editors with time and the resources to embark on scholarly activities such as this, as well as our host institutions, the Université de Montréal and McGill University. We are grateful to our editor, Len Husband, and his team at the University of Toronto Press, as well as two anonymous peer reviewers who helped refine the dominant themes of the book. The University of Toronto Press adheres to the highest standards of scholarship, so we are proud to publish the volume with them. Many thanks to Wayne Herrington for shepherding the copyediting queries and to Noeline Bridge for her excellent work on the index. We would like to acknowledge Heather Whipps, the Administrative Coordinator at the Institute for Health and Social Policy, for her tireless organization of the original conference and Renée Saucier, for research assistance in support of the book. The cover image was identified and retrieved with the kind assistance of Gerry Maffre and the Canadian Immigration Historical Society (www.cihs-shic.ca). Permission to reprint the photo was granted by the original photographer, Roger St Vincent, and the Canadian Museum of

viii Acknowledgments

Immigration at Pier 21, Halifax, which curates thousands of wonderful photos documenting the history of immigration to Canada. Special thanks to Jennifer Hevenor at Pier 21 for digitizing the photograph at such short notice. Finally, many of these chapters incorporated dozens of interviews of doctors who migrated across national lines during a century of political, social, and cultural upheaval. Their remarkable stories provide for so much of the compelling historical material contained in these chapters. On behalf of the many scholars who contributed to this book, we dedicate the volume to them and their families. Laurence Monnais David Wright Montréal, Canada

DOCTORS BEYOND BORDERS The Transnational Migration of Physicians in the Twentieth Century

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Introduction  Doctors beyond Borders: Entanglements and Intersections in the Modern History of Medical Migration laurence monnais and david wright

Learned men (and women) have always travelled abroad seeking a more ­congenial intellectual milieu to realise their full potential. Alfonso Mejía1

Doctors and historians will learn important lessons from the 2014 Ebola outbreak. Among other things, it demonstrated the need for communication among health experts across the globe and has revealed the many roles doctors have to play in emergency operation centres, frontline clinics, and local communities, tracing the disease, containing it, educating the people about it, and taking care of infected people. Médecins sans frontières, the “French doctors,” in particular, have been a symbol of this much-needed transnational multitasking in the age of (re)emergent infectious diseases. In early 2014 they warned the World Health Organization (WHO) of a catastrophic outbreak if nothing was done locally. The “preparedness” policies2 of the Gates Foundation and other non-governmental organizations (NGOs) had been put in place, driven by an obsession for global security and a marginalization of “old school” public health policies, but it would prove hard to transform into efficient and locally adapted responses to the disease. The chapters in this volume are more than a history of the expert mobility and polyvalence of a group of humanitarian doctors during a pandemic threat. Its objective is to offer fresh perspectives on some global dimensions of the history of modern medicine and health by focusing on medical figures who learned and/or practised medicine abroad, developing medical expertise “here” and applying it “there.” It questions the idea of medical science as universal knowledge, emphasizing the role of migration in challenging – and sometimes transforming –

4  Laurence Monnais and David Wright

local health policies and medical day-to-day practices. To be sure, migrant doctors often faced a profession and institutions firmly constituted within borders. However, far from being a book solely about discrimination against foreign medical practitioners and the barriers in trying to move between nations, the chapters presented here demonstrate how being “foreign” (and often marginalized) as a healthcare professional might have helped to shape local medicalization and international health standards from the late nineteenth century onward. Crossing Borders The migration of physicians in the twentieth century draws on a rich tradition in the history of medicine, one that owes its debt to pioneering scholarship on the history of (infectious) disease, colonialism, and immigration. Diseases are avid “border-crossers,” requiring scholars to adopt transnational perspectives that deemphasize state frontiers.3 From the “Columbian Exchange” posited by Alfred Crosby,4 to the continued ­fascination with the flu,5 medical historians have attempted to understand disease and migration through the transnational lens of pestilence and pandemics.6 Seen in this light, the global landscape has been one of the oldest and most popular themes of the history of medicine. With the formation, consolidation, and expansion of nation states – and the co-production of modern imperialism – came the challenge of responding to quickly growing epidemics. The waves of cholera, bubonic plague, and smallpox in the nineteenth century entangled nations in projects of border surveillance, prompting national jurisdictions to coordinate interventions, such as immigration control and quarantine. Following the advent of bacteriology, the challenges of containing these infectious diseases led to several successive international congresses to coordinate responses effectively.7 The Pan American Sanitary Bureau (soon to be renamed the Pan American Health Organization) was founded in 1902, followed by a series of organizations based in Europe, including the Office International d’Hygiène Publique (founded in Paris in 1907), which collected and disseminated statistics on the incidence and prevalence of infectious diseases in sixty nations. Indirectly, these supranational initiatives recognized the limits of national influence in the face of international trade and immigration. Policing national boundaries became matters of national interest and security, with immigration legislation emerging in settler

Introduction 5 

c­ ountries in a vain attempt to examine the medical and mental fitness of new arrivals.8 These international meetings and initiatives simultaneously legitimized the importance of national units of administration and sanctioned the need for supranational organizations in the face of global epidemics and transnational migration. National and supranational agencies were complemented by the rise of powerful NGOs that accelerated the circulation of scientific expertise, medical professionals, medical technologies (such as vaccines and the hypodermic syringe), and public health interventions, such as the Rockefeller Foundation, l’Institut Pasteur, the International Red Cross, and the Wellcome Trust. These influential organizations acted (and act) in a capacity that was transnational, but local circumstances shaped the outcomes of the public health interventions that originated, at least in policy terms, in Western industrialized countries. The pioneering work of Marcos Cueto on malaria eradication in Mexico,9 Sunil Amrith on the recourse to “magic bullets” against tuberculosis and malaria in Southeast Asia,10 and Steven Palmer on the control of hookworm in the Caribbean,11 for example, demonstrated the interplay and exchange between transnational organizations, like the Rockefeller, and “national” public health systems in developing countries.12 The focus, however, continued to be global viruses and the control of infectious diseases, rather than the migration and the versatile work of the “missionaries of science”: the medical practitioners themselves.13 Doctors on the Move At a time of growing medical professionalization, an important but complicated circulation of physicians and surgeons emerged in the late nineteenth century, predicated along imperial and linguistic lines. As is well known from the history of colonial medicine, medical practitioners helped to expand the reach and settlement of the British, French, Japanese, and other empires.14 As colonial agents (often working abroad as civil servants), their work was changing; it was less about reporting potential infectious threats and more about implementing and running local health policies that were supposed to last in the name of civilization. They tracked down smallpox and sleeping sickness, ran hospitals and infirmaries, trained local personnel, conducted research on new vaccines, new pharmaceuticals, and neglected tropical diseases. At the same time, multiple medical cultures were exported, negotiated, and naturalized overseas.

6  Laurence Monnais and David Wright

Ann Crowther and Marguerite Dupree have demonstrated the prolific production of Scottish medical schools in the second half of the nineteenth century, when graduates of Glasgow and Edinburgh flooded into South Africa, Upper Canada, the British West Indies, and Australasia. They took with them traditions and practices in a time of scientific transformation (particularly the new germ theory of disease) to the far corners of empire. Crowther and Dupree refer to the Scottish medical diaspora as acting, in part, as “tools of empire.”15 Medical practitioners, of course, did travel in service of empire, as military doctors or employees of colonial institutions. But many moved abroad for personal benefit and without direct support or employment by colonial authorities, as revealed by the rich Irish history of medical education and migrations. David Dammery, for example, has argued that “the lure of land and gold … led to an increasing number of doctors migrating to Australia.”16 Physician migration was thus often motivated by an oversupply (or perceived oversupply) of physicians in home countries. In her study of the medical “El Dorado,” Anne Digby suggests that in encouraging practitioners to relocate to South Africa, British authorities were “exporting some of its problems – in the form of an oversupply of medical practitioners to its empire.”17 Many physicians, especially those with degrees from less prestigious universities, migrated to the Cape, eventually relocating to rural areas as more doctors flooded the market. The original generation of migrant doctors fared financially much better than if they had remained in England, yet eventually the allure of South African medical incomes brought more doctors, fees dropped as a result of high competition, and other colonies began to appear more appealing.18 Although the role of Scottish medical schools is well known, Greta Jones has illustrated (in this volume) that the experience of Irish medical graduates was no less important. From 1860 to 1905, Ireland developed and encouraged a network of medical institutions that trained far more physicians than were needed in Ireland itself, creating a culture of “willing immigrants” who left colonial Ireland (and later Eire) for prospects abroad. No fewer than 41 per cent of graduates of Irish medical schools were practising abroad during the first half of the twentieth century, a figure that masks a gradual decline from about 50 per cent at the turn of the century to 33 per cent in the 1950s.19 These figures, nonetheless, are staggering and reflect a proportion of nationals practising abroad that is matched only by South Africa and Cuba at the end of the twentieth century.20 The Irish institutions encouraged their

Introduction 7 

native-born sons and daughters to emigrate, creating a continuous flow of doctors leaving the island throughout the late nineteenth and into the twentieth centuries. Many first migrated to England to find work; however, a substantial number served in the armed services, throughout the empire or attached to British international companies “and thus remained within the British sphere of influence.”21 Such a national rate of medical attrition was, paradoxically, considered to be a point of national pride. The Irish had long reconciled themselves to a loss of their “young and brightest” since the Great Famine of the 1840s, but in this case, the medical school overproduction had become deeply embedded in the culture and economy of Irish medical education. Irish graduates continued to be part of the British Medical Register (even after Independence and Partition during 1920–2), a status that guaranteed ready access throughout the British dominions and later Commonwealth. Ireland also provided a “last chance” option for medical school for many aspiring doctors in the United States and Canada who were unsuccessful in their applications to medical school in their own country. It further operated as an unofficial locus of medical training for certain Atlantic World colonies, such as Newfoundland.22 The complexity of physician migration for medical education is captured in the opening chapter by Juanita De Barros. Aspiring young Caribbean men regularly travelled to Britain and Canada to seek undergraduate medical education. African- and Indo-Caribbean medical students who travelled abroad experienced a growing racism and intolerance in the first three decades of the twentieth century. Canadian schools – like McGill and Queen’s universities – that had once accepted “coloured” West Indian candidates, began to close their doors by the 1920s. In Britain, those who did manage to find acceptance were often met with hostility from senior practitioners and patients and found it increasingly difficult to secure a crucial hospital appointment after their undergraduate training. Discrimination, however, did not end there; the most secure positions back in the British West Indies were ones in the Colonial Medical Service, which gave priority, when they could, to “European” doctors. Some native-born Caribbean doctors did successfully set up private practices, but the relative poverty of the non-white communities, combined with sparse island populations, made such an option difficult for many. The natural solution – a medical school for the British West Indies – was delayed for decades for many reasons, including the fragmentation of the islands along racial, proto-nationalistic, and linguistic lines.23 Even when the medical school of the University

8  Laurence Monnais and David Wright

of the West Indies was created, the islands suffered leakage of medical practitioners who travelled to Britain and North America for advanced training and remained there permanently. This necessity to circulate as students and young practitioners was specific to neither the West Indies nor to non-Western colonies. Some of these dynamics can be also seen in New Zealand where, as evidenced by John Armstrong’s chapter in this book, at least three-quarters of all Kiwi doctors, and as many as nine out of ten specialists, travelled abroad to obtain postgraduate experience and qualifications. Unlike the Caribbean islands, New Zealand had a network of medical schools by the early twentieth century, but the small and rural population was not sufficient to support comprehensive postgraduate training. As a consequence, New Zealand practitioners were “internationalists” by circumstance, with almost one-third of hospital-based practitioners working abroad at any particular time. The primary destination, unsurprisingly, was Britain, which, by the middle decades of the twentieth century, would depend increasingly upon foreign-trained doctors to staff the wards of their public hospitals. Ultimately, as Armstrong demonstrates, “certain British institutions functioned as hubs for their respective specialties.”24 The recognition of qualifications throughout the British Commonwealth, and reciprocal agreements between Ireland and Britain, and between the United States and Canada, would frame the migration of physicians, either for training or for permanent settlement. Armstrong describes the importance of inter-generational personal contacts: undergraduates in New Zealand would rely on connections made by their mentors, who themselves had most likely been educated in Britain. This evolved into a “self-perpetuating” system that had, within it, the preservation of a model of white, middle-class, male graduates. While New Zealand doctors did not have to confront implicit (or explicit) racial barriers that affected African- and Indo-Caribbean medical students abroad, the process of selection was still one of inclusion and exclusion. Armstrong cleverly demonstrates how, notwithstanding the multiple barriers that women doctors overcame, medical migration of New Zealand doctors further frustrated their attempts to gain parity within the medical profession. Women were less likely to migrate than their male colleagues.25 Indian-trained physicians would become, numerically speaking, the most important national group of medical migrants in the twentieth century. South Asian physician migration was both encouraged and

Introduction 9 

framed by the unique relationship between the Indian Medical Service (IMS) and the General Medical Council (GMC) of Britain. The British East India Company had established the IMS as early as 1764 to look after Europeans in British India. In order to service hospitals and apothecaries more effectively, the IMS decided to subordinate assistants to help European doctors and surgeons who looked after the health of European civilians and military employees. On 9 May 1822, the IMS created an institution to instruct twenty native Indians in order to fill the position of European doctors in the Presidency of Bengal, which led to the creation of the Native Medical Institution in Calcutta where classes were conducted only in English from 1835.26 As a result, some Indian doctors decided to use their degrees abroad. The cultural influence of Britain on the Indian medical education system, however, strengthened with political changes that formalized British hegemony from 1858. By 1860, the Lahore Medical College began a trend of affiliation of the established medical schools with the new universities. By the time of Partition, in 1947, India had twenty-seven medical colleges, with only nine under private control. The partition of India into two separate states and the end of the British Raj in 1947 did not slow the creation of medical colleges. From 1947 to 1950, a further nine new medical colleges were established. Central to the circulation of Indian doctors by the twentieth century was the fact that the GMC of Britain recognized Indian medical degrees as equivalent to British ones for over a century (until 1976).27 Despite the evident racism that they experienced on the wards of British teaching hospitals in the 1950s, hundreds of Indianborn and Indian-trained doctors thus found it possible to emigrate to and practise in Britain (and later the Commonwealth), throughout the twentieth century. Their numbers peaked in the 1960s and early 1970s during the crisis in staffing in the National Health Service (NHS) and the subsequent exodus of British-born physicians to Canada, the United States, and Australia.28 Four chapters in this volume address aspects of the vast and complicated South Asian medical diaspora of the post–Second World War era. Before the dramatic exodus of South African physicians, South Asian practitioners represented the largest group of migrant practitioners in the second half of the twentieth century. Certainly, some Indian and Pakistani doctors migrated principally for better incomes and working conditions or for short-term postgraduate medical training. But there was also a rich tradition, as occurred in the Caribbean, of South Asian doctors who migrated to Britain for advanced training, before

10  Laurence Monnais and David Wright

returning to the Indian subcontinent, as reflected in the chapters by Simpson, Snow, and Esmail, and by Bornat, Raghuram, and Henry. Some Indian doctors trained in Burma; others relocated to South-east Asian or South Pacific destinations with significant ethnic Indian populations (such as Indonesia or Fiji). India also acted as its own “centre,” providing a locus of medical training for Indo-South Africans and Indo East-Africans who had limited options for such training in their native countries – the Pondicherry School of Medicine acted as a training centre in the last third of the nineteenth century for young men coming from several French territories in Asia. These complicated layers of professional identity and racial politics, as Margret Frenz demonstrates in her chapter, played out in different ways. Often it created interstitial elites in multi-ethnic communities; physicians were both the elite in (and often political advocates for) South Asian communities outside of the subcontinent, but also suffered systematic marginalization by the medical communities in their own countries. This circulation of medical practitioners from different parts of the world engendered tensions and collaborations between “native-born” physicians and “alien” practitioners. Throughout the twentieth century, the overwhelming proportion of practitioners – even those in state-administered health systems – were private practitioners sensitive to preserving and maintaining their own practices. The anxieties about being flooded by “foreign” physicians fed into the professional associations, which often voiced protectionism thinly veiled in the rhetoric of medical national “self-sufficiency.” As John Weaver illustrates in this book, the fear that there would be a “glut on the market” led to systemic measures of medical associations to restrict physician inflow and licensing to Australia and New Zealand. On the other hand, physician shortages, such as the ones described by Sasha Mullally and David Wright in rural and remote post-war Canada, might encourage the immigration of foreign-trained doctors who might gravitate to underserviced areas where, notwithstanding profound cultural differences, they managed to thrive professionally and financially, if not socially. Immigrant Doctors and (the Fate of) Medical Systems As the thousands of foreign-trained doctors who entered industrialized countries in the post–Second World War era began to rise through the ranks and assume positions of power, the tone changed from one

Introduction 11 

of protectionism to more technical issues of accreditation. In many English-speaking industrialized countries, foreign medical graduates comprised an astounding one-quarter to one-third of the active practitioners by the early 1980s. Foreign-trained doctors rose to be chairs of departments, deans of medical schools, ministers of health, and eventually presidents of national medical associations. Over time, criticisms of medical immigration became more nuanced and coded, emphasizing “objective” skills and language ability rather than playing the “race” or “national” card that was so evident in the middle decades of the century. Still, restrictive measures – such as retraining and re-­examination, the limitation of the number of residency positions, geographical restrictions, and probationary periods in underserviced areas – were all employed to control and channel the flow of new foreign medical graduates. Within this complicated political and professional debate, elites within the medical schools were often ambivalent, desiring an increase in funding and medical school places within their own jurisdiction, but also wanting the latitude to bring in leading medical researchers for key faculty positions. The immediate post–Second World War era ushered in a period of health services transformation, with European countries like France, Britain, and members of the British Commonwealth introducing universal health insurance during the period 1945 to 1970. The introduction of state-administered medical services, usually with a parallel, if attenuated, system of private delivery, unleashed a pent-up demand for medical care that was accelerated by the population explosion – the baby boom – of the 1950s. Many national jurisdictions felt themselves unprepared to address this new demand with the pre-existing domestic supply of doctors. As a consequence, many Western countries became increasingly reliant on foreign-trained doctors – often young and in their early stages of postgraduate or fellowship training – to fill the gap. Medical associations in the 1950s and 1960s warned their governments of the impending shortage of trained medical practitioners, but politicians were slow to act, and the establishment of new medical schools often took a decade to complete, from initial architectural plans to the graduation of their first students. The default measure was to relax immigration regulations so as to permit occupations of “exceptional demand,” of which physicians and nurses became a prime example in the 1960s and 1970s.29 In this way, the revision of immigration laws away from “preferred nations of origin” to a new focus on “highly skilled manpower” would act in concert with physician shortages.

12  Laurence Monnais and David Wright

The period between the mid-1960s and the mid-1970s, in particular, would witness an extraordinary international movement of physicians. As the WHO began to recognize the global implication of the physician exodus (often, but not always) from poorer to richer jurisdictions, it talked in vain about the implications for developing countries.30 National politicians, by contrast, saw opportunities in the thousands of health-care practitioners who, already trained by a foreign nation, could be relatively easily used to address physician undersupply or mal-distribution. Some health economists even posited that there was a macroeconomic rationale for industrialized nations to resist the call for constructing new medical schools in the 1960s and 1970s – when the demand appeared to be the greatest – and instead rely solely on the quicker and cheaper option of calling on foreign physicians to fill the gap. Yet despite the explicit use of foreign doctors for internal political and health policy expedience, this book includes some powerful case studies of how skilled immigrants – in this case, physicians – influenced the evolution of health services in their adopted countries. In their case studies of foreign-trained doctors in Manchester (England), Simpson and his colleagues illustrate how foreign doctors found themselves in working-class districts, redirected from more popular and lucrative areas of practice by the racism of the post-war NHS. British-born doctors shied away from particular types of practices as well, opening up the way for certain specialties, like geriatrics, general practice, and psychiatry, to be dominated by foreign, often non-white medical practitioners. These case studies challenge traditional narratives of immigration in the twentieth century, which tend to be focused on disempowered groups at the lower end of the socio-economic spectrum. In the case of migrant doctors, these immigrants were highly educated elites who, in moving, often occupied interstitial spaces of power between pre-existing (medical) elites and the general population. We see this in Margret Frenz’s work on East Africa (where the interstitial space was doubly reinforced by the status of Indians as being neither white nor African). We also see this in the South Asian geriatricians in Britain, or the non-white, British-trained medical practitioners in the Caribbean. These medical practitioners thus defy easy categorization as both elites and marginalized within their own profession (though hardly disempowered when compared to the general population). Moreover, since foreign-trained practitioners often found themselves in deprived geographical areas or low-status institutions (such as state mental

Introduction 13 

hospitals or working-class districts), their professional marginalization was accompanied by elite socio-economic status among impoverished, poorly educated, and sometimes vulnerable constituencies, as exemplified in the oral histories collected by Sasha Mullally. In parallel, as Parvati Raghuram and her team have argued, South Asian doctors flooded into underserviced specialties and, in the case of geriatrics, in effect created a discipline that allowed for upward professional mobility and innovation.31 Rarely did medical practitioners decide to relocate to other countries for reasons that were singular – for only educational, social, economic, or political reasons. Oral histories, which figure prominently in many recent studies, including in several chapters in this book, offer few easy generalizations. Testimonials of what some countries sometimes refer to as “international medical graduates” reveal multiple and sometimes conflicting motivations. In certain cases, however, medical migrants might move for reasons that were, at times, more straightforward, such as immediate personal or familial danger in their home countries. Three chapters in this edited volume provide fresh perspectives on the well-known phenomenon of medical refugees immediately before, during, and after the Second World War.32 Here one sees some parallels to the experience of Jewish doctors in the crumbling Soviet Union, where, in the early 1990s, thousands left the former republics of the Soviet Union for Israel, Canada, and the United States. Unlike the experience of many practitioners escaping Germany for Britain in the 1930s and 1940s, these “Soviet doctors” often found themselves shut out of medical practice, particularly in North America.33 More research needs to be done on other, lesser-known episodes of involuntary medical migration, such as the expulsion of Indo-African physicians (among “non-Africans” in general) from Uganda in the 1970s and the exodus of doctors from Vietnam after the Fall of Saigon in 1975 – more than half of the Vietnamese health professionals left the country and moved to France, the United States, and Canada in the aftermath of the country’s reunification – to name only two other fascinating examples. Rewriting Migrant Physicians into Medical History In the 1950s, the Royal Society in Britain influentially referred to the “brain drain” of British scientists and doctors to the United States and Canada.34 Since then, the narratives in Western and non-Western countries have waxed and waned, bemoaning the loss of the “best and

14  Laurence Monnais and David Wright

the brightest” to foreign lands. Alfonso Mejía, who led the team of WHO researchers into the international migration of nurses and doctors, spoke of a “more congenial milieu” to which highly skilled men and women would always be drawn. His quotation comes across now as somewhat defensive and apologetic, even though he was acutely aware of the emerging problem of physician outmigration from lessindustrialized countries. Although there was some confusion in the 1960s and 1970s about the size of physician migration flows between countries, and the proportion of physicians who did not return to their native countries, by the end of the 1970s it was clear that the general movement of physicians to wealthier jurisdictions was becoming a significant global health problem. Nevertheless, the transnational migration of physicians between wealthy, industrialized countries – such as the loss of physicians from Britain to Canada, the United States, and Australia – continued, and was substantially entangled with the inmigration of health practitioners to these very same countries. Thus, as Wright and his colleagues demonstrate in their chapter, Britain and Canada were listed in the top ten “donor” as well as top ten “recipient” countries during the 1960s and 1970s by WHO estimates. Even the United States, which was unsurprisingly the net recipient of thousands of foreign-trained doctors during the twentieth century, had its own exodus during the era of the Vietnam War and its well-publicized doctor draft. Despite the acceleration of numbers of foreign-trained doctors both during and immediately after the Second World War, foreign doctors are largely absent from the writing of “national” histories of medicine in the twentieth century. The standard surveys of the evolution of health services in twentieth-century Britain, Canada, the United States, Australia, and New Zealand, for example, are conspicuously silent on the contribution of foreign-trained doctors, representing a “collective amnesia.”35 Researchers in the WHO, Britain,36 and the United States began to comprehensively examine the predominance of foreign-trained doctors. But such is the awkward integration of global history and the history of medicine that the two have appeared somewhat incompatible. The rewriting of foreign-trained doctors into “national” medical history carries with it both intellectual and public policy implications. Historians of global health have been particularly sensitive to the way “history” is used by global health planners and to the possible policy implications of their own historical scholarship. Just as Mark Jackson has called for historians of medicine to reengage with the implications of their work

Introduction 15 

in global health histories,37 this edited volume also has contemporary relevance. In this way, examining transnational migration of physicians has the potential to destabilize conventional narratives of health services that dominate many Western countries. Indeed, it is one of the ironies of twentieth-century health services that “national” systems of health care, some of which became cultural icons of national identity, survived only by the support and influx of foreign nationals as doctors and nurses. This volume, like any collective work, is selective in its coverage and dependent upon the research recently undertaken. It focuses on physician migration, and in particular on the migration of practitioners within the English-speaking world. Needless to say, nurse migration is certainly no less important but has already found its champions in pioneering works on health-care diasporas, such as Catherine Choy’s Empire of Care.38 There are also important histories still to be written of the great transnational migration of allied health-care practitioners, from dentists to pharmacists (and midwives, another important group of women medical practitioners who, at least within the colonial empires, were sometime educated abroad and travelled as well), which also figured prominently in the twentieth century but remain largely silent in historical literature. There is no doubt important work is being done on the transnational migration of French practitioners throughout la francophonie from the colonial to the post-colonial times and the movement of Spanish-speaking practitioners throughout Latin America. This is without mentioning the importance of historicizing the role of the “French doctors” we talked about at the beginning of this introduction and of the history of these “medical missionaries” (both men and women) involved in humanitarian medicine and various forms of medical diplomacy long before the advent of the League of Nations and the WHO – a history of medical nomadism that, according to Anne-Marie Moulin, helped circulate new ideas and techniques, professionalize the field of medicine, stabilize states, and medicalize societies over centuries.39 Moreover, with the rise of “medical tourism,” there is renewed interest in the movement of people, in this case patients “without or beyond borders”40 rather than practitioners, to engage in medical encounters of various kinds. The field is a rich one, and we hope this volume contributes to this important topic, shedding new light from a global (if not globalizing) perspective on a too-long neglected component of the evolution of health services and health in the twentieth century.

16  Laurence Monnais and David Wright Notes 1 Alfonso Mejía, “Migration of Physicians and Nurses: A Wide World Picture,” International Journal of Epidemiology 7 (1978): 207–15. 2 See Andrew Lakoff, “The Generic Biothreat, or, How We Became Unprepared,” Cultural Anthropology 23, no. 3 (2008): 399–428; and VinhKim Nguyen, “Ebola: How We Became Unprepared and What Might Come Next,” Cultural Anthropology, 7 October 2014, http://www.culanth. org/fieldsights/605-ebola-how-we-became-unprepared-and-what-mightcome-next. 3 Hans Zinsser, Rats, Lice, and History: Being a Study in Biography, Which, after Twelve Preliminary Chapters Indispensable for the Preparation of the Lay Reader, Deals with the Life History of Typhus Fever (New York: Black Dog & Leventhal Publishers, 1935); William McNeill, Plagues and Peoples (1976; New York: Anchor, 1998). 4 Alfred Crosby, The Columbian Exchange: Biological and Cultural Consequences of 1492 (Westport, CT: Greenwood, 1972). 5 See, inter alia, Howard Phillips and David Killingray, The Spanish Influenza Pandemic of 1918–19: New Perspectives (London: Routledge, 2003). 6 Sanjoy Bhattacharya and Niels Brimnes, “Introduction: Simultaneously Global and Local; Reassessing Smallpox Vaccination and Its Spread, 1789–1900,” Bulletin of the History of Medicine 83, no. 1 (Spring 2009): 1–3. 7 Paul Weindling, ed., International Health Organizations and Movements, 1918–1939 (Cambridge: Cambridge University Press, 1995). 8 Alison Bashford, ed., Medicine at the Border: Disease, Globalization and Security from 1850 to the Present (London: Palgrave Macmillan, 2006). See also Michael Worboys and Lara Marks, eds., Migrants, Minorities, and Health: Historical and Contemporary Studies (London: Routledge, 1997). 9 Marcos Cueto, Missionaries of Science: The Rockefeller Foundation and Latin America (Bloomington: Indiana University Press, 1994). 10 Sunil Amrith, Decolonizing International Health: India and Southeast Asia, 1930–65 (New York: Palgrave Macmillan, 2006). 11 Steven Palmer, Launching Global Health: The Caribbean Odyssey of the Rockefeller Foundation (Ann Arbor, MI: University of Michigan Press, 2010). 12 See also John Farley, To Cast Out Disease: A History of the International Health Division of the Rockefeller Foundation, 1913–51 (Oxford: Oxford University Press, 2004). 13 Sunil Amrith’s book looks at some individual experiences of nurses, DDT sprayers, itinerant health workers, but they are mostly local workers. Laurence Monnais and Hal Cook’s Global Movements, Local Concerns:

Introduction 17 

14

15

16 17 1 8 19

20

2 1 22 23

2 4 25

Medicine and Health in Southeast Asia (Singapore: NUS Press, 2012), addresses the role of medical practitioners within Southeast Asia but does not comprehensively analyse the circulation and exchange of these experts between different national or imperial jurisdictions. See Laurence Monnais and Hans Pols, “Health and Disease in the Colony: Medicine in the Age of Empire,” in The Routledge History of Western Empires, ed. Kirsten MacKenzie and Robert Aldrich (London: Routledge, 2013), 270–84. Anne Crowther and Margaret W. Dupree, Medical Lives in the Age of Surgical Revolution (Glasgow: University of Glasgow Press, 2010). The “tool of empire” concept is borrowed from Daniel R. Headrick’s seminal Tools of Empire: Technology and European Imperialism in the Nineteenth Century (Oxford: Oxford University Press, 1981). David Dammery, “Early Medical Registration in Australia: Part 2,” Australian Family Physician 30, no. 11 (2001): 1090. Anne Digby, “‘A Medical El Dorado?’ Colonial Medical Income and Practice at the Cape,” Social History of Medicine 88, no. 3 (1995): 463. Ibid. Greta Jones, “‘Strike Out Boldly for the Prizes That Are Available to You’: Medical Emigration from Ireland 1860–1905,” Medical History 54, no. 1 (2010): 55–6, and table 1. See, inter alia, R. Weiner, G. Mitchell, and M. Price, “Wits Medical Graduates: Where Are They Now?” South African Journal of Science 94, no. 2 (1998): 59–63; Hugh Grant, “From the Transvaal to the Prairies: The Migration of South African Physicians to Canada,” Journal of Ethnic and Migration Studies 32, no. 4 (2006): 681–95; Robert Huish, “How Cuba’s Latin American School of Medicine Challenges the Ethics of Physician Migration,” Social Science & Medicine 69, no. 3 (2009): 301–4. Jones, “Strike Out Boldly for the Prizes,” 57. Newfoundland did not join the Canadian Confederation until 1949. Even then, it did not have its own medical school until 1968. See Juanita De Barros, Steven Palmer, and David Wright, eds., Health and Medicine in the Circum-Caribbean: Historical Perspectives (New York: Routledge/Taylor and Francis, 2009). See Armstrong in this volume. In other contexts the experience of migration for women doctors/students has had more positive outcomes. For example, through the Dufferin Fund, British women were trained to provide care to Indian women and mothers from the 1880s. It was argued that upper-caste women would refuse care from men, necessitating the training of female health professionals.

18  Laurence Monnais and David Wright

26 27

28

29

30

31

32 33

3 4 35

This argument also helped British women to demand expansion of medical training for themselves in the metropole. Moreover, travelling to India helped women medical workers to gain experience in new fields of expertise and provided opportunities for female doctors to run hospitals. See Parvati Raghuram, “Caring About ‘Brain Drain’ Migration in a Postcolonial World,” Geoforum 40 (2009): 30–1. Roger Jeffery, “Recognizing India’s Doctors: The Institutionalization of Medical Dependency, 1918–39,” Modern Asian Studies 13 (1979): 302. Excluding a brief hiatus between 1930 and 1936. David Arnold, The Cambridge History of India (Cambridge: Cambridge University Press, 2000), 3:176. By contrast, if one excludes the case of the medical school of Algiers (where most of the students were of French origin) France did not recognize degrees from medical schools that had opened in its colonies (and followed the French curriculum) until the late 1930s. See Laurence Monnais, “La professionnalisation du ‘médecin indochinois’ au XXe siècle: Des paradoxes d’une médicalisation coloniale,” Actes de la Recherche en Sciences Sociales 143 (2002): 36–43. For Indian doctors emigrating to Canada, see David Wright, Sasha Mullally, and Mary Colleen Cordukes, “‘Worse Than Being Married’: The Exodus of British Doctors from the National Health Service to Canada, c. 1955–1975,” Journal of the History of Medicine and Allied Sciences 65, no. 4 (2010), doi:10.1093/jhmas/jrq013; and Mullally and Wright in this volume. Sasha Mullally and David Wright, “La Grande Séduction?: The Immigration of Foreign-Trained Physicians to Canada, c. 1954–76,” Journal of Canadian Studies 31 (2007): 1–22. David Wright, Nathan Flis, and Mona Gupta, “The ‘Brain Drain’ of Physicians: Historical Antecedents to an Ethical Debate, c. 1960–79,” Philosophy, Ethics and Humanities in Medicine 3, no. 24 (10 November 2008), doi: 10.1186/1747-5341-3-24. Pavarti Raghuram, Johanna Bornat, and Leroi Henry, “Ethnic Clustering among South Asian Geriatricians in the UK: An Oral History Study,” Diversity in Health and Care 6 (2009): 287–96. See “Refugee Doctors,” special issue, Social History of Medicine 22, no. 3 (2009). J.T. Shuval and J.H. Bernstein, Immigrant Physicians: Former Soviet Doctors in Israel, Canada, and the United States (Westport, CT: Praeger Publishers, 1997). Wright, Flis, and Gupta, “‘Brain Drain.’” Julian M. Simpson, Aneez Esmail, Virinder S. Kalra, and Stephanie R. Snow, “Writing Migrants Back into NHS History: Addressing a ‘Collective

Introduction 19 

36 37 38

39 40

Amnesia’ and Its Policy Implications,” Journal of the Royal Society of Medicine 103, no. 10 (2010): 392–6. David John Smith, Overseas Doctors in the National Health Service (London: Policy Studies Institute, 1980). Mark Jackson, “Introduction,” in The Oxford Handbook of the History of Medicine, ed. Mark Jackson (New York: Oxford University Press, 2011), 12. Catherine Ceniza Choy, Empire of Care: Nursing and Migration in Filipino American History (Durham, NC: Duke University Press, 2003). See also Anne-Marie Rafferty, “The Seduction of History and the Nurse Diaspora,” Health & History 7, no. 2 (2005): 2–16. Anne-Marie Moulin, Le médecin du prince. Voyage à travers les cultures (Paris: Odile Jacob, 2010). Andrea Whittaker, Lenore Manderson, and Elizabeth Cartwright, “Patients without Borders: Understanding Medical Travel,” Medical Anthropology 29, no. 4 (2010): 336–43.

1  Imperial Connections and Caribbean Medicine, 1900–1938 juanita de barros

In 1938, Harold Moody, a Jamaican-born physician and long-time resident of England, testified before a British government inquiry into the causes of violent labour protests in the Caribbean. Among other things, he called for the establishment of a medical school and discrimination-free hiring practices in the colonial medical service. ­ Discussions about where West Indian medical students should be educated and the roles they should play in the region once they returned home from their studies abroad occurred regularly in the first four decades of the twentieth century. Before 1948, when the first university and medical school opened in the British Caribbean, West Indians who wanted to become physicians travelled to the United Kingdom or North America, where they faced economic and social obstacles; the cost of studying abroad for years was high, and for non-white West Indians, racial discrimination constituted a significant, additional social and professional burden.1 Many also found their ambitions stymied once they returned home. Official discrimination on the grounds of race prevented many from working in the government medical services. In the early ­twentieth-century British Empire, an imperial bureaucracy worried about the “suitability” of black men for colonial service. In an empire whose reach extended to places as diverse as Jamaica, Nigeria, and Ceylon, they argued that white Britons were the most acceptable choice. Afro–West Indian physicians such as Moody challenged these policies and demanded equal access to medical training and employment. But as this chapter shows, migration did more than give them opportunities for professional training; it also provided the tools to fight against discrimination at home and abroad. Foreign travel, especially in the metropolitan urban centres that were home to many non-white

Imperial Connections and Caribbean Medicine  21 

c­ olonials, brought these sojourning West Indians into contact with an international group of pan-Africanists who attacked colonialism and racism more broadly. West Indian physicians were part of this network, and they drew on it to protest discrimination in their home colonies. The “revolution in medicine and public health” that Randall Packard has located in the second half of the nineteenth century provides the context for the developments addressed in this chapter.2 These years saw growing government attention to public health problems and sanitation, and changing ideas about the nature of disease and disease causation. In European colonies in the Old and New World as well as in areas of U.S. involvement in the Americas, these years were also marked by the emergence of “tropical” medicine, part of an attempt by government officials to ensure the survival of Europeans in the colonies as well as of the colonized peoples whose labour underwrote these imperial ventures.3 Colonial powers targeted diseases such as malaria, yellow fever, and sleeping sickness, characterized as “tropical” diseases, despite their presence in more temperate locales.4 European governments established schools of tropical medicine to tackle these ailments, providing specialist training for physicians, in London, Liverpool, Hamburg, Brussels, Paris, and Marseilles.5 Would-be physicians destined for the colonies were to attend these schools, and attendance was mandatory in most cases.6 In Britain, the School of Tropical Medicine in London trained physicians to work in the colonial medical services.7 Prospective physicians who aimed to work in European colonies in Africa, Asia, and the Caribbean attended these schools of tropical medicine, as well as the longer-established medical schools in Europe. Facilities for medical training in the colonial world were harder to find, so students travelled abroad. Before the Second World War, medical training in Britain’s “tropical” empire was limited to colleges in India, Ceylon, Malaya, and Hong Kong that were recognized by the British General Medical Council.8 Financial and administrative obstacles prevented similar development in the British Caribbean. In this part of the empire, each colony was administered and financed separately, and none had the financial resources to establish a medical college. But as Margaret Jones has noted, ideas about race also played a role, what she has characterized as “the often-expressed low opinion of the capabilities” of the local population.9 A.J. Stockwell’s observations about the reluctance of colonial officials to support the establishment of universities in British colonial Africa suggests that these qualms were not limited to the Caribbean. He argues that officials regarded

22  Juanita De Barros

the growth of universities in India from the middle years of the nineteenth century as the source of “numerous overqualified, unemployable, politically ambitious and intractable young men” and that they were reluctant to “repeat this blunder elsewhere.”10 In British Africa and the British Caribbean, imperial and colonial officials were more enthusiastic about establishing medical schools to train locals as “subordinate” health workers, such as dispensers, medical assistants, nurses, and midwives. They were cheaper to train and employ and had the added benefit of not upsetting colonial social categories in the way that non-white professionals did. After the Second World War and the push for more self-government in the colonies, some of these schools eventually affiliated with universities and began training locals as physicians.11 Uganda’s Makerere College, which Frenz discusses in this collection, is one example; it was established in 1923 and had its medical degrees recognized by the British General Medical Council in the late 1950s.12 In British West Africa, an attempt was made to establish a medical school in the late 1920s to train medical assistants, but the effort was short-lived, apparently doomed by internal disagreements. The colonial government in Nigeria founded its own facility, the Yaba Medical Training College to educate medical assistants; by the late 1940s, it provided physician training and offered diplomas recognized by the Royal College of Physicians and Surgeons in England.13 There seems to have been a similar pattern in other parts of Europeancolonized Africa, where facilities training medical assistants developed first before developing into medical schools in the 1960s that provided physician training.14 The shortage of colonial facilities to train physicians meant that would-be doctors had to leave their homes to train abroad. As a result of medical registration laws, most West Indians and many other inhabitants of Britain’s colonies ended up in the United Kingdom. Under the British Medical Registration Act of 1858, physicians who qualified in English, Scottish, and Irish medical schools were permitted to practise in the United Kingdom and the empire.15 In most British Caribbean colonies, physicians who trained in Canada or the United States could practise, but they had to register in accordance with local medical registration laws that varied from colony to colony. Some colonies had relatively open policies and allowed graduates of medical colleges outside the United Kingdom to register, as in Barbados, Grenada, St Vincent, the Bahamas, and British Honduras (Belize). In St Lucia and Jamaica, non-U.K.-trained physicians had first to be examined by the

Imperial Connections and Caribbean Medicine  23 

local medical boards before they could be registered.16 At the turn of the century, Guyana and Trinidad allowed only individuals who had registered in the United Kingdom to practise.17 However, exceptions were possible, as the example of John Monieth Rohlehr shows. This Afro-Guyanese man studied medicine at the University of Bishop’s College in Lennoxville, Quebec, but was unable to register as a medical practitioner in Guyana. Thirty-three residents of Berbice (Rohlehr’s home county) protested his exclusion and submitted a petition to the governor pleading for special dispensation in which they noted that Rohlehr could not afford to travel to Britain for further qualifications.18 Governor Knutsford acquiesced and a special law was passed in 1890, allowing Rohlehr to register.19 The petitioners’ comments about Rohlehr’s financial resources point to a key obstacle to medical studies. Members of the local elites (mostly white, but some creoles as well) could rely on family support to pay for the cost of studying abroad. The handful of island scholarships that most colonies began to provide from the mid-nineteenth century provided assistance for a few fortunate few. These scholarships supported students studying at universities in Britain or in the empire.20 According to Anne Spry Rush, Jamaica provided the most awards, but even it gave out only five in 1930.21 For West Indians, the scholarships provided one of the few means to obtain medical education. Winning the Island Scholarship in 1920 allowed the Afro-Trinidadian William Besson to fulfil his dream of studying medicine.22 His brother, who also wanted to become a physician, was unable to do so as he did not win the scholarship, ending up as a druggist in New York, where he emigrated.23 Other medical students had to earn the money themselves, using savings accrued from working, sometimes as dispensers. James Sholto Douglas, for example, a Guyanese man of African descent, used his earnings as a dispenser to pay for his medical education in the late nineteenth century.24 Most British Caribbean medical students studied in British territories, where language, imperial ties, and colonial medical registration laws eased their way. Scottish universities, especially the University of Edinburgh, were the most appealing by far. There, students could take advantage of the relatively low cost of Scottish medical education as well as its universities’ reputation for training physicians for the empire.25 The Caribbean-Scotland connection was long-standing. Between 1744 and 1830, nearly five hundred West Indians studied medicine at the University of Edinburgh,26 a pattern that continued

24  Juanita De Barros

into the post-slavery period. In 1871, for example, thirty-six medical students graduated from the universities of Edinburgh (twenty-nine) and Glasgow (seven).27 The data for the early twentieth century are less studied, but sources suggest that Edinburgh, and the United Kingdom more generally, were favoured destinations. In 1912, for example, over 30 per cent of registered physicians in Barbados had attended university in Scotland.28 And in Jamaica in 1914, approximately 45 per cent of physicians working as district medical officers had trained in Edinburgh and 9 per cent in Aberdeen. By the late 1930s, the numbers who trained in non-British territories had risen, but at least in Jamaica, most (over 70 per cent) still trained in the United Kingdom, most probably in Scotland. The example of Rohlehr shows that some Caribbean medical students chose Canada, although by the late 1910s, discriminatory policies at some universities presented an obstacle to non-white West Indians. In 1912, approximately 20 per cent of the registered medical practitioners in Barbados had studied at McGill University and approximately 5 per cent at Queen’s University in Kingston, Ontario.29 In the late 1930s, 7 per cent of practising physicians in Jamaica had studied in Canada.30 The sources do not indicate the racial and ethnic background of these students, but by the late 1910s, non-whites were prevented from enrolling at two of the schools. In 1918, the medical faculty at Queen’s told the West Indian medical students currently enrolled that it would not “accept any more coloured students.”31 The faculty blamed the unwillingness of white patients to be treated by “coloured students,” but the secretary-treasurer of the West Indian Club of Queen’s University, E.W. Reece, was sceptical of this reasoning. He noted that there had been no examples of such reluctance during the twenty-five years that West Indians had attended this university. Reece was especially concerned, as McGill University had announced a similar policy two years earlier, and he worried that this “action [was] becoming widespread through the greater centres of learning in Canada.”32 The decision seems to have reflected a general policy at McGill. Robin Winks has noted that although the University of Toronto and Queen’s University allowed in “qualified blacks,” McGill was criticized for “applying racial restrictions in the 1920s, 1930s” and after the Second World War.33 These West Indian medical students who travelled to the United Kingdom and Canada were part of a long tradition of Caribbean people who looked abroad for work and opportunities. From the late nineteenth century, Caribbean men and women regularly travelled

Imperial Connections and Caribbean Medicine  25 

throughout the region and the mainland areas of Central and South America looking for work. The United States, Canada, and the traditional centres of empire in Europe also attracted migrants who looked for work but also, as this chapter shows, for professional training. Migration brought them into contact with members of other colonized territories and African-descended peoples from around the world, and it immersed them in some of the important intellectual and political ideas of the day, such as pan-Africanism, Negritude, anti-colonialism, and Marxism. Medical students and other West Indians in Europe and North America found themselves in cities experiencing what Thomas Holt has described as a “heady mix of radical ideologies, cultural innovations, and social-professional interactions” in an interwar period that witnessed the emergence of a “sharpened political consciousness” in the “black world.”34 For West Indians, experiences of racism in North America and Europe, especially, could be radicalizing and took many forms. From the mid-to-late 1910s, the Universal Negro Improvement Association (UNIA) established branches throughout the Caribbean as well as places of British West Indian migration, including Canada and the United States. Indeed organizations such as this were one of the responses of Caribbean people to the discrimination they encountered abroad.35 The examples of William Besson and Harold Moody indicate the impact of migration on non-white Caribbean medical students, personally and professionally. They belonged to a group of relatively privileged non-whites who had attended the best colonial schools. Although they had doubtless experienced discrimination in their home colonies, class and socially sanctioned accomplishments offered a measure of protection. In the United Kingdom, they associated with other West Indians and other residents of the empire, drawing companionship from others also grappling with life in the metropole. When William Besson arrived in Edinburgh, he was “immediately welcomed into a West Indian student community.”36 He and other West Indians socialized with West African students, many of whom were also studying medicine, and joined the school’s West African Association. In 1923, Besson formed the Edinburgh West Indian Student Association, which attracted enough members to mount a cricket team.37 Besson recounts similar tales of Liverpool, where he studied for the diploma in Tropical Medicine and Hygiene, needed for anyone who wanted a position as a government medical officer in the colonies. Some of his Edinburgh classmates joined him in Liverpool, including two Nigerians and a

26  Juanita De Barros

Chinese-Trinidadian. In Liverpool, he and other colonial physicians (including the Chinese-Trinidadian and two West Indians) and an Indian “scientist” rented rooms from a Welsh family.38 The cosmopolitan world that Besson found himself in seemed typical for West Indian migrants, including medical students. But it was not a racial paradise. Besson described “race relations” between “the coloured overseas students and the Scottish” as generally “very good.” But he did encounter racism, mostly at the hands of white South Africans.39 For Harold Moody, British discrimination seemed to have helped transform him into an activist. He arrived in England in the early 1900s for medical training but encountered problems finding landlords who would rent to him and hospitals that would hire him.40 Moody responded by becoming active in organizations that aimed to address the “colour bar” in Britain. He was the vice-chairman of the Joint Council for the Understanding between White and Coloured People in the United Kingdom, established in 1931 by the Society of Friends.41 Believing that an organization led by African-descended peoples was necessary, something along the lines of the U.S. National Association for the Advancement of Coloured People (NAACP), Moody founded the League of Coloured Peoples in Britain in 1932,42 whose main goal was to challenge the “colour bar” and to “promote and protect the Social, Educational, Economic, and Political Interests of its members; … interest members in the Welfare of Coloured Peoples in all parts of the World; [and] … improve relations between the Races.”43 The league and the joint council protested against “racial discrimination” generally; but, perhaps pushed by Moody, they paid particular attention to that experienced by medical and nursing students. An editorial in the league’s journal, the Keys, noted that they experienced discrimination (“the spiked heel of race prejudice”) and found that “the door of knowledge [was] barred to them on the grounds of colour.”44 In a letter to the Times, Moody noted the difficulty that “coloured graduates” were rarely given “house appointments following qualification.”45 Moody and J.H. Rushbrooke and John Fletcher – chairman and secretary, respectively, of the joint council – asked the secretary of state to ensure that medical students had access to facilities for postgraduate medical training.46 Rushbrooke and Fletcher argued that a “colour bar” in “most London hospitals” prevented nurses and medical students from completing their studies and complained that it was particularly unfair given the requirement that physicians have “British qualifications” to practise in British colonies.47 These appeals seemed to have

Imperial Connections and Caribbean Medicine  27 

had little impact. Philip Cunliffe Lister, the British colonial secretary of state, expressed sympathy but refused to get involved, arguing that tact was required in matters of such “delicacy” and that anyway, his actions would likely have little impact.48 This campaign targeted discrimination in the medical education system. But non-white British West Indian doctors found themselves excluded from medical positions once they returned home. In her chapter in this collection, Frenz has argued that South Asian physicians who trained abroad found themselves relatively marginalized in East Africa. Although some held respected positions in the medical hierarchy and in society more generally, they had little clout, and policies of racial segregation limited where they could practise.49 Despite the absence of formal segregation, informal policies in the British Caribbean government medical services imposed similar obstacles for returning nonwhite physicians. Most returning West Indian medics probably found employment as private practitioners. In her work on Jamaica, Margaret Jones has argued that travelling abroad for medical training forced physicians to attempt to “recoup that expense through lucrative private practice.”50 Indeed, as Carl Campbell has observed, a private medical practice offered the possibility of “an independent profession,” something that was especially important for non-whites.51 The ease with which doctors could establish these practices varied considerably. Large urban areas could and did support more physicians than did rural or more isolated districts.52 The former could also be more remunerative. Jamaica’s larger population was able to support an equally large number of private practitioners for this part of the world, some 200 in the early 1930s. In comparison, in the same period, there were approximately 94 private practitioners in Trinidad, 42 in Guyana, and around 30 in Barbados.53 The colonial government medical services that were established in most British Caribbean colonies in the last few decades of the nineteenth century also provided employment. These government medical systems were created in response to concerns by colonial and imperial officials about the effects of a “shortage” of formally trained physicians on the health of rural populations after the end of slavery. These worries seemed even more pressing in places such as Guyana and Trinidad, where planters imported large numbers of indentured South Asian workers after 1838 to labour on the sugar estates. Government medical officers were to provide free or cheap medical care for estate workers and, in some cases, for paupers, but they often were allowed to see

28  Juanita De Barros

private patients as well. They also worked in district hospitals. The size of these government medical systems varied from colony to colony, depending on the size of the local populations.54 Barbados did not have a system of district medical officers, but private practitioners worked for the parochial poor law boards (eleven) or as health officers with the board of health (sometimes for both).55 Imperial policies and practices combined to discriminate against nonwhite physicians. Colonial governments paid the employment costs of their medical staff and put in requests for new hires, but Colonial Office officials in London oversaw the hiring and they filtered applications. Officials on both sides of the Atlantic considered factors such as the applicants’ education as well as their work experience and the tenor of the “testimonials” the hopeful candidates submitted.56 Officials also considered “suitability,” by which they invariably meant race. Imperial officials in the Colonial Office such as A. Cooke were adamant that African-descended men were “unsuitable” for colonial appointments, particularly in those cases “where they would have to treat Whites and Officials.”57 This policy was followed for other parts of the empire in the early twentieth century.58 The Afro-Trinidadian William Besson noted that he could not apply for a medical position on a tea plantation in Ceylon, as the advertisement stated that only Europeans should apply.59 Similar discriminatory policies existed for the British Caribbean, but as the last section of this chapter shows, they were not always followed. Local exigencies and the pressure exerted by West Indians, both at home and abroad, combined to blunt their effects. The example of Besson shows the impact of this policy on young West Indians. As a young man in Trinidad, Besson realized the odds against him professionally. He observed that there “were few situations in the medical service which were available to coloured Creoles” such as himself and that the “heads of hospitals and heads of departments were usually European.”60 However, by 1926 when Besson had finished his medical training, things were starting to change, albeit slowly. His letter of application to the Crown agents won him an interview and the offer of a position, in either Belize (then, British Honduras) or Guyana. He chose Guyana because he knew more about it and because it was closer to his home in Trinidad. Despite being offered this position, racism still played a role in the process. One of the interviewers asked Besson whether he had sat for Trinidad scholarship examinations because his parents were poor, to which the young Trinidadian replied that he “won these scholarships because [he] couldn’t help it.” Besson

Imperial Connections and Caribbean Medicine  29 

speculated that the interviewer was “racist” or that perhaps he was “testing [Besson’s] ability to meet an awkward situation.”61 Officials turned to non-white men like Besson to staff the government medical systems because they could not obtain the white physicians they preferred. Relatively low salaries (lower than in other parts of the empire) was one factor that limited the region’s appeal to white applicants.62 The demands imposed by the First World War were also significant and contributed to a shortage of “suitable” physicians. Problems with obtaining enough “European medical officers” were so great that, according to one Colonial Office official, the governor of the Windward Islands was forced to “[appoint] anybody he could get on the spot,” such as “coloured men, men with Canadian qualifications,” and physicians from the United States, who were allowed to practise “under temporary war ordinances.”63 That Besson was hired to work in Guyana was not surprising. He had the necessary skills and education, but he was also available. Guyanese officials were especially concerned about the “shortage” of white medics.64 By the late 1910s, the scarcity of European candidates and the large number of vacancies in the Guyanese government medical service led the governor and officials in the Colonial Office to reluctantly approve the appointment of a number of physicians of African, South Asian, and Chinese ancestry.65 In 1921, the Guyanese governor, Wilfred Collet, expressed his concerns about this development in a confidential report to the secretary of state for the colonies, Winston Churchill. Collet noted that, in 1912, just over 62 per cent of the colony’s government medical officers were British-born or of British ancestry, and 25 per cent were of African descent, many of them Guyanese.66 By 1921, however, the proportion of Britons or men of British descent had fallen to 29 per cent and those of African descent had risen to almost 38 per cent. (By this time, the service also included three men of South Asian ancestry and one of Chinese background.)67 This “steady reduction in the number of the medical men of British race” worried Collet, who believed that it had “appreciably weakened the strength of the Medical Department” and would “make [future] promotion to the more responsible posts a matter of great difficulty and anxiety.”68 One colonial official noted glumly that the colony had not recruited a “white Doctor” since the First World War and that it had been unsuccessful in its efforts to lure white medics from Canada and the United States.69 Collet’s complaint made its way to other Colonial Office officials and was the subject of discussion at a meeting of the Colonial Medical Services Committee, where his pleas

30  Juanita De Barros

for “more European practitioners” to help “[strengthen]” the service were relayed.70 Although one Colonial Office official believed that nonwhite physicians should be retained, as “some” were “conspicuously good,” he argued that that they should not be allowed to “dominate.”71 This official was destined to be disappointed. By the 1930s, more non-white West Indians were part of the government medical services. Relatively low salaries continued to discourage white applicants, much as they had in the late 1910s.72 Increased local control over medical appointments was another important factor. The establishment of the Colonial Medical Service in 1934 gave colonial governments the power to determine “junior [medical] appointments.”73 The example of Trinidad suggests its impact. There, government policy by the second half of the 1930s was to appoint locals whenever possible. Between 1935 and 1939, eleven such appointments were made,74 and by the late 1930s, all but three were held by “local people,” most of African descent, “although there were some East Indians, and a smaller number of Chinese.”75 Locals were also a majority in Jamaica by this time and probably in Guyana as well.76 Nevertheless, the new system was condemned as discriminatory. Critics focused on the power that Colonial Office officials retained over appointments to the more senior positions in the Colonial Medical Service, the “scheduled posts.”77 Physicians such as Moody and other West Indians who belonged to international panAfricanist groups used the protests of the 1930s to draw attention to these practices and push for their end. The violent protests and labour strikes of the 1930s provided West Indians with the discursive space to address many issues. The economic crisis of the period helped spark the protests. In the British Caribbean, it was accompanied by a dramatic fall in sugar prices and the return of migrant workers from Cuba and Central America, whose governments were also grappling with the crisis. Their presence deprived family members of the money sent home and added to the growing numbers of unemployed.78 The economic strains of this period highlighted social inequalities and political tensions in these colonies. Crown colony governments in most of the British Caribbean and a highly restrictive franchise common to all deprived most West Indians of a formal political voice.79 West Indians used the British government’s response to the protests to weigh in on what they saw as some of the ills of their societies and to offer solutions.80 Physicians were among the many groups who participated. They pointed to inadequate numbers of health-care workers and poor

Imperial Connections and Caribbean Medicine  31 

medical facilities, but they also emphasized problems they faced as medical professionals. Non-white West Indian physicians complained about a colour-based, two-tier system in the Colonial Medical system. They maintained that whereas white physicians were appointed to senior positions throughout the service, including the Caribbean, West Indians “not of pure European descent” were not, and regardless of their qualifications, they were excluded from “scheduled posts” in the Caribbean and elsewhere in the empire.81 They complained of “discrimination … on the grounds of race and colour.” As one representative of the British Medical Association noted, “[A] West Indian, however well qualified, feels that he will never under the existing conditions be appointed to a better post outside the West Indies or move to a senior position within the West Indies.”82 Afro–West Indians living abroad, such as Moody, helped publicize some of these issues. As members of an international network of black activists and intellectuals, he and other West Indian migrants could mobilize considerable pressure. The involvement in these protests of West Indians who were not physicians also indicates the extent to which these matters were seen as relevant to the larger non-white professional classes. Moody joined forces with two other members of the activist West Indian community in London, George Padmore and Peter Blackman. All three men had spent many years abroad and were based in London in the 1920s and 1930s, where they were active in anti-racist and anti-colonial campaigns. Padmore (born Malcom Nurse) was an AfroTrinidadian whose wide travels and experiences made him an articulate spokesman for anti-colonial and anti-racial issues. He was involved with the Communist Party for a number of years and with London-based pan-Africanist groups such as the West African Students’ Union.83 Blackman was an Afro-Barbadian active in similar organizations, including the Communist Party and the League of Coloured Peoples.84 Moody, Padmore, and Blackman condemned the “gross discrimination” that barred “natives of colour” from high government positions in favour of “English-born people,”85 seeing a recent advertisement for a colonial medical officer that stipulated a preference for candidates of “European parentage” as highlighting this problem. The British head of medical services in Jamaica justified the advertisement on the grounds that there were no “suitable qualified officer[s]” available in Jamaica for the position.86 The advertisement became a transatlantic controversy, due to the actions of West Indians in Britain and the response of an Afro-Jamaican

32  Juanita De Barros

physician (who was also the mayor of Kingston, Jamaica), Oswald Anderson.87 Anderson had practised medicine in Jamaica since the late 1910s and was a long-time critic of flaws in the colony’s health system. He argued that the “recent advertisement in British Medical Journal, for Health Officer for Jamaica discriminated against nearly all Jamaicans and other West Indians alike.” He declared that “there [was] a distinct medical service which [was] for those of European parentage alone” and that it “shut the door in the face of the Jamaican – the West Indian.”88 The local controversy became an international matter when other members of the Kingston Town Council censured Anderson. The council objected to the “grossly improper” manner in which Anderson phrased his opposition. In the aftermath of deadly riots and on the eve of the Moyne Commission’s arrival, his words were seen as potentially dangerous. As Councillor C.S. Cargill, noted, Anderson’s comments could “create class prejudice” and “inflame the people of Jamaica against the Government officials and the Government.” Cargill convinced most of the councillors to support his motion that the council “disassociate” itself from Anderson’s statements and that Anderson himself refrain from comments that came close to “sedition” and that could lead to popular violence.89 Anderson resigned in protest at his censure and called on West Indian physicians – notably Harold Moody and Peter Millard – to publicize the case. Like Moody, Millard was an Afro–West Indian physician (Guyanese in this case) who lived in Britain in the 1930s. A member of the Advisory Committee on West Indian affairs, he moved in the same activist circles as did individuals such as George Padmore and Peter Blackman. Along with fellow Guyanese T.R. Makonnen (born George Griffith), who belonged to the International African Service Bureau, Millard attempted to rally British opinion. They wrote a letter to the editor of the Manchester Guardian in which they described the injustice of the situation,90 pointing out that there were “native West Indians” who were “qualified” for the position. They roundly condemned what they saw as a weak Colonial Office response to the situation, declaring that officials had merely observed that “colour discrimination in appointments to the civil service was beyond its jurisdiction.” The two men were not surprised at the criticisms that Anderson received and saw them as part of a larger political problem. Indeed, something of the sort was to be “expected in a colony where absentee vested interests and a small white oligarchy” were determined to remain in power. Anderson’s subsequent resignation, they declared, was the “courageous act of

Imperial Connections and Caribbean Medicine  33 

one who objected to the mechanical earning of posts for Europeans.”91 As Moody, Padmore, and Blackman would subsequently argue in their submission to the Moyne Commission, Millard and Makonnen maintained that West Indians had a “claim to first consideration in appointments to jobs, especially those in the public health services.”92 Anderson’s correspondence with expatriate West Indians led to the issue being addressed in the hearings of the Moyne Commission. In their written submission, Moody, Padmore, and Blackman repeated Millard and Makonnen’s argument that West Indians should be hired for medical positions, arguing that “native West Indians” understood “local conditions better than outsiders.”93 Like other West Indians active in pan-African organizations, they saw the advertisement as indicating continuing racial discrimination in colonial life. But they also regarded this kind of bias as particularly oppressive for members of the middle class such as themselves. In a memorandum following their interview with the commissioners, Moody, Padmore, and Blackman argued that this “problem” did not touch “workers and peasants who [had] no aspiration to enter the colonial civil service.” However, it was of “vital importance to large sections of the West Indian communities,” especially the intellectuals and middle classes, whose “future so largely depend[ed] upon finding employment in the Government services.”94 Members of the “intellectual and middle classes” were not alone in seeing the whole episode as symptomatic of a deeper malaise in West Indian society. In letters to the Gleaner newspaper and deputations to visit Anderson himself, many individual Jamaicans condemned the actions of the Kingston Town Council and called for Anderson to be reelected,95 but their combined efforts had mixed results. Colonial Office officials were recalcitrant and defensive. They condemned Moody as a “busybody” and Anderson as a “nuisance” who was “out for publicity” and declared that the neither the British nor the Jamaican governments had to “justify” themselves or “reply in detail” to Anderson’s claims.96 The acting governor of Jamaica, on the other hand, worried about the “resentment” that had been “aroused” and was, as he noted, “being used to fan the already existing racial feelings.” As a result, he asked that a physician be appointed to the position temporarily until a doctor currently in Jamaica’s medical service could acquire the “necessary qualifications.”97 But the events also seemed to have convinced officials that they just needed to be more discreet. The Jamaican ­governor recommended that the secretary of state refrain from wording future advertisements in such as way as to make it appear that Jamaicans

34  Juanita De Barros

were excluded.98 At least one imperial official agreed, observing that the racial restriction was unnecessarily “specific” and could have been “applied later, if necessary, when the selection was made.”99 As these comments suggest, ideas about race continued to shape the professional lives of West Indian physicians, even as the events of the 1930s seemed to promise a new era in the Caribbean. This chapter has shown that discriminatory imperial and colonial policies in the first four decades of the twentieth century significantly restricted West Indians’ access to the medical profession. It has also shown that the experience of migration shaped their response. Studying abroad brought them into contact with other West Indians and immersed them in international networks that could be mobilized to attack racist local policies. Notes 1 H.S. Fraser, “Medical Sciences at the University of the West Indies,” West Indian Medical Journal 57, no. 6 (2008): 537. 2 Randall Packard, The Making of a Tropical Disease: A Short History of Malaria (Baltimore: Johns Hopkins University Press, 2007), 115. 3 The scholarship on the field is extensive, but some of the key early works include the following: David Arnold, ed., Imperial Medicine and Indigenous Societies (Manchester: Manchester University Press, 1988); and Arnold, ed., Warm Climates and Western Medicine: The Emergence of Tropical Medicine, 1500–1900 (Amsterdam: Rodopi, 1996); Philip D. Curtin, Death by Migration: Europe’s Encounter with the Tropical World in the Nineteenth Century (Cambridge: Cambridge University Press, 1989). 4 Deborah Neill, Networks in Tropical Medicine: Internationalism, Colonialism, and the Rise of a Medical Specialty, 1890–1930 (Stanford: Stanford University Press, 2012), 15. 5 Ibid., 22, 23. 6 Ibid., 50. 7 Ibid., 51. 8 Margaret Jones, Public Health in Jamaica, 1850–1940: Neglect, Philanthropy and Development (Kingston: University of the West Indies Press, 2013), 31, 32; A.J. Stockwell, “‘The Crucible of the Malayan Nation’: The University and the Making of a New Malaya, 1938–62,” Modern Asian Studies 43, no. 5 (2009): 1154; Roger Jeffery, “Recognizing India’s Doctors: The Institutionalization of Medical Dependency, 1918–39,” Modern Asian Studies 13, no. 2 (April 1979): 302, 303, 305; see also David Arnold,

Imperial Connections and Caribbean Medicine  35  Colonizing the Body: State Medicine and Epidemic Disease in NineteenthCentury India (Berkeley: University of California Press, 1993), 54–6, 57, 58; Helen Power, “The Calcutta School of Tropical Medicine: Institutionalizing Medical Research in the Periphery,” Medical History 40, no. 2 (1996): 197–214; Margaret Jones, Health Policy in Britain’s Model Colony, Ceylon (1900–1948) (New Delhi: Orient Longman, 2004), 75. 9 Jones, Public Health in Jamaica, 31, 32. There were a handful of postsecondary institutions in the British Caribbean before the 1940s, however. Codrington College was founded in Barbados in the seventeenth century to train ministers, and the Imperial College of Tropical Agriculture was established in 1921 in Trinidad. In the 1870s, proposals were made for a university college in Jamaica, but the initiative faltered as the result of “sectarian differences.” On this point, see Lloyd Braithwaite, Colonial West Indian Students in Britain (Kingston: University of the West Indies Press, 2001), 9, 10. In contrast, medical schools were established earlier in the Spanish-speaking territories, in Cuba in 1726, Puerto Rico in 1814, and the Dominican Republic in 1538. Suriname saw the establishment of a medical school in 1882, although its graduates could work only in the West Indies, according to Hoefte. Francisco Guerra, “Medical Colonization of the New World,” Medical History 7, no. 2 (1963): 151, 153; Rosemarijn Hoefte, In Place of Slavery: A Social History of British Indian and Javanese Laborers in Suriname (Gainesville: University Press of Florida, 1998), 151. 10 Stockwell, “‘Crucible of the Malayan Nation,’” 1150, 1151. 11 Susan Lawrence, “Medical Education,” Companion Encyclopedia of the History of Medicine, ed. W.F. Bynum and Roy Porter (London: Routledge, 1993), 2:1170. 12 Margret Frenz, “From Zebra to Motorbike: Transnational Trajectories of South Asian Doctors in East Africa, ca 1870–1970,” 144, in this collection. See also John Iliffe, East African Doctors: A History of the Modern Profession (Cambridge: University of Cambridge, 1998), 2, 62. 13 Adell Patton, Jr, Physicians, Colonial Racism, and Diaspora in West Africa (Gainesville: University Press of Florida, 1996), 33. 14 Ibid., 32, 35. 15 Douglas M. Haynes, Imperial Medicine: Patrick Manson and the Conquest of Tropical Disease (Philadelphia: University of Pennsylvania Press, 2001), 185n8. And see Sendall to Chamberlain, 27 March, 1900, CO 111/518, CO no. 11445, BG no. 78, National Archives, London, U.K. (hereafter NA). 16 “Colonial Office Minute,” [nd], CO 111/518, Colonial Office no. 11445, BG no. 78, NA; “Jamaica – Law 28 of 1885, The Medical Laws of 1872 and 1879, Amendment Law, 1885,” in The Laws of Jamaica, Passed in 1885

36  Juanita De Barros

17

18 1 9 20

21 22

23 24

25

26

27 28 29 0 3 31

(Jamaica: Government Printing Establishment, 1885), ss 4, 5; “The Medical Law, 1908 (Jamaica),” Obeah Histories: Researching Prosecution for Religious Practice in the Caribbean, http://obeahhistories.org/jamaicamedical-law-1908/. See also CO 137/665, Jamaica no. 33014, NA. “Colonial Office Minute,” [nd], CO 111/518, Colonial Office no. 11445, BG no. 78, NA; Sendall to Chamberlain, 27 March 1900, CO 111/518, CO no. 11445, BG no. 78, NA. “Memorial,” in Gormanston to Lord Knutsford, 13 February 1890, CO 111/455, no. 40, NA. Gormanston to Knutsford, 8 October 1890, CO 111/457, no. 317, NA. For example, see Alleyne Leechman, ed., The British Guiana Handbook, 1913 (Georgetown: Argosy, 1913), 118. Studies outside the British world were possible with permission. Anne Spry Rush, Bonds of Empire: West Indians and Britishness from Victoria to Decolonization (Oxford: Oxford University Press, 2011), 43. William W. Besson, Caribbean Reflections: The Life and Times of a Trinidad Scholar (1901–1986); An Oral History Narrated by William W. Besson, ed. Jean Besson (London: Karia, 1989), 51. Ibid., 55. The sources do not provide an ethnic breakdown of the scholarship winners. See Juanita De Barros, “‘Spreading Sanitary Enlightenment’: Race, Identity, and the Emergence of a Creole Medical Profession in British Guiana,” Journal of British Studies 42, no. 4 (October 2003): 483–504; E.W. Reece to the officer administering the government of the Colony of Barbados, 15 April 1918, CO 28/293, no. 32545, confidential, NA, 335. See James Bradley, Anne Crowther, and Marguerite Dupree, “Mobility and Selection in Scottish University Medical Education, 1858–1886,” Medical History 40, no. 1 (January 1996): 4, 18, 19. Richard B. Sheridan, Doctors and Slaves: A Medical and Demographic History of Slavery in the British West Indies, 1680–1834 (Cambridge: Cambridge University Press, 1985), 58. M. Anne Crowther and Marguerite Dupree, Medical Lives in the Age of Surgical Revolution (Cambridge: Cambridge University Press, 2007), 23. “List of Medical Practitioners Appearing on the Medical Register in January 1912,” Official Gazette, 9 February 1912, 300, in CO 28/47, no. 64, NA. Ibid.; E. Goulburn Sinckler, The Barbados Handbook (London: Duckworth, 1914), 69, 81–2. Jones, Public Health in Jamaica, 32. E.W. Reece to the officer administering the government of the Colony of Barbados, 15 April 1918, CO 28/293, no. 32545, confidential, NA, 335.

Imperial Connections and Caribbean Medicine  37  32 Ibid., 336; acting governor of Barbados to Walter Long, secretary of state for the colonies, 4 June 1918, CO 28/293, confidential, NA, 332. It is not certain whether this policy was a blanket prohibition or if it was restricted to the medical faculty. David Austin has noted that “elite Caribbean and African students” were admitted to McGill in the 1960s. David Austin, “All Roads Led to Montreal: Black Power, the Caribbean, and the Black Radical Tradition in Canada,” Journal of African American History 92, no. 4 (Fall 2007): 517. 33 Robin W. Winks, The Blacks in Canada: A History, 2nd ed. (Montreal and Kingston: McGill-Queen’s University Press, 1997; 1971), 387. 34 Thomas Holt, The Problem of Freedom: Race, Labor, and Politics in Jamaica and Britain, 1832–1938 (Baltimore: Johns Hopkins University Press, 1992), 392. Similar reasons lay behind the migration of French West Indians, although they journeyed mostly to Paris. The story of French West Indian medical students in France in this period is still waiting to be told. 35 The scholarship on this subject is extensive. For example, see Manning Marable, “Marxism, Memory, and the Black Radical Tradition,” Souls: A Critical Journal of Black Politics, Culture, and Society 13, no. 1 (January– March 2011): 1–16; Winston James, Holding Aloft the Banner of Ethiopia: Caribbean Radicalism in Early Twentieth-Century America (London: Verso, 1998); Anne Spry Rush, “Imperial Identity in Colonial Minds: Harold Moody and the League of Coloured Peoples, 1931–50,” Twentieth-Century British History 13, no. 4 (November 2002): 356–86; Rush, Bonds of Empire; Daniel Whittall, “Creating Black Places in Imperial London: The League of Coloured Peoples and Aggrey House, 1931–1943,” London Journal 36, no. 3 (November 2011): 225–46. 36 Besson, Caribbean Reflections, 59. 37 Ibid., 61, 62. 38 Ibid., 75. 39 Ibid., 67, 72, 73, 78. 40 Anne Spry Rush, “Imperial Identity in Colonial Minds,” 357, 364–5; see also David Killingray, “‘To Do Something for the Race’: Harold Moody and the League of Coloured Peoples,” in West Indian Intellectuals in Britain, ed. Bill Schwarz (Manchester: Manchester University Press, 2003), 52, 58–9. 41 Paul B. Rich, Race and Empire in British Politics, 2nd ed. (Cambridge: Cambridge University Press, 1990), 137; Daniel James Whittall, “Creolising London: Black West Indian Activism, and the Politics of Race and Empire in Britain, 1931–1948” (PhD diss., University of London, 2012), 202. 42 Whittall, “Creolising London,” 202.

38  Juanita De Barros 43 Keys 1, no. 1 (July 1933); see also Killingray, “‘To Do Something for the Race,’” 62. 44 “Editorial,” Keys 1, no. 1 (July 1933): 2; see also Keys 1, no. 5 (July 1934): 17. 45 League of Coloured Peoples to the editor, Times, nd, rpr. in The League of Coloured Peoples, Seventh Annual Report (Year 1937–8), CO 318/425/2, NA, 104. 46 See correspondence in CO 323/1218/5, NA. 47 J.H. Rushbrooke and John Fletcher to Sir Philip Cunliffe Lister, 9 May 1933, CO 323/1218/5, NA. 48 R.V. Vernon, draft, to Moody, 10 June 1933, CO 323/1291/5, no. 10565, 3, NA. 49 See Frenz, “From Zebra to Motorbike.” 50 Jones, Public Health in Jamaica, 32. 51 Carl C. Campbell, The Young Colonials: A Social History of Education in Trinidad and Tobago, 1834–1939 (Barbados: Press University of the West Indies, 1996), 27. 52 For example, see West India Royal Commission, “Medical Services, Colonial Office Memorandum,” CO 950/47, NA, 9, 10. 53 British Medical Association, British Guiana Branch, “Oral Testimony,” CO 950/645, NA, 33, 17, 18, 34; “West India Royal Commission, Twentieth Session Held in Trinidad, on Tuesday the 14th March, 1939,” in “Witness, the Medical Board,” in “Trinidad, British Medical Association, Memorandum of Evidence,” CO 950/795, NA, 1. There were 133 registered medical practitioners in Trinidad. 54 British Medical Association, “Medical Services in the West Indies,” CO 950/888, NA, 5. Figures for the late 1930s provide an indication of the variation. In Jamaica there were seventy-eight; Trinidad, thirty-nine; Guyana, thirty-six; Belize, seven; Virgin Islands, one; Antigua, five; Montserrat, two; St Kitts, seven; St Lucia, seven; Dominica, four; St Vincent, nine; Grenada, ten. WIRC, “Medical Services, Colonial Office Memorandum,” CO 950/47, NA, 6–8. 55 Sinckler, Barbados Handbook, 69, 81–2. 56 Colonial Medical Services Committee, “Minutes of Meetings and of Evidence Taken before the Committee, together with Correspondence,” CO 885/26/13, NA, 19, 20. See also Crozier’s description of this process. Anna Crozier, Practicing Colonial Medicine: The Colonial Medical Service in British East Africa (London: I.B. Tauris, 2007), 18. 57 Colonial Medical Services Committee, “Minutes of Meetings and of Evidence,” 23. 58 Ryan Johnson has noted that the West African Medical Staff, which was established in 1902, was “explicitly racist” and stipulated that physicians

Imperial Connections and Caribbean Medicine  39 

5 9 60 61 62 63 64 65

66 6 7 68 69 7 0 71 72

73

74

75 76

not of European origin were not to be admitted. Ryan Johnson, “‘An AllWhite Institution’: Defending Private Practice and the Formation of the West African Medical Staff,” Medical History 54, no. 2 (2010): 237. Besson, Caribbean Reflections, 73. Ibid., 51. Ibid., 74. Colonial Medical Services Committee, “Minutes of Meetings and of Evidence,” 94; De Barros, “‘Spreading Sanitary Enlightenment,’” 494. Colonial Medical Services Committee, “Minutes of Meetings and of Evidence,” 95. Some of these points have been addressed in De Barros, “Spreading Sanitary Enlightenment.” Colonial Medical Services Committee, “Minutes of Meetings and of Evidence,” 43. See also De Barros, “Spreading Sanitary Enlightenment,” 495. “Government Medical Officers in 1912 Classified According to Race,” confidential, CO 111/638, CO no. 74706, NA. Ibid. Collet to Churchill, 6 April 1921, confidential, CO 111/638, CO no. 74706, NA. Colonial Medical Services Committee, “Minutes of Meetings and of Evidence,” 45. Ibid., 21, 95. Ibid., 98. WIRC, “Medical Services, Colonial Office Memorandum,” CO 950/47, NA, 50, 51. Crozier has noted the high prestige attached to the African and Indian medical services. Crozier, Practicing Colonial Medicine, 22. Anthony Kirk-Greene, On Crown Service: A History of HM Colonial and Overseas Civil Services, 1837–1997 (London: I.B. Tauris, 1999), 35; “Medical Services. Colonial Office Memorandum,” CO 950/47, NA, 6. “A Note on the Control of Public Health and on Medical Personnel,” Trinidad and Tobago, “West India Royal Commission, 1938–39,” Memorandum submitted by Control of Public Health and Medical Personnel, CO 950/836, NA, 12, 13. WIRC, “Medical Services, Colonial Office Memorandum,” CO 950/47, NA, 51. Medical Services. Colonial Office Memorandum, CO 950/47, NA, 61, 76. The sources consulted so far do not indicate the number of nonwhite physicians in the government medical services. Indeed, officials themselves may not have known. In response to a question during the

40  Juanita De Barros Moyne Commission hearings, the head, Arthur John Rushton (A.J.R.) O’Brien, chief medical advisor for the Colonial Office, noted that he could not say how many private practitioners in Jamaica were white or “coloured.” CO 950/47, NA, 76. 77 Kirk-Greene, On Crown Service, 35; see also Crozier, Practicing Colonial Medicine, 5. “Medical Services. Colonial Office Memorandum,” CO 950/47, NA, 6. 78 On some of the causes of the protests of the 1930s, see Cary Fraser, “The Twilight of Colonial Rule in the British West Indies: Nationalist Assertion vs Imperial Hubris in the 1930s,” Journal of Caribbean History 30, no. 1 (January 1996): 1–27; O. Nigel Bolland, The Politics of Labour in the British Caribbean: The Social Origins of Authoritarianism and Democracy in the Labour Movement (Kingston: Ian Randle Publishers, 2001), 299, 356–7, 358–9; Bolland, On the March: Labour Rebellions in the British Caribbean, 1934–39 (Kingston: Ian Randle Publishers, 1995). 79 Fraser, “Twilight of Colonial Rule in the British West Indies,” 6; Bolland, Politics of Labour in the British Caribbean, 299, 356–7, 358–9. 80 See Howard Johnson, “The Political Uses of Commissions of Enquiry (1): The Imperial – Colonial West Indies Context, The Forster and Moyne Commissions,” Social and Economic Studies (Jamaica) 27, no. 3 (1978): 268, 271–3; John La Guerre, “The Moyne Commission and the West Indian Intelligentsia, 1938–39,” Journal of Commonwealth Political Studies 9, no. 2 (1971): 134–5. 81 British Medical Association, “Medical Services in the West Indies,” in British Medical Association, “Memorandum of Evidence,” CO 950/888, NA, 9. 82 Ibid. 83 Amar Wahab, “Padmore, George,” in The Oxford Companion to Black British History, edited by David Dabydeen, John Gilmore, and Cecily Jones (Oxford: Oxford University Press, 2007; 2008), 358. See also Bill Schwarz, “Introduction: Crossing the Seas,” West Indian Intellectuals in Britain, edited by Bill Schwarz (Manchester: Manchester University Press, 2003), 6; Whittall, “Creolising London,” 24, 22. 84 David Killingray, “Blackman, Peter McFarren,” in Dabydeen, Gilmore, and Jones, Oxford Companion to Black British History, 58; Marika Sherwood, “Blackman, Peter McFarren,” in Oxford Dictionary of National Biography online, http://dx.doi.org/10.1093/ref:odnb/101295. 85 International African Service Bureau, League of Coloured Peoples, and the Negro Welfare Association, “Addition to Serial No 21,” CO 950/30, NA, 1, 2; “West India Royal Commission, Ninth Session,” 29/9/38, CO 950/30, NA, 303.

Imperial Connections and Caribbean Medicine  41  86 “Memorandum on Contents of Dr Anderson’s Letter of the 5th July (No. 9) and of the Comments of Dr Moody and of the Comments of Dr Moody and Governor Thereon,” CO 318/425/2, NA, 32; Edward Denham to Orsmby Gore, 8 February 1938, Jamaica no. 64, CO 137/828/9, NA. I am grateful to Henrice Altink for giving me an early copy of her article, which addresses this case. See Henrice Altink, “A True Maverick: The Political Career of Dr Oswald E. Anderson, 1919–1944,” New West Indian Guide 87, nos 1 and 2 (June 2013): 3–29. 87 “Memorandum on Contents of Dr Anderson’s Letter of the 5th July (No. 9) and of the Comments of Dr Moody and of the Comments of Dr Moody and Governor Thereon,” CO 318/425/2, NA, 32. 88 Oswald E. Anderson, “Memorandum,” in West India Royal Commission, Dr Oswald Anderson, Memorandum of Evidence, CO 950/145, NA, 8. 89 “Nominations July 27. Citizens Want Dr Anderson Back,” Daily Gleaner, 15 July 1938, 3; governor to Malcolm MacDonald, secretary of state for the colonies, 16 November 1938, confidential, CO 318/425/2, NA, 20. 90 Amon Saba Sakaana, “Makonnen, Ras,” in Dabydeen, Gilmore, and Jones, Oxford Companion to Black British History, 283; David Killingray, “Milliard, Peter,” in Dabydeen, Gilmore, and Jones, Oxford Companion to Black British History, 299. 91 Peter Milliard and T.R. Makonnen, letter to the editor, Manchester Guardian, 18/8, CO 137/828/9, NA, 6. 92 Ibid. 93 International African Service Bureau, League of Coloured Peoples, and Negro Welfare Association, “Memorandum on the Economic, Political, and Social Conditions in the West Indies and British Guiana,” CO 950/30, NA, 23. 94 International African Service Bureau, League of Coloured Peoples, and Negro Welfare Association, “Second Addition to Serial No. 21,” CO 950/30, NA, 4, 5. 95 Altink, “True Maverick,” 17. 96 Stevens, 16/11/38, CO 318/435/2, NA, 11; Emmens, 16/11/38, CO 318/435/2, NA, 11, 12; Stevens memo, 15/12/38, CO 318/435/2, NA, 13. See also Whittall on this exchange, in “Creolising London,” 320. 97 Officer administering the government of Jamaica to secretary of state for the colonies, telegram, 1 July 1938, confidential, CO 137/838/9, NA, 8. 98 Ibid. 99 “Memorandum on Contents of Dr Anderson’s Letter of the 5th July (No. 9) and of the Comments of Dr Moody and of the Comments of Dr Moody and Governor Thereon,” CO 318/425/2, NA, 32; memorandum by N.L. Mayle, 20/8/38, CO 137/828/9, 8, NA.

2  Pathways of Perseverance: Medical Refugee Flights to Australia and New Zealand, 1933–1945 john weaver

Movement is the defining property of global history. Accounts of migrations substantiate that claim, but they also raise consciousness about individuals’ aspirations, fate, tenacity, and adjustment. At one extreme, economically motivated journeys have led out of the Old World’s constraints into New World opportunities. At another extreme, slave traders have forced migrations throughout history. A further category arises from movements connected to epic crises. Famines, pogroms, revolutions, wars, and genocide figure in numerous urgent migrations of the nineteenth and twentieth centuries. These crisis migrations demonstrate individual resolve; as well, they expose deplorable and uplifting conduct in host countries. The flight of Jews from Nazi Europe is such a migration. The long and often convoluted journeys of Jewish medical doctors to Australia and New Zealand comprise a well-­documented subset of men and women from the larger crisis migration. The term refugee Jews is consistent with Nazi racialization. Therefore, in this chapter, the short-hand expression will be used with the understanding that it explains what drove men and women into exile. Moreover, “Jewish identity was variable.”1 The doctors’ experiences were also variable. The formal requests of individuals to enter a country and secure registration to practise medicine precipitated debates within medical boards, medical schools, and Parliaments. When and where governments and boards jointly oversaw schemes to manage the immigration and registration, the documentation is rich. To establish credentials and loyalty, applicants collected documents, summarized their lives, and occasionally described their difficult journeys and strenuous sojourns. Wartime exigencies eventually lowered barriers, but then host countries steered the internal migrations. Unlike unconstrained travels to

Pathways of Perseverance  43 

acquire an education, secure special training, pursue opportunity, or extend humanitarian help, these medical migrants were tightly administered. Or so it seems. Control was never complete. Refugees enlisted relatives, friends, aid groups, and solicitors to assist with opening legal paths to medical practice, while a few ignored regulations and on arrival practised medicine without authorization. Persistence and resistance show individuals migrating figuratively through a tangle of politics, protectionism, and prejudice. Paul Weindling, who has written about refugee doctors in Britain, came to a conclusion that applies equally well to those who reached Australia and New Zealand. Life histories depict patterns of flight that were “often complex and settlement generally had many stages.”2 Approximately 350,000 refugees fled Nazi Germany before September 1939, and thousands more managed to escape from then until the mid-1940s; several thousand were doctors.3 Over a thousand from Germany, Austria, Italy, and Czechoslovakia reached the United Kingdom before the surrender of France in June 1941. Weindling calculates that there were over five thousand medical refugees in the United Kingdom from 1933 to 1950.4 Relative to their population, Australia and New Zealand took in a substantial number of men and women who subsequently faced opposition to resuming their careers. The number of refugee doctors who immigrated to Australia is difficult to determine accurately, because some never bothered to pursue registration; they accepted official warnings that doctors were less welcome than farm labourers. Likely between 300 and 350 refugee doctors arrived in Australia from 1933 to 1941; 100 to 150 achieved registration from 1933 to 1941. The Commonwealth of Australia, that is the federal government, granted temporary wartime licences to an additional 60 to 75 from early 1942.5 New Zealand granted a right of entry to 67 refugee doctors, on the initial condition that they could not practise medicine. Forty made the trip. Twenty-one eventually completed a three-year course at the University of Otago to qualify for registration. More individuals made inquiries about coming to these countries and, discouraged by the cool replies, went elsewhere if they could.6 In Queensland, the board deterred Drs Arnheim, Barr-David, Baumitz, Bleichroder, Cohn, Fabish, Goldberger, Hirsch, Kinsbrunner, Kyeberg, Lefman, Levi, Löfkovits, Mandl, Margulies, Monheimer, Newmann, Schenlbaum, Schneider, Soloman, Verzeans, and likely others unmentioned at meetings. The board discouraged general inquiries from foreign consulates.7

44  John Weaver

Nazi nihilism effloresced in the regime’s determination to destroy a set of doctors – approximately 10 per cent of all German doctors – weakening private practice, public health agencies, and hospitals.8 The Nazi empire’s loss was not automatically a gain for countries combating the tyranny. The aggregate number of migrants disguises the fact that individual voyages were not tidy point-to-point trips but included complicated escapes and capricious twists. Moreover, the numerical estimates on successful registrations pass over the struggles and tactics required to get official sanction to practise medicine. Migrations varied by path, duration, destination, and reception. To arrive did not necessarily mean to settle into a new professional life. Modern states before the 1930s had already started to tighten control over immigration and they had moved to regulate the medical profession. Quite a few individuals in the host countries’ medical boards were bigoted, financially self-interested, or professionally insecure. However, in most Australasian jurisdictions, it helped refugees that a few astute politicians could be opportunistic; it helped that most states were rule-conditioned enough to accept a law or judgment. With legal advice or assistance, a number of migrant doctors negotiated through prejudice, envy, and economic protectionism.9 This chapter reviews the legal setting for medical registration in Australia and New Zealand (1901–40), the shift from ad hoc rejection to broader policies (1938–9), the intensification of gatekeepers’ efforts and counter-strokes of perseverance (1938–40), and wartime management (1940–5). The Legal Maze and Preparatory Journeys Medical practice acts delegated to medical boards a guild-like authority to register doctors as legally entitled to treat patients. In Australia, state Parliaments were responsible for the medical practice acts, and state medical boards administered the profession; in New Zealand, the national Parliament did the same.10 The duly empowered medical boards informally served another master too, because they drew members from local branches of the British Medical Association, and these branches followed the BMA lead on many issues. The BMA at home and abroad favoured laws or administrative practices that set quotas on refugee doctors, or a long period of residency in a British dominion, or completion of a full degree program in a medical school in the United Kingdom or a dominion.11

Pathways of Perseverance  45 

Medical schools functioned independently from medical boards and, generally speaking, had a less protectionist outlook on the registration of refugee doctors, but they did not control registration. Across the empire each board and each government differed in its handing of the issue; boards and governments kept in contact, although in some jurisdictions there was more agreement and collaboration than in others. The political context was characterized by permutations; however, it is useful to outline the instruments of protectionism available to boards and governments. They were straightforward and included legislation to restrict the numbers of refugee doctors, a board’s narrow interpretation of credentials, recourse to solicitors to find weaknesses in the case, insistence on documents or testimonials from authorities in hostile jurisdictions, postponements of decisions, and denial of reciprocal registration privileges where in law they truly existed. Countermeasures were repeated in many places: medical schools introduced courses to give refugees credentials; some politicians and newspapers exposed the conduct of boards; and refugee doctors formed associations and hired solicitors to threaten action. One route to registration pursued by refugee organizations on behalf of a few doctors had a strange history that requires elaboration, since it had a significant role. Italian credentials provided a way for a few doctors to secure registration. This path originated in struggles at the turn of the century for the control of spas in Switzerland and Italy, and the resorts of southern France where the wealthy British went into winter quarters.12 For a suitable bedside manner, a proper Englishman was preferred. Until the 1880s, “free transnational movement prevailed among students and the medically qualified.”13 But at the end of that decade and again after the First World War, national regulations and medical board nativism restricted freedom to practise across national boundaries. The federated Swiss government in 1889 prohibited U.K. doctors from treating patients in Switzerland, because Swiss doctors wanted exclusive control of the spa business.14 Likewise, in 1898, the Italian government threatened to bar foreign doctors from practising in Italy, so the British expatriate medical community lobbied at home for action to prevent this prohibition.15 The British medical profession favoured reciprocity. The Medical Act of 1886 had given the General Medical Council authority to recognize equivalent qualifications from countries that treated the United Kingdom with reciprocal fairness.16 Understandably, the British expatriate medical lobby praised Italy’s even-handedness. “No other

46  John Weaver

country gave English practitioners the privileges that Italy did.”17 British advocates of reciprocity claimed that few Italians would find much to attract them to England, and the few who came posed no threat. Reciprocity seemed an advantageous measure.18 On the advice of the medical council, the Privy Council extended reciprocity to Italy in 1901. At the time, the self-governing dominions accepted the authority of the British government in foreign affairs, and the Order in Council ostensibly extended to them. In the early twentieth century a few Italian doctors secured registration in Australia,19 establishing a precedent. No one could deny that doctors with Italian credentials had been registered in Australia. None appear to have gone to New Zealand before Nazi persecution, and at that point the New Zealand Medical Council implausibly denied that the Order in Council had applied to New Zealand. The council’s mendacious denial of reciprocity closed off the Italian route to registration in New Zealand. Upon inquiry from a firm of solicitors representing an Italian doctor, the secretary of the council flatly denied there was any reciprocal agreement between New Zealand and Italy.20 The government watched this development, because rejection hinged on a constitutional position. When another doctor applied with Italian qualifications, the Health Department consulted the Crown Law office, which advised that since the United Kingdom had committed the dominions to a treaty obligation without consulting them, the medical council should deny registration. Had the applicant, Dr Neumann, appealed, the director-general of health was certain the courts would have decided in the doctor’s favour. Neumann was later offered and accepted a posting as medical officer in Samoa.21 Italian medical schools remained open to Jews throughout the 1930s; Jewish doctors continued to be registered by the Italian equivalent of a medical council, the Ordine dei Medici. The British Medical Association and, through it, affiliates in the empire, were alerted to the Italian route in 1934 by an inquiry from a Deborah Stosch-Wortley who may have been acting on behalf of a refugee group. She asked the secretary of the British Medical Association “whether a German doctor (Jewish) holding the degree of the Royal University of Florence (Italy) together with the Diploma of the State Governing Board, would be eligible for registration in England, or South Africa – or Australia – without having to pass a further examination in either of these countries.” She surely knew about the agreement between the United Kingdom and Italy.22 A.D. Macpherson, assistant medical secretary of the British Medical

Pathways of Perseverance  47 

Association, prepared a cold reply on behalf of the BMA executive. Yes, anyone who held an Italian degree and was registered with the Ordine dei Medici in one of the provinces would be eligible for registration in England. “On the other hand, it is doubtful whether the Home Office would accord such a foreign member of the medical profession permission to stay and practice in this country.”23 Macpherson revealed why the BMA hoped that the Home Office would turn back such individuals. As the United Kingdom, South Africa, and Australia, it was alleged, “were already being well provided with doctors, it is in my opinion extremely doubtful whether such an applicant would be accorded permission to register, practice or remain in any of these areas.”24 Macpherson alerted the association’s branches in South Africa and Australia and asked that they reply directly to StoschWortley. Australian boards took a firm stand on reciprocity and registration. There was no reciprocity between Great Britain and Germany, therefore German credentials could not be recognized. The position was spelled out at a 1933 meeting of the Queensland board: “Dr J. Leon Jona of Melbourne inquiring whether German medical degrees held by Jews who had been forced to leave Germany would be recognized in Queensland for registration. It was decided to reply that as reciprocity did not exist between Great Britain and Germany, German diplomas could not be recognized but that if the holders of those degrees also held British degrees they would be entitled to be registered.”25 The stated reason betrayed “absentmindedness,” because Queensland had been the destination of many German immigrants, and the board had registered a few German doctors before 1914. If anything, the board had once had a high regard for doctors trained in Germany and rejected those with American or Japanese degrees.26 After 1933, German-trained doctors were barred by simply applying a technicality that had been waived in the past. But other openings could not be so readily closed, and their existence drove boards to hold policy discussions about refugee doctors. In the eyes of protectionists, developments in Scotland suddenly allowed foreigners to threaten the livelihood of locally trained doctors. Scottish medical educators and medical board members had established a fifteen-month Scottish Conjoint Diploma (medical and surgical) program for refugees. Kenneth Collins, who has studied the several Scottish programs for refugee doctors, explains that some of the receptivity derived from “a long Scottish tradition of attracting overseas doctors,” and this experience was less pronounced in pre-war England.27 The fortunate refugees who went

48  John Weaver

through the program and emigrated to the dominions still had to be registered by local boards.28 However, imperial reciprocity in medical credentials usually meant that boards in the dominions had to register applicants. When refugees bearing Scottish certificates began to appear in the dominions, local doctors and some politicians investigated ways to block reciprocity. The medical board for the State of Victoria refused to register a licentiate from the Scottish program, but an appeal against that decision was successful.29 In mid-1937, the government of South Africa refused to recognize the certificates, claiming that the holders had flooded the country. Until South Africa ended reciprocity, its medical council had no alternative but to admit the graduates from Scotland, which it did not want to do.30 Subsequently, the British medical council stepped in to prohibit graduates of the Scottish course from practising in the United Kingdom, a decision with consequences throughout the empire, because it undercut reciprocity.31 Critics denounced the Scottish short course, not because it allowed unqualified doctors to move about the empire, but because it was “a subterfuge.” The Queensland board noted at its meeting of 13 September 1937 that “this short course in Scotland has become a subterfuge to obtain registration in other parts of the British Empire. Already in some British Countries legislation has been put into operation to prevent this.”32 The board secured the services of prominent Queensland attorney Neal Macrossan to advise on draft legislation to block reciprocity.33 Across the Tasman Sea, New Zealand was not greatly affected by the Scottish courses; the director-general of health reported in August 1941 that over the preceding three years only eight refugee doctors had been registered on the basis of any British degrees.34 At its annual meeting in July 1938, with representatives from the empire in attendance, the BMA considered the plight of Jewish doctors in Central Europe. Opinions included outright hostility towards the refugees. “Last year,” said one doctor, the country let in numerous nonAryan doctors from Germany, and “now they were threatened with an invasion of non-Aryan doctors from Austria.”35 Others professed deep concern for the turmoil affecting Jewish doctors across Central Europe, but they still wanted limits on the number admitted to practise in the United Kingdom. The Home Office suggested to the BMA that the United Kingdom should take in 500. The council agreed to register no more than 50 and established a committee to review applications. The Scottish colleges were criticized.36

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Resistance in South Africa and then the United Kingdom to the registration of refugee doctors with Scottish credentials further emboldened like-minded protectionists around the empire. Ontario, Canada, was an exception, because in 1927 the province’s College of Physicians and Surgeons had cancelled reciprocity with the United Kingdom. When the Ontario body re-established reciprocity, as a wartime measure in 1940, it barred most refugee doctors by stipulating that applicants had to have British citizenship, except in “exceptional cases,” to be judged on the basis of individual interviews conducted by the committee of education and registration. Paul Weindling suggested that Canada was “notably restrictive when it came to refugee doctors and medical students.”37 There is reason to agree, because the executive committee of the Canadian Medical Association struck a protectionist note at its 1938 meeting when it resolved that Canada “did not need to import doctors from foreign lands, in as much as our medical schools are producing quite as many doctors as the country can reasonably absorb.”38 Pronouncements about a saturation of doctors proliferated around the empire from mid-1938 until at least early 1942, when the war, now truly a world war, intervened. Even then some boards remained hostile. Rarely did protectionists openly espouse anti-Semitism, although bigotry was not completely absent from boards. Competition was the medical profession’s declared enemy; however, a strictly economic explanation for protectionism is insufficient. References in Australia and New Zealand to preserving the profession for future generations of the native-born against foreigners served as veiled disapproval of Jews. For a few individuals, migration began with trips to Italy or Scotland. For some, these were countries of transit.39 Meanwhile, in distant dominions, determined protectionists and bigots on medical boards collaborated to stop migrations at the transit countries. From Ad Hoc Rejection to Policy Debates Each phase in Nazi persecution created a corresponding increase in refugee inquiries.40 The Nazi government began targeting Jewish doctors in early 1933, when it ordered Berlin hospitals to relieve Jewish doctors of their duties, and within a few days, the orchestrated discrimination spread to Bavaria.41 In short order, German Christians throughout Germany were advised to shun Jewish doctors.42 At first, the Nazis hoped for a popular movement against Jews; however, they soon turned to edicts. The Nuremburg Laws of 1935 removed Jews

50  John Weaver

from most ­professions and the civil service.43 During the lead up to the Berlin Olympic Games in 1936, persecution abated but returned in late 1938. The medical licences of Jews were cancelled, and Jews were allowed only to treat other Jews. Persecution inexorably followed German aggression into neighbouring countries.44 In each occupied country, Jewish doctors were banned from practice.45 Inquiries about medical registration in Australian states and New Zealand began shortly after the Nazi assumption of power; at first, family members and friends in Australia and New Zealand initiated contact with the boards.46 In late 1933, the Queensland Medical Board received its first refugee inquiries. At the same time, refugee doctors began applying for admission to New Zealand and registration by the country’s medical council. The medical profession there was hostile to the first five who arrived from 1933 to 1935.47 As well, from 1933 to 1937, inquiries to medical boards in both countries trickled in on behalf of Jews still in Germany. In late 1938 and into 1939, boards suddenly received a torrent of inquiries from Europe. Over a third of Australia’s refugee doctors landed in 1938, a quarter in 1939, and a tenth in 1940. The Sydney Morning Herald in 1941 estimated that 90 per cent of the refugee doctors in New South Wales had arrived in Australia in the eighteen months preceding the war.48 The number coming to New Zealand in 1939 exceeded any previous year. Prior to and during 1938, refugees originated largely from Germany; following the Munich Agreement, they started to arrive from Czechoslovakia. Austrian applications surged because regulations in that country in October 1938 cancelled the licences of Jewish doctors.49 Enough complaints about inquiries from refugee doctors emanated from Australia’s boards that in January 1938 the Commonwealth’s minister of health, Earle Page, convened a meeting of state ministers of health for the last week on February. Page wanted to rationalize the registration of doctors, dentists, nurses, and chemists through Commonwealth law, and that included “the admission of Jewish doctors to registration in Australia.”50 Stating that the subject was Jewish doctors rather than refugee doctors was a revealing slip of the tongue, but the Commonwealth government was not as hostile to registration of refugee doctors as some state boards. When bigotry surfaced in the registration controversies, it came from state boards. By mid-1938 an intensely parochial atmosphere was evident at the Australasian BMA branches and state boards. A sequence of events in the state of Victoria shows how easily a rumour contributed to hostility.

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The state’s board complained in July 1938 that forty refugees with medical training had arrived by a single vessel; the erroneous story was not only believed but it also sustained the idea of a threatening deluge of foreign doctors.51 The board asked the government for legislation to prevent newcomers from practising unless they had five years of study in Victoria or a reciprocating jurisdiction.52 Agitated by impressions that the state would be flooded with refugee doctors, a majority of medical students at the University of Melbourne signed a petition favouring limits.53 If the BMA in the United Kingdom wanted to practise protection, then, asked protectionist doctors in Australia, why should Australian doctors sacrifice to make room? The Queensland board took a serious interest in prohibition as soon as it learned that the government of South Africa barred graduates of the Scottish program; however, unique among Australian states, Queensland’s government refused to assist the board with an amended medical practice act.54 In general, the evidence from Australia and New Zealand supports Paul Weindling’s surmise that “prejudice could be more intense on the remote peripheries,” although evidence from Queensland reveals pragmatism as well.55 The Queensland board recommended that the state legislate five years of residence in the United Kingdom before British credentials would be recognized. The target was the Scottish program. The government rejected the board’s request, insisting that the state needed medical personnel. The press reported on a shortage of doctors and blasted protectionism. Brisbane’s Courier Mail noted in October 1939 that “the first class to graduate from Queensland medical school was in 1939; there were 21. But there were 22 vacancies at Brisbane Hospital and 55 vacancies throughout the state.”56 Press commentary failed to help doctors with German, Czech, and Austrian qualifications who applied for registration in Queensland through 1938 and 1939.57 They received the usual answer: no reciprocal agreement, no registration. When one applicant presented a letter of endorsement from Queensland’s minister of health and home affairs, the board rejected him because he held a German degree.58 Doctors on state boards claimed they were asserting professional independence.59 In Queensland, more than any other state, this independence did not impress the government, which refused to help block reciprocity. As the minister put it, “The wisdom of enacting such legislation is seriously open to question.”60 Other state governments more readily instituted protectionist measures. In December 1938, Victoria’s Parliament passed an act stipulating that registration required the completion of a prescribed course of study

52  John Weaver

at an Australian university or one that recognized Australian medical degrees.61 The government of South Australia in June 1938 legislated to allow the registration of refugee doctors after they had taken a special course, but a quota was imposed.62 New South Wales responded with a new medical practices act in late 1938 that set an annual registration quota of eight refugee doctors, who had to meet specific requirements and demonstrate “outstanding capabilities.”63 A special commission reviewed applicants.64 Tasmania and Western Australia adopted restrictive legislation.65 The New South Wales act was perhaps better than the status quo, whereby the medical board routinely turned down foreign degreeholders. Nevertheless, the act set a number as a ceiling, not as a quota to be achieved, so the board did not have to register any foreign applicants. In the course of a protracted letters-to-the-editor debate over the act, one observer stated the lesson: emigrants were expected to put their children in Australian schools to learn “British justice and fair play, and at the same time we prevent their parents from earning a living.”66 Several members of the state Parliament exposed and condemned the board’s delays in registering the eight doctors allowed by the act. A backbencher revolt over the matter threatened the United Australia Party government. Parliamentarians who protested against a Cabinet that did the BMA’s bidding threatened a political storm.67 The Scottish short course inspired imitation by several medical schools in Australia and New Zealand. When Australian university vice-chancellors met in August 1939, they discussed a common policy for a short course. The University of Sydney, the University of Adelaide, and the University of Queensland set up programs that allowed refugee doctors to enter the fourth year of the six-year course of study.68 Not as generous as the Scottish program, the plan was better than nothing, which was what the University of Melbourne offered.69 Melbourne’s lack of cooperation kept alive the spirit of the 1938 student petition and was consistent with statements from Dean W.A. Osborne to the effect that German medical training was “more philosophical and attentive to science than the human patient.” Osborne denied that he had anything against Jews: “Many of our finest doctors are Jews.”70 A shortened course of study would have met the conditions of Victoria’s protectionist legislation and negated its intended purpose of drastically reducing refugee applicants for registration. If vice-chancellors and some medical faculty believed they had expedited the registration of refugee doctors, they were mistaken. ­

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State boards could prevent registration by pressing the medical schools to limit the number of refugee students. They threatened to take the strict view that, since the universities’ medical upgrade programs granted certificates and not degrees, applicants for registration would still have to furnish proof of prior medical degrees.71 Refugee doctors may have learned something, but the courses did not necessarily lead to a ­trouble-free registration.72 In New Zealand prior to 1938, the refugee doctor question was handled on an ad hoc basis, as it had been in Australian states. Several arrivals had their credentials accepted, and the medical council recommended several others for a three-year course of training at Otago. However, in July 1938, the New Zealand council expressed alarm at “the considerable numbers of applications that are being received.” Practices now became formalized. Previously, the council’s secretary simply forwarded files assembled by immigration officials to the medical school at Otago. Henceforth, the council acting as gatekeeper reviewed applications at formal meetings.73 In early 1939, it recommended a limit of fifty refugee doctors.74 Possibly as early as mid-1938, the New Zealand high commissioner in London had been sending a standard letter to potential immigrants declaring that the likelihood of entry for a non-British subject was “even less in the case of professional persons, such as doctors and lawyers, than in the case of most other classes of workers.”75 The phrase mirrored warnings sent by the Commonwealth of Australia to prospective immigrants. Gatekeeper Practices and Migrant Perseverance The declaration of war against Germany in September 1939 placed refugee doctors temporarily in a worse situation than before. In some Australian states, the refugees’ status as enemy aliens invited misplaced retribution, because in both countries there was a return to a First World War mentality. A German was a Hun. The premier of New South Wales, Alex Mair, wanted to preclude German doctors from registration, even though the Commonwealth government informed the states that it would treat each refugee as an individual for the purposes of entry into the country.76 The United Australia Party government in New South Wales banned German-born refugees from applying for the eight positions a year that the Medical Practice Act of 1938 had opened to refugees. Despite the obvious objection that “they are victims of Germany, and are not our enemies but our allies,”77 Premier Mair insisted

54  John Weaver

that “the Government has not shifted ground, nor will it do so.”78 He rejected as unfair the idea that refugee doctors could serve communities where doctors had joined the army medical corps and proposed that refugee doctors would be German at heart and therefore security risks.79 The New South Wales branch of the BMA denounced calls for German doctors to be sent to outlying areas when other doctors joined the army. “This [replacement idea] meant let the Australian give his best years, his prospects, his livelihood, and maybe his life, and let a foreigner enter and deprive him of his means of subsistence should he return from active service.” Allowing registration in any form would “lead to the ever-expanding registration of foreigners by a back-door route.”80 In 1939, the origins of applications to Australian medical boards altered to include far more men and women who had fled to Italy, secured medical degrees, and stayed in Italy to practise medicine. As an ally of Germany, Mussolini’s government took steps against foreign Jewish doctors in May 1939 by restricting their right to practise medicine unless they qualified as Italian citizens.81 The Australian boards had little choice but to register the applicant if all the documentation could be validated. Legal counsel occasionally assisted applicants and attacked bureaucratic foot-dragging. During an interlude of Italian neutrality from September 1939 to June 1940, channels of communication stayed open. Australian boards made inquiries to Italian consular officials about Italian policies on the registration of foreign-born Jews as doctors and requested authentication of applicants’ documents.82 Boards sometimes requested applicants to furnish documentation directly from Italy. Perhaps board members who approved of obstructionist tactics reasoned that diligence was in the public interest, although there were other motives, including anti-Semitism and fear of competition. Most hostility towards refugees in Australia seems to have had an economic character. However, diligence could also be predicated on a group slur that revealed insecurity and parochialism. Refugee applicants for registration, wrote a Dr W. Maxwell in a late 1939 issue of the Medical Journal of Australia, needed to be carefully examined because they came from a group noted for duplicity. “These men came from Vienna mostly … Are there not refugees who are not what they profess to be … I know the techniques of these alien people with other standards of ethics.”83 The deployment of obstructionist tactics is illustrated by the actions of the Queensland board when it received applications from Eric Fox, Genoa (graduated 1936), Sura Markovitz Weyman, Milan (1932), Leon Wugmeister, Padua (1924), and Izydor Ropschitz,

Pathways of Perseverance  55 

Padua (1925). The state of Victoria had registered Fox, but he wished to move to Queensland. I served for a period of at least twelve months in the Hospital Asola, Italy, and the Bologna University Clinic, obtaining the prescribed experience in medicine, surgery and obstetrics at each institution. However, owing to the war and racial prejudice it would probably be impossible for me to now obtain Certificates to this effect and I shall be pleased if you will waive this when dealing with my application. I was unable to practice in Italy for more that twelve months before mentioned and arrived in Victoria in May, 1939. The Medical Board of Victoria granted me registration on 4th July, 1939 and my first engagement in this state was at Murrayville where I have practiced for the last four months.84

In March 1940, the Queensland board insisted that Fox produce further documentation. The application of Sura Markovitz Weyman, Milan (1932), was supported by Dr Rappoport of Brisbane and Dr Horowitz of Cairns. She was awaiting other references. A certain Dr Quinn, a fanatic who led the charge against registering refugee doctors, arrived late at a board meeting but just in the nick of time to introduce two motions. First, “that this application be deferred pending inquiries from the Consul General for Italy in Australia as to whether the qualifications held by her entitles her to practice in Italy and that the matter of the dates on the certificates be cleared up.” Second, “that Dr Weyman be informed that the Board is not satisfied with her certificate of character. Such certificate should be from some public official in Italy, for instance, the Registrar of the Ordine dei Medici in Milan.”85 The Italian consul general replied with information that enabled the board to erect another roadblock. “Under Italian laws,” he wrote, “Jewesses are allowed to practice their profession as doctors of medicine and surgery just as any other national. There are no restrictions. Similarly with foreign Jews, provided they can establish their right to reside in Italy, no restrictions are imposed on them practicing their profession.” The board could now ask if applicants had had a right to reside in Italy and if not they should not claim reciprocity.86 The dependably perverse Dr Quinn, noting that unauthorized residents could no longer practise in Italy and thus could not be accorded reciprocity in future, wished to know if the change would affect the status of doctors registered already under the reciprocal agreement.87 He wanted to revoke their registration.

56  John Weaver

Leon Wugmeister had applied at around the same time as Sura Weyman. He submitted character letters from two Brisbane doctors and another from the mayor of Milan attesting “to good civil, moral, and political conduct.” He had a certificate of registration from the “Fascist Provincial Organization of Physicians certified by the British Consulate General, Havana, Cuba.” As a final blocking effort in his case, the board “directed that the applicant and other applicants similarly circumstanced be required to show the Board that they can establish their right to reside in Italy.” Unable to do that, Wugmeister applied anew as a Polish citizen, whereupon the board informed him that Poland had no reciprocal agreement with the United Kingdom.88 Comparable yet distinctive circumstances applied to Maurice Beraha, Naples (1936); he had had to leave Italy and applied to work at Innisfail Hospital, but the board learned that he had not been formally registered by any provincial chapter of the Ordine dei Medici on account of his Greek citizenship. His request and subsequent appeal for registration were rejected. There was no reciprocal agreement with Greece.89 The origins of applicants and the means to block their aspirations corresponded to the collapse of European civil order. The application of Izydor Ropschitz, Padua (1925), returns us to the topic of health tourism, because “he was a very well-known doctor on the Italian Riviera among British residents.” A Polish Jew who had gone to Italy, but could stay no longer, Ropschitz had trained at the Vienna General Hospital. Fleeing to England, he had volunteered for emergency medical work in London and then signed on as a ship’s surgeon aboard the Tyandareus. That was how he arrived in Australia. He carried character references from a Lt Col. G.S. Hibbert, who had known him well for three years, and a Commander F.G.C. Coates, who wrote that he knew him well for ten years. Ropschitz was represented by J.S. Hutchinson, barrister at law. He had not known Ropschitz until recently, but his wife’s cousin was a Manchester cotton merchant who spent several months annually at Alassio, Italy, knew him, and wrote that the doctor had been ordered to leave Italy.90 The board insisted on character references and a security report from the Commonwealth Investigation Department.91 Eventually, after Wugmeister’s counsel threatened the board with a proceeding by way of mandamus, he was registered and so too was Ropschitz.92 They were the last doctors to be registered in Queensland through the Italian reciprocity agreement, because in early December 1940 the Queensland board received a cable from the General Council for Medical Education

Pathways of Perseverance  57 

and Registration of the United Kingdom. The British council forwarded a copy of an Order in Council revoking reciprocity. Australian states were reminded that they retained the authority to accept the Italian credentials if they wished.93 From 1933 to 1940, at least forty-three refugee doctors with Italian credentials had applied for registration in Queensland. Twenty were successful. To some degree Victoria also honoured reciprocity with Italy.94 What happened to the refugee doctors whom state boards in Australia had refused to register or immigrants who, to improve their prospects for entry, declared they would not seek registration? Some managed to complete the journey and found work at water, milk, and local health boards as chemists, in hospital and university laboratories as technicians, and with pharmaceutical firms. Several female doctors married and abandoned their careers; others worked as hospital dieticians or in pharmacies. A few unregistered doctors living in Sydney practised as “specialists” without a licence; there was a narrow space within state laws that permitted someone to advertise as a skin specialist, orthopaedic specialist, respiratory specialist, nose and throat specialist, and so forth. They could neither advertise as a doctor nor prescribe medicine. Several stated on their nameplates that they were “not registered in New South Wales.”95 When he applied for a temporary Commonwealth license to practise medicine during the war, Ernst Fabian noted on his application form that he was a building superintendent and “health practitioner unregistered.”96 Erich Ziegler fled Germany and relocated in Brussels, where he worked as a medical officer for a Jewish Aid Centre. He made his way to Sydney, where he worked as an “unregistered medical practitioner.”97 Samuel Haneman declared, “I am settled as unregistered practitioner with predominant ear-nose-throat practice.” He had been practising for seven years and had a fully equipped surgery. “There is no other Doctor in the neighbourhood (Fletcher Street, Bondi),” he explained.98 These doctors took a risk. They could be charged with manslaughter in a patient’s death. Barred from practice in Central Europe because they were supposedly not German enough, refugee doctors were now prohibited from legally practising for being German. Between late 1939 and mid-1940, the alignment of countries into hostile blocks was incomplete and combat fronts not solidified. Consequently, the journeys of several Central European refugee doctors to Australia were facilitated by Italian steamship lines and the imperial Japanese government. The former profited from conveying Jews to the

58  John Weaver

Far East and Australasia.99 Japan meanwhile distanced itself from the anti-Semitic horrors of Germany. Until July 1940 Shanghai remained an international anomaly where arrivals did not require a passport or visa.100 In August 1939, the Japanese administration in occupied China required the British-dominated municipal council to institute visa requirements for Shanghai. They were poorly enforced, and until March 1941, the Japanese embassy in Moscow still issued so-called transit visas that enabled refugees to reach Shanghai via Russia on the pretext that the traveller was in transit to somewhere else.101 By May 1940, Germany’s western offensive made flight from the Continent to the United Kingdom exceedingly difficult. Until mid1941, the Nazis promoted the departure of some Jews from Europe.102 Several routes remained open to Australasia. A few doctors, along with other refugees who had recently arrived in England, were sent via the passenger ship Dunera to Australian internment camps as part of the British policy of deporting thousands of refugees.103 Until the German invasion of Russia in late June 1941, Jews in small numbers crossed Russia by the Trans-Siberia Railway and sailed from Vladivostok to Japan and on to Shanghai. A few refugees found passage the way Izydor Ropschitz had; they signed on as a ship’s doctor and fled east to an Asian refuge. Between 17,000 and 20,000 Jews arrived in Shanghai from 1938 to 1941.104 Dr Meyer Mirski was one. He left Poland, found work in a Lithuanian hospital, and secured transit documents from the Japanese consul in Kovno, who assisted a number of refugees. Mirski crossed Siberia, reaching Japan in February 1941. There he worked briefly as a medical officer at the Polish Embassy, before sailing for Australia in August 1941.105 The Japanese offensive against the British Empire and the United States in December 1941 closed escape routes from East Asia to Australia and New Zealand.106 Several doctors had fled Germany and Austria in 1938–9 to practise medicine in Shanghai or at missionary hospitals in China. Shanghai attracted a substantial number of refugee doctors who shared the general poverty of their patients. Eventually, the American Joint Distribution Committee set up a hospital at Hongkew, and it took in several refugee doctors.107 As valuable as Shanghai was as a refuge for thousands of Jews, many regarded it as an insecure and temporary sanctuary. They looked to move on to Australia. Roman Zieher, for example, left Austria after the German occupation and arrived in Shanghai in September 1939, joined the staff of an American hospital in Changchow in October, enlisted as a doctor with the British army at Shanghai in

Pathways of Perseverance  59 

November 1941, and was bound for Singapore when the start of the Pacific war diverted him to Manila, and then almost immediately to Melbourne.108 The New Zealand council behaved as a protectionist gatekeeper, like counterparts in Australia. It monitored protectionist developments in New South Wales, but developed its own protectionist case, which addressed the Otago program.109 In September 1939, a subcommittee of the council drafted a resolution on restricting the doctors’ activities: “That in order to safeguard the interests of medical practitioners in this Dominion and particularly of those overseas, it is a recommendation to the Medical Council that alien enemy medical men who qualify for registration in New Zealand be admitted to the Register only on condition that they limit their practice to resident positions and other duties as may be determined.”110 Compared to BMA (New Zealand branch) policy, this resolution was soft. The BMA branch unanimously proposed that the medical council suspend the registration of any enemy alien practitioners.111 Fearing adverse publicity if they acted overtly against the Otago program, the council set out to craft a plausible case against it or else “our motive might be misunderstood.”112 Members of the council thought that recent increases in the numbers of New Zealand–born medical students, in addition to the likely limited capacity of the Otago medical school, would offer plausible cover for terminating the scheme. They had not counted on faculty members disputing their portrayal of an over-worked faculty; in fact, the medical faculty voted to continue to admit refugees – although the motion to continue passed only by a majority of one.113 The government, hospital administrators, medical educators, and some doctors insisted there was a doctor shortage. There were rumours in favour of the newcomers to the effect that they were better qualified than their Otago instructors.114 Envy also surfaced in scorn for the specializations of the European doctors; it was claimed that they were so narrow that they could not tackle rural general practice. In a letter to the council’s secretary, a prominent Dunedin doctor referred to “these psychotherapy know-alls from Vienna.”115 Although the medical faculty at Otago voted to continue with the special program, the council had the last word. It informed the school in March 1940 that no further files would be passed to the school. The council let refugees on a waiting list know that “in the future no concession in this respect [the Otago program] to foreign graduates in medicine will be granted.”116 A few individuals who had reached

60  John Weaver

New Zealand were affected, but at this juncture additional parties holding entry permits were not expected to reach New Zealand.117 In the aftermath of German conquests in May and June 1940, confusion and disbelief misled some members of the New Zealand branch of the BMA to consider the possibility that refugee doctors might include “planted agents.”118 Hostility from New Zealand doctors towards the refugee doctors embodied confusion about world affairs and the country’s best interests. To control the movements of certified refugee doctors so that they would not congregate in the large centres to compete in a well-served market, thus annoying the council, the government considered directing refugee doctors graduating from Otago to specific sites.119 However, regional hospital boards, short of doctors, were not all willing to take aliens. The Nelson Hospital Board wanted them and opposed their freedom of movement; boards in Gisborne, Hawkes Bay, Christchurch, Cromwell, Ashburton, Gore, and Invercargill did not want them at all.120 The director-general of health, summarizing the opinions of his contacts, warned the government that “the refugee doctors are not welcomed in the public hospitals.”121 Whether his assessment was sound is impossible to establish. Regardless, migration was incomplete after registration. The Pacific War drove European doctors out of Canton, Singapore, Malaya, the Dutch East Indies, Papua, Manila, and the Solomon Islands.122 Interned as enemy aliens, late refugees with a medical degree found employment in internment camps as medical assistants. Soon, recent internees as well as many earlier refugee doctors who had been rejected by state medical boards were able to practise medicine legally to aid the war effort, although the boards maintained their opposition and extracted concessions from the Commonwealth of Australia and government of New Zealand. Wartime Management As noted previously in this chapter, some adversaries of refugee doctors branded them enemy aliens when the war began. The irrepressible Dr Quinn of Queensland attempted to thwart applicants whenever and however he could. In March 1940, he introduced a resolution “that the board approach the Commonwealth Government about precluding the registration of foreign doctors for the duration of the war, and that other state boards be approached about undertaking the same lobby.”123

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At the same time, war gave impetus to the formation of national associations of refugee doctors and the hiring of solicitors to assist with registration through Italian reciprocity.124 Refugee doctors also acquired a new significance with governments facing an acute demand for personnel. In Australia, resistance from the medical profession and the army medical service slowed acceptance of a scheme for the wartime registration, even though a British defence regulation of 1939, revised in 1941, provided guidance. That scheme allowed refugee doctors temporary registration to work in civilian hospitals and clinics as assistants to British practitioners.125 In September 1939, according to Marion Berghahn, the BMA had permitted 1,000 refugee doctors on a temporary register.126 The Tasmanian-born chairman of the Commonwealth Financial and Economic Committee, Professor Lyndhurst Falkiner Giblin, referenced this British scheme when he proposed a similar plan to the minister of the army, Percy Spender, in early April 1941.127 When Giblin’s memorandum circulated, it stirred fervent opposition from the army’s medical services branch, where senior officers drew upon the First World War rather than the current world situation. They concluded that the public would reject treatment by “the Huns.” Such was the opinion of Major-General R.H. Fetherston, director general of Medical Services in “the Great War.”128 The current director-general of Medical Services, Major-General F.A. Maguire, concurred, and in a May 1941 minute to the adjutant general added another reason why the army should oppose the use of refugee doctors in civilian positions. In his mind, they would be “competing with Australian doctors absent on active service.” If necessary, he suggested, Australia might have to do what the United Kingdom had done and recruit American doctors.129 When the medical profession in May to July 1941 lobbied the government against registering refugees, it returned to the idea that it would be wrong to allow foreigners to compete with Australians who were away at war. In Australia it was estimated that as many as a third of the country’s doctors would be called up for military service; in April 1941 an estimated 300 of Victoria’s 1,700 registered doctors were in uniform. Thus, in April–July 1941, the shortage of civilian doctors – not military ones – and the attendant press clamour convinced Australia’s war Cabinet to follow Giblin’s advice and take advantage of the refugees by licensing them to serve in country areas or in institutions for the duration of the emergency, with or without the consent of medical boards.

62  John Weaver

In late 1941, the Commonwealth government consulted the medical profession through a newly created wartime Central Medical Coordinating Committee. This national committee argued against, but reluctantly accepted, wartime registration as an expedient.130 It alleged that a shortage of country doctors existed before the war and thus was not a war emergency; higher state subsidies for country doctors and an extended Flying Doctors program, it proposed, could have obviated the need to license aliens to help in remote areas. Enclosing a petition from medical personnel with the Australian Imperial Force in Malaya and referring to another from the Middle East, the committee insisted that military doctors felt betrayed. European states had not granted Australia reciprocity, except for Russia; the United States and Canada had not granted reciprocity, so why should Australians be generous? The doctors worried about re-establishing their practices after the war; so long as that anxiety existed, claimed the committee, it would impede the enlistment of medical practitioners as medical officers in the services.131 Legal opinion supported the constitutionality of the emergency measure under the terms of the National Security Act of 1939, therefore the government pressed on, despite the boards’ disapproval.132 A circular letter of 6 January 1942 informed state premiers of the scheme. They agreed to cooperate, although Victoria’s Premier A.A. Dunstan informed Prime Minister John Curtin that registering aliens was not policy in his state; however, he was bending because rural residents were annoyed that their premier “harped away on the possibility of Australians losing their practices.”133 To appease the states, the Commonwealth director-general of health let state health departments have the authority to assign the refugee doctors to their duties. As a further concession, the regulations forbade any medical practice by aliens unless they were registered; the temporary registration ordinance included a section that banned unregistered practices under pain of a heavy penalty. The coordinating committee, representing the views of the medical boards, argued that, since temporary registrants would have to practise in places specified by the state boards, unregistered practitioners would have the unfair advantage of mobility. A newly established Commonwealth Alien Doctors Board went after the unlicensed doctors at its first meeting.134 Unregistered doctors were prosecuted.135 Immediately upon announcement of the temporary registration program, there were ninety-one applicants (forty-seven from New South Wales, forty from Victoria, eleven from Queensland, three from South Australia, and one from Western Australia).136

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More applicants trickled in over the next three years.137 To secure registration, applicants had to pass a written and an oral exam; depending on their performance, they were assigned to general practices or institutions under supervision. State governments delegated the licensees to narrow fields of service. For example, Dr Johan Philip van Leendt, Leiden (1937), was assigned to the Javanese Seamen’s Home in Sydney and to Dutch ships, but could not initially treat even the family members of Royal Netherlands service personnel.138 Throughout the program’s existence, doctors could petition for further tests to widen their licence’s scope. The program was wound down at the end of the war. By then some refugees had established five years’ residency in a British dominion. The war changed official opinions. A ministers for health meeting in Canberra, 6–7 December 1943, passed a resolution that all would recommend to their respective Cabinets “that the registration of alien doctors who have been licensed during the war should be continued after the war.”139 The government of New South Wales, which had been resistant to refugee registration, amended its medical practice act to allow the permanent registration of the temporary licence-holders.140 Conclusions The public interest and the values of the official bodies managing the healing profession clashed when refugee doctors attempted to resume their professional lives in Australia and New Zealand.141 These countries could have used more medical professionals. In 1939, Australia had about one doctor for every thousand residents, which was a poorer ratio than in the United Kingdom; in addition, the country lacked medical services in sparsely settled regions. Politicians from outside the major cities had a more accommodating attitude than urban doctors. Medical boards advanced plausible rationalizations for their opposition to registering refugees. The Great Depression had hurt Australasian doctors, who were thus defensive about competition. As well, their isolation from Europe contributed to poor awareness of the evils of their times, although in that they were not alone. A few board members felt bitter about the fact that medical degrees from their universities had been rejected by European bodies. A tit-for-tat anti-German attitude was in play, a professional pique out of all proportion to the situation.142 As well, some may have truly believed that refugees were ill-qualified or lacked language competence. Bigotry may not have been

64  John Weaver

the sole explanation for resistance to admitting refugee Jewish doctors to medical practice, but it seems a powerful undercurrent. Most opponents to registration avoided explicit anti-Semitic remarks. Instead, the more prejudiced ones applied a coded vocabulary that alleged sly practices, deceit and false pretences, and culturally unsuitable medical arts. Since nearly all applicants were Jews fleeing persecution, these specific remarks with their hostile tone registered anti-Semitic meanings. There was more to the resistance from medical boards than simply a commitment to public safety, pursuit of self-interest, retribution against Germans, and envy. The migration of refugee doctors elicited resentment. A portrayal of hostility and practicality attending a crisis migration is only part of the story. Between the lines of the formal documentation, there are glimpses of resourcefulness and the determination of the refugees. With assistance from support networks, a few individuals overcame barriers and eventually re-established medical careers. Life histories, as Paul Weindling proposed for the refugee doctors in the United Kingdom, present “a dynamic and developing situation with set-backs in 1940 followed by rapid relaxation.”143 Events in Australia and New Zealand match this summary. Histories of migrations depend on documented accounts of journeys initiated and completed. The ill-fated are barely visible. Left with the histories of exceptional individuals, we have to wonder what distinguished each one: luck, kinship ties, determination, ingenuity, or particular combinations. Notes 1 Paul Weindling, “Medical Refugees and Modernisation of British Medicine,” Social History of Medicine 22, no. 3 (2009): 499. 2 Paul Weindling, “Medical Refugees in Britain in Britain and the Wider World, 1930–1960: Introduction,” Social History of Medicine, 22, no. 3 (2009): 465. 3 Michael Marrus, the Holocaust in History (Toronto: Lester & Orpen Dennys, 1987), 203–5. 4 Weindling, “Medical Refugees and Modernisation of British Medicine,” 499. 5 It is difficult to estimate the numbers because official lists were specific to a program and did not cover the entire period. I base the estimate on the records for Queensland. Only records from that state cover the entire period. With about one-eighth of the country’s population, it seems

Pathways of Perseverance  65  reasonable that Queensland would have encountered an eighth of the refugee doctors seeking registration, or 320. Winterton notes that in December 1943 there were 116 men and 32 women holding foreign degrees in Australia. Peter Winterton, “Alien Doctors: The Western Australian Medical Fraternity’s Reaction to European Events, 1930–50,” Health and History 7, no. 1 (2005): 68. His estimate may have been based on the special wartime registration program discussed in this chapter. It is too low. 6 Archives New Zealand, Wellington Repository, Health Department, series 163, sub-number 47, Admission of Foreign Doctors into New Zealand (hereafter NZ Health), form letter prepared by the Medical Council of New Zealand. NZ Health, C.J.C.J. Drake to a list of recipients, 2 May 1939. 7 Queensland State Archives (QSA), see various entries in A/38182, Queensland Medical Board, Minute Book, 14 January 1926 to 10 June 1937(hereafter minute book 2); A/38183, Medical Board of Queensland, Minute Book, 8 July 1937 to 8 February 1940 (hereafter minute book 3). 8 Kenneth Collins, “European Refugee Physicians in Scotland, 1933–1945,” Social History of Medicine 22, no. 3 (2009): 514. 9 Weindling notes the same diversity of attitudes; the medical schools were more likely to be hospitable than medical boards. Weindling, “Medical Refugees and Modernisation of British Medicine,” 500, 506. 10 In some jurisdictions they were known as medical councils. In this chapter, the term board applies to Australian jurisdictions and the term council applies to New Zealand. This is roughly consistent with contemporary practice. 11 Weindling, “Medical Refugees and Modernisation of British Medicine,” 489–91. 12 Times (London), 25 November 1889, 11. 13 Weindling, “Medical Refugees and Modernisation of British Medicine,”  492. 14 Times (London), 20 August 1889, 7. 15 Times (London), 6 May 1898, 15; 28 May 1898, 9. 16 Times (London), 28 May 1898, 9. 17 Times (London), 5 December 1899, 12. 18 Times (London), 5 December 1899, 12. 19 QSA, A/38181, Queensland Medical Board, Minute Book, 17 February 1901 to 17 December 1925 (hereafter minute book 1), 4 April 1901, 2 April 1903, 1 October 1903, 28 August 1905, 2 November 1905, 7 April 1910, 6 October 1910. 20 NZ Health, C.J. Drake, secretary to the Medical Council, to T.H. Sutherland, branch secretary, Labour Party, 21 March 1939;

66  John Weaver

21 22

23

2 4 25 26

2 7 28 2 9 30 31 32 33 34 3 5 36 7 3 38 9 3 40 41

Messrs Bamford, Brown, and Wheaton to the Medical Council, 22 March 1939; Messrs Bamford, Brown, and Wheaton to C.J. Drake, 6 April 1939. NZ Health, director-general of health to minister of health, “Refugee Doctors Domiciled in New Zealand” [March–April 1941]. QSA, A/38203, Correspondence of the Medical Board, 1932–51 (hereafter MB letters), Deborah Stosch-Wortley to the secretary, British Medical Association, 15 September 1934 [copy]. MB letters, A.D. Macpherson, assistant medical secretary, British Medical Association, to Deborah Stosch-Wortely, 19 September 1934. Ultimately, an estimated 176 Italian degree-holders arrived in the United Kingdom. See Weindling, “Medical Refugees and Modernisation of British Medicine,” 493; Kenneth Collins, “European Refugee Physicians in Scotland, 1933–1945,” Social History of Medicine 22, no. 3 (2009): 515. Macpherson to Stosch-Wortley. Minute book 2, 9 November 1933. Minute book 1, October 1901, 5 June 1902, 2 June 1904, 6 June 1905, 2 November 1905, 7 May 1908, 7 July 1910, 2 February 1911. The board was more suspicious of credentials from the United States and biased against Japanese-trained doctors who wanted to practise among pearl fishers on Thursday Island. 2 March 1911, 3 August 1911, 2 May 1912, 7 August 1913, 8 January 1914, 2 November 1912. Collins, “European Refugee Physicians in Scotland, 1933–1945,” 516. See, for example, minute book 3, 12 August 1937, 10 March 1938, 12 May 1938, 9 November 1939. Winterton, “Alien Doctors,” 68. Minute book 3, 16 September 1937. Times (London), 16 July 1938, 12. Minute book 3, 16 September 1937. Minute book 3, 10 June 1937. NZ Health, W.H. Watt, director-general of health to C.E. Hercus, dean of medical school, University of Otago, 8 August 1941. Times (London), 16 July 1938, 17. Ibid. Also see A.J. Sherman, Island Refuge: British Refugees from the Third Reich, 1933–1939 (Newbury Park: Frank Cass, 1973), 123–4. Weindling, “Medical Refugees in Britain and the Wider World,” 455. Globe and Mail, 12 April 1940, 19; “Association Notes,” Canadian Medical Association Journal 39, no. 6 (December 1938): 593. Weindling, “Medical Refugees in Britain and the Wider World,” 456. Collins, “European Refugee Physicians in Scotland, 1933–1945,” 514. Times (London), 20 March 1933, 11; 27 March 1933, 11.

Pathways of Perseverance  67  Times, 1 April 1933, 10. Marrus, Holocaust in History, 27. Times (London), 10 July 1933, 13, 92. The Quisling government in Norway instituted the ban. Argus (Melbourne), 5 October 1940, 3. 46 Freya Klier, Gelobtes Neuseeland: Fluchten bis ans Ende der Welt (Berlin: Aufbau Taschenbuch Verlag, 2006), 79–80. 47 Ibid., 80–1. 48 National Archives of Australia (NAA), Melbourne Repository, series no. MP508/1, control symbol 65/710/123, Enemy Alien Doctors. Employment [box 102], Sydney Morning Herald, clipping 17 April 1941, no page cited. 49 NAA, Canberra Repository, series A1928, control symbol 652/17A, Application Forms of Alien Doctors Licensed under National Security (Alien Doctors) Regulations (hereafter Applications 1942), application of Arthur Kessel. 50 NAA, Canberra Repository, Health Conference, Commonwealth and State Ministers, series no. A461, control symbol, I347/1/2, Earle Page, draft letter of invitation prepared for Cabinet review, 19 January 1938. Letters were sent to the state premiers on 8 February. 51 Australian newspapers were accessed on-line through “Trove,” the newspaper-article search page maintained by the National Library of Australia. Argus (Melbourne), 16 July 1938, 9; Canberra Times, 22 July 1938, 1. 52 Argus (Melbourne), 16 July 1938, 9. 53 Argus (Melbourne), 27 July 1938, 13. 54 Minute book 3, 9 September 1937, 12 May 1938; Argus (Melbourne), 11 July 1939, 3. 55 Weindling, “Medical Refugees in Britain in Britain and the Wider World,” 455. 56 MB letters, clipping, Courier-Mail, 12 October 1939. 57 Minute book 3, 8 December 1938, 19 January 1939. 58 Minute book 3, 9 June 1938. 59 Argus (Melbourne), 11 July 1939, 9. 60 Minute book 3, 3 March 1940. 61 Argus (Melbourne), 8 August 1939. The article refers to the act as passed at the last session. 62 Times (London), 28 June 1939, 13. 63 Canberra Times, 17 March 1939, 4. 64 NAA, Canberra Repository, series A472, control symbol W5733, National Security (Alien Doctors) Regulations (hereafter NAA, Alien Doctors), NSW Premier, Alex Mair, premier, New South Wales, to prime minister, 14 September 1939.

4 2 43 44 45

68  John Weaver 65 Times (London) (London), 7 June 1939, 15. Winterton, “Alien Doctors,” 71. 66 NAA, Alien Doctors, Sydney Morning Herald, clipping 13 December 1939, no page cited. 67 NAA, Alien Doctors, Sydney Morning Herald, clippings 5 and 6 December 1939, no page cited. 68 Argus (Melbourne), 21 August 1939, 2. 69 NAA, Alien Doctors, Melbourne Herald, clipping 22 December 1939, no page cited. Argus (Melbourne), 22 August 1939, 4. 70 Argus (Melbourne), 28 July 1938, 10. 71 Melbourne Herald, clipping 22 December 1939, no page cited; Argus (Melbourne), 1 July 1939, 2; NAA, series A1928, control symbol 652/17/3/ Section 3, Registration of Persons Who Have Qualified Elsewhere, secretary, New South Wales Medical Board to Curt Rosenthal, 16 October 1942. Also see series A1928, control symbol 652/17/3/Section 5, Registration of Persons Who Have Qualified Elsewhere, New South Wales Medical Board to F. McCallum, director-general of health, Commonwealth of Australia, 9 October 1945. 72 NAA, series A1928, control symbol 652/17/3/Section 3, Registration of Persons Who Have Qualified Elsewhere, L. Landa, member of Parliament, New South Wales, to E.J. Holloway, minister of health, 21 October 1942. 73 NZ, Health, director-general of health, memo for the minister of health, “Admission of Foreign Doctors to New Zealand,” 22 August 1938. 74 NZ Health, C.J.C.J. Drake, secretary to the Medical Council, to Stuart Moore, 14 March 1939. 75 NZ Health, C.B. Burdekin, intelligence officer, draft form letter on letterhead of New Zealand Government Offices, The Strand, London [n.d., but possibly as early as 1938]. 76 NAA, Alien Doctors, NSW premier, memorandum to the Prime Minister’s Department, 26 October 1939. 77 NAA, Alien Doctors, Sydney Daily Telegraph, clipping 7 December 1939, no page cited. 78 NAA, Alien Doctors, NSW premier, Sydney Daily Telegraph, clipping 11 December 1939, no page cited. 79 NAA, Alien Doctors, NSW premier, Sydney Morning Herald, clipping 11 December 1939, no page cited. 80 NAA, Alien Doctors, NSW premier, Melbourne Herald, clipping 5 December 1939, no page cited. 81 Canberra Times, 1 May 1939, 1.

Pathways of Perseverance  69  82 QSA, A/38184, Medical Board of Queensland, minute book, 8 February 1940 to 16 December 1940 (hereafter minute book 4), 9 May 1940. 83 NAA, Alien Doctors, cited in Sydney Morning Herald, clipping 15 December 1939, no page cited. 84 Minute book 4, 3 March 1940. 85 Minute book 4, 11 April 1940. 86 Minute book 4, 13 June 1940. 87 Ibid. 88 Minute book 4, 8 August 1940. 89 Minute book 4, 10 October 1940. 90 Minute book 4, 12 September 1940. 91 Ibid. 92 Minute book 4, 14 November 1940. 93 Minute book 4, 16 December 1940. 94 Times (London), 7 June 1939, 15; Argus (Melbourne), 16 July 1939, 9; 18 August 1939, 12. 95 Winterton, “Alien Doctors,” 69. 96 NAA, series A1928, control symbol 652/17A, Application Forms of Alien Doctors Licensed under National Security (Alien Doctors) Regulations (hereafter Applications 1942), Ernst Fabian. 97 Ibid. 98 NAA, series A1928, control symbol 652/17A, Applications 1942, Samuel Haneman. 99 Horst Peter Eisfelder, Chinese Exile: My Years in Shanghai and Nanking (South Caulfield: Makor Jewish Community Library, 2003), 10–12. Also see Argus (Melbourne), 18 November 1938, 4. 100 Antonia Finnane, Far from Where? Jewish Journeys from Shanghai to Australia (Carlton South, Victoria: University of Melbourne Press, 1999), 103. 101 Marvin Tokayer and Mary Swartz, The Fugu Plan: The Untold Story of the Japanese and the Jews during World War II (New York: Paddington, 1979), 17, 27. 102 Michael Marrus and Robert Paxton, “The Nazis and the Jews in Occupied Western Europe, 1940–1944,” Journal of Modern History 54, no. 4 (December 1982): 687–714, repr. in Michael Marrus, ed., The Nazi Holocaust: Historical Articles on the Destruction of European Jews: Part 4. The “Final Solution” Outside Germany (Westport: Meckler, 1989), 1:107. 103 For an account of life in the internment camp at Hay, see Klaus Wilczynski, Das Gefangenenschiff: Mit der “Dunera” über vier Weltmeere (Berlin: Verlag am Park, 2001), 199–249. Michael Marrus, The Unwanted:

70  John Weaver European Refugees in the Twentieth Century (New York: Oxford University Press, 1985), 205. 104 Bernard Wasserstein, Britain and the Jews of Europe, 1939–1945, 2nd ed. (London: Leicester University Press, 1999), 43. Also see Voices from Shanghai: Jewish Exiles in Wartime China, ed., trans., intro. by Irene Eber (Chicago: University of Chicago Press, 2008), 7. 105 NAA, series A1928, control symbol 652/17A, Applications 1942, Application of Meyer Mirski. On Senpo Sughara and Polish and Lithuanian Jews, see Tokayer and Swartz, Fugu Plan, 20–43. 106 Marrus and Paxton, “The Nazis and the Jews,” 113. 107 Eisfelder, Chinese Exile, 45–6. 108 NAA, series A1928, control symbol 652/17A, Applications 1942, Roman Ziehler. Also see NAA, Medical Practitioners (Registration in Australia of Persons Who Have Qualified Elsewhere) National Security (Alien Doctors) Regn. 1942 – Licences under – Applications and Correspondence, Victoria Section 1, series no. A1928, control symbol 652/17/4 Section 1, Zeiher to director general of medical services, 13 February 1942. 109 NZ Health, C.J. Drake to the secretary, New South Wales Medical Board, secretary, 7 June 1939; New South Wales Medical Board to C.J. Drake, n.d. [received 22 June 1939] and 1 September 1939. 110 NZ Health, handwritten minute on margins of report on the New Zealand Medical Council meeting of 26 September 1939. 111 NZ Health, general secretary, British Medical Association, New Zealand, to C.J. Drake, 10 October 1939. 112 NZ Health, Hugh Douglas to C.J. Drake, 14 June 1939. 113 NZ Health, C.J. Drake to the registrar, University of Otago, 4 March 1940. 114 NZ Health, undated clipping [April 1939] “Refresher Course in Dunedin.” 115 NZ, Health, W. Newland to C.J. Drake, 28 March 1939. 116 NZ Health, C.J. Drake to the registrar, University of Otago, 4 March 1940. 117 For a detailed summary of the state of the sixty-seven refugee doctors and the Otago program, see W.H. Watt, memorandum for the minister of health [March 1941]. 118 NZ Health, general secretary, British Medical Association, New Zealand, to director-general of health, 2 July 1940. 119 NZ Health, W.H. Watt, director-general of health, memorandum for the minister of health, War Control of Newly Registered Medical Practitioners [March or April 1941]. 120 NZ Health, W.H. Watt, director-general of health, memorandum for minister of health [April 1941].

Pathways of Perseverance  71  121 NZ, Health, director-general of health, memorandum to the minister of health “War Control of Newly Registered Medical Practioners” [April to June 1941]. 122 NAA, series A1928, control symbol 652/17A, Applications 1942, Robert Gruenfeld, Edgar Herz, H.F. Bettinger, Roman Ziehler, Eric Kolmer, Robert Fruchtman. 123 Minute book 4, 14 March 1940. 124 Czechoslovakian doctors in Australia had an organization. See NAA, Medical Practitioners (Registration in Australia of Persons Who Have Qualified Elsewhere) National Security (Alien Doctors) Regn. 1942 – Licenses under – Applications and Correspondence, Victoria Section 1, series no. A1928, control symbol 652/17/4 Section 1, form letter reply to M.G. Brunton, noting that he was secretary of the Association of Czechoslovak Doctors in Australia. There also was an Alien Doctors Association. See, in the same file, Erich Lowenthal to the director-general of health, 16 February 1942. 125 NZ Health, Nordmeyer, minister of health, memorandum for directorgeneral of Health, 30 July 1941. Also see Times, 8 October 1941, 2. Collins, “European Refugee Physicians in Scotland, 1933–1945,” 525. 126 Marion Berghahn, Continental Britons: German-Jewish Refugees from Nazi Germany (Oxford: Berghahn Books, 1988), 84–5. 127 NAA, Melbourne Repository, series no. MP508/1, control symbol 65/710/123, Enemy Alien Doctors. Employment [box 102], L.F. Giblin to P.C. Spender, 3 April 1941. 128 Ibid., R.H. Fetherston, former director-general of medical services to F.A. Maguire, director general of Medical Services, 12 May 1941. 129 Ibid., Minute on Employment of Enemy Alien Doctors, 19 May 1941. 130 NAA, Alien Doctors, F.A. McGuire, chairman, Central Medical Coordinating Committee, Appreciation by Central Medical Coordinating Committee, 4 September 1941. 131 NAA, Alien Doctors, petition, Medical Practitioners, Australian Imperial Force, Malaya, 22 July 1941 132 NAA, Alien Doctors, assistant secretary, Department of Health, to director-general of Health, 2 February 1942. 133 NAA, Alien Doctors, prime minister to premiers, 6 January 1942 [copy]; Premier A.A. Dunstan (Victoria) to the prime minister, 16 January 1942; Premier Robert Cosgrove (Tasmania), 19 January 1942; Premier T. Playfair (South Australia) to the prime minister, 21 February 1942; Premier W.J. McKell (New South Wales) to the prime minister, 19 February. On Dunstan’s harping, see NAA, Medical Practitioners (Registration in

72  John Weaver Australia of Persons Who Have Qualified Elsewhere) National Security (Alien Doctors) Regs. 1942 – Press Cuttings, series no. A1928, control symbol 652/17/8652, clipping Herald, 12 September 1941, 6. 134 NAA, Alien Doctors, J.H.L Cumpston, director-general of health, memorandum, 18 March 1942; NAA, series A1928, control symbol 652/17/3/Section 5, Registration of Persons Who Have Qualified Elsewhere, minister of health to R. Herman, 4 December 1942; J.H.L Cumpston, memorandum, 27 November 1942. On stopping unregistered doctors from practising, see Cumpston to minister of health, 3 May 1942 (draft); Resolution of the Alien Doctors Board, First Meeting, Canberra, 1–2 May 1942. 135 See the case of Joseph Gonzwa in NAA, Personal Papers of Prime Minister Curtin Correspondence “G,” series no. M1415, control symbol 427, acting director-general of health to Prime Minister John Curtin, 31 October 1944. 136 NAA, series A1928, control symbol 652/17/1 Section 2, Alien Doctors, J.H.L. Cumpston, to J. Newman Morris, 7 April 1942. 137 NAA, series A1928, control symbol 652/17/3/Section 3, Registration of Persons Who Have Qualified Elsewhere, J.H.L Cumpston, chairman, Alien Doctors Board to Stratford Sheldon, 21 November 1942. 138 Ibid., J.H.L. Cumpston, chairman, Alien Doctors Board, to Hugh Devine, 26 January 1943. 139 NAA, Canberra Repository, series no. A461, control symbol L347/1/2, Conference of Ministers for Health Held at Canberra A.C.T., 6, 7 December 1943, resolutions. 140 NAA, series A1928, control symbol 652/17/3/Section 5, Registration of Persons Who Have Qualified Elsewhere, L. Polk to chairman, Alien Doctors Board, 28 December 1945. 141 Sherman, Island Refuge: British Refugees from the Third Reich, 259. 142 Argus (Melbourne), 22 June 1939, 3. 143 Weindling, “Medical Refugees and Modernisation of British Medicine,” 495.

3  Public Health and Persecution: ­Debates on the Possible Migration of Jewish Physicians to Sweden from Nazi Germany annika berg

Rather than telling a story of migration, this chapter will deal with non-migration. More specifically, it will focus on intra-professional discussions in favour of, and against, the reception of Jewish refugee physicians in Sweden in the late 1930s and early 1940s, and show that just as the widespread resistance among Swedish physicians against “import” of refugee colleagues had several motives, including but not limiting themselves to anti-Semitism, those who actually did promote such immigration were far from being driven exclusively by humanitarian motives. During the 1930s, Sweden’s capacity to receive refugees became a topic of harsh debate both within and outside of the Swedish parliament. The controversy was, of course, fuelled by the contemporary developments on the other side of the Baltic Sea. As early as in April 1933, the communist Ture Nerman raised his voice in Riksdagen, the Swedish parliament, suggesting that he should ask the minister in charge to investigate whether Sweden could give asylum to some of those German artists and intellectuals who were now being persecuted because of their race or political convictions. The proposal was outvoted 62–59, but approved a few days later by the second chamber of Riksdagen. The minister, Arthur Engberg, answered cautiously that “political refugees” would be welcome to apply for work at Swedish state institutions, but that suitable positions would be rare “in these times of depression.” In both chambers of parliament, some members – liberals, social democrats, and communists – argued that Sweden had a responsibility to protest against violence and protect German minorities and dissidents from persecution, while others – mainly c­ onservatives – argued that Sweden should not interfere with

74 Annika Berg

the internal affairs of a foreign country.1 A similar divide would manifest itself in public debates.2 In the following years, hundreds of thousands of Jews and political dissidents fled Germany. Few of those refugees picked Sweden as their first choice. Nevertheless, Sweden kept the very restrictive immigration policy that had been in practice since the First World War and codified in law by the Aliens Act of 1927. The revision of the Aliens Act in 1937 led to no improvement for Jewish refugees.3 The earlier legislation had been motivated by fear of competition in the Swedish job market as well as by fears for the purity of the Swedish race, and these motives influenced the new legislation as well, although the racial motive was not spelled out in the new law.4 As before, two distinct groups opposed each other in the discussions that led up to the 1937 Foreigners Act. On the one hand, a group of social democrats wanted to open national borders for “political refugees” in a wide sense; on the other hand, a conservative group, dominated by the right-wing parties Högern and Bondeförbundet, warned against an invasion of foreign (implicitly, and sometimes explicitly, Jewish) elements. The result was a compromise: a law that gave political refugees right to enter Sweden and search for asylum there, but did not acknowledge people oppressed because of their race or ethnicity as political refugees.5 Still, the legislation was vague enough to pave the way for further debate. When the situation got worse in 1938, the Swedish government sharpened its visa requirements – making it hard for foreign Jews to enter Sweden even temporarily – and argued that the League of Nations should solve the Jewish question by letting them migrate to a faraway country, preferably Madagascar.6 At the same time, several non-governmental organizations and individual activists, such as the entertainer Karl Gerhard and the peace activist Signe Höjer, argued strongly for a more generous refugee policy.7 Small quotas of Jewish refugees were actually let into Sweden but were then expected to transit to other countries.8 Jewish physicians were specifically targeted by the Nazi regime. As John Weaver points out in his chapter of this volume, persecutions had started right after the Nazi takeover in 1933, and in the following years Jewish doctors were increasingly banned from practice in Germany and the occupied territories.9 At an infamous meeting in Uppsala in February 1939, hundreds of students protested loudly against a plan to import a very modest number of Jewish physicians from Germany. This meeting has become an emblematic event in the historiography of Sweden in the

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Second World War period, where it is regularly used to demonstrate the pervasiveness of fascist and national-socialist influences in the Swedish student community, as well as the silent majority’s passivity in front of fascism and anti-Semitism. On the other hand, the proposal to import physicians has been eagerly used, not least by the actors involved in proposing it, as historical evidence of their eagerness to fight against fascism.10 As I will show in this chapter, the meeting in Bollhuset in Uppsala was part of a wider discussion that went beyond anti-Semitism. The issue at stake for the combatants on either side of this battle was not merely, or even primarily, the desirability of Jewish refugees, but rather, the need for physicians in the present and future Swedish health-care system, and the possible need for transnational transfer of expertise to train future physicians. Faced with the possible immigration of Jewish physicians, several conflicting lines of interest emerged. They had to do with race, culture, and national identity, but also with healthcare politics, educational policy, and the labour market. Key participants staked claims to positions on a medical, yet highly politicized field of expertise, and helped define the role of medical expertise in a wider public health project, seen as a crucial part of the construction of a Swedish welfare state. To shed light on this wider set of conflicts and explore how they affected the question of migration (or non-migration) of medical specialists, I will analyse the media debate that followed the disclosure of the plans to import Jewish physicians, a battle that primarily pitted Axel Höjer, general director of the Royal Medical Board, against leading members of the Swedish Medical Association. A Contested Proposal In late January 1939, a few months after Kristallnacht, some statements by Axel Höjer, the general director of the Royal Medical Board, ignited a debate that would go on for years – although the grounds for debating would seem to alter quite significantly over time. In an interview published in the conservative daily newspaper Svenska Dagbladet, Höjer revealed that he was personally involved in the development of a plan that would let a dozen Jewish medical specialists obtain a work permit in Sweden.11 In the interview, Höjer characterized Sweden as a backward country, at least when it came to admitting refugee physicians: “While other countries have been fairly generous in granting work permits to Jewish or other physicians who have had to leave Germany, Sweden’s

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policy so far has been very restrictive regarding physicians as well as dentists and pharmacists,” Höjer was quoted as saying in the article. Sweden, which had proportionately fewer physicians than neighbouring countries, should be able to accommodate a larger number than presently, he believed, even considering that an increased number of medical students would graduate in the coming years. Furthermore, the threat of war meant that an acute shortage of medical professionals might be imminent. Therefore, to provide temporary work for a suitable selection of foreign physicians would be “to unite the demands of the state and the demands of humanism,” Höjer claimed.12 To foster support for these plans, he took to comparing Sweden with neighbouring countries. This strategy he had used before. As a young physician in the early 1920s, Axel Höjer, in cooperation with the aforementioned Signe Höjer – who was his wife and educated as a nurse – compiled examples from England and France to promote development of a new system of publicly funded infant health-care services aimed at all children born in Sweden. Those strategies had born fruit too. In 1937, a law on preventive health care for infants and mothers, that instituted the nationwide establishment of barnavårdscentraler (child health-care centres), was passed in Sweden. The institution bore strong resemblance to the Höjers’ pilot projects and ensuing policy proposals that Axel Höjer had launched in strategic contexts.13 In the 1930s, after failing to obtain a professorship in hygiene and public health, Axel Höjer had chosen another path to realize his – and Signe’s – more overarching (one could say utopian) plans for public health and social reformation – namely, the path of the medical bureaucrat. From 1935, as general director of the Royal Medical Board, Axel Höjer was the highest-ranking medical official in Sweden, and arguably the nation’s most powerful professional expert on questions of public health. At this position, his ambitions grew. Soon, he would consider nothing less than the complete health of all citizens as the goal for his work. A few years later, a similar goal would be manifested in the constitution of the World Health Organization, which stated that health was “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”14 Axel Höjer’s wide-­reaching goal and his ambition to act preventively in a long-term perspective meant that he wanted to provide everyone, regardless of means or background, the best health care possible. But it also led him to the conclusion that not everyone should be allowed to breed. Axel Höjer was dedicated to a kind of reform eugenics, enforcing sterilization

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of certain groups with supposedly genetic flaws, and especially those groups categorized as sinnesslöa (feeble-minded). At the same time as Axel Höjer made himself comfortable in his role as head of the Royal Medical Board, he and Signe Höjer were on their way to establish themselves firmly in the elite of the Social-Democratic movement. Axel, in particular, would also develop strong connections to the ruling Social-Democratic government. Using his unique position as a medical doctor and a public official, Axel Höjer could thus act quite independently in relation to the medical profession, but still draw on his own medical expertise when he wanted to.15 In other words, as a representative of medical expertise, Axel Höjer could act on behalf of the medical profession. He did so, for example, when he tried to limit the work opportunities for people who made therapeutic claims without belonging to the medical profession, and who could therefore be written off as “quacks.”16 At the same time, as a representative of the state and relieved from previous academic ambitions, Axel Höjer could, when he so wished, act despite the interests of the organized medical corps. Actually, when represented by a person like Axel Höjer, the state itself could claim medical expertise, just as well as the medical profession could. Nevertheless, Axel Höjer’s statements led to great commotion. In the very article where Höjer was first quoted, the secretary of the Swedish Medical Association, John P. Edwardson, went on the counterattack. Edwardson (whom Axel Höjer would later describe as competent, but Nazi-friendly) claimed to speak in the general interest of the medical profession when he expressed his misgivings. They centred on the fact that, at present, there was an abundance of Swedish physicians lacking either employment or private practice. This was particularly obvious when it came to junior physicians. According to Edwardson, several hundred young physicians were presently attending patients without pay. At the best, internships were interwoven with short temporary appointments. The Swedish Medical Association, therefore, had systematically refused nearly all applications for work permits from foreign doctors in recent years and had no plans to change this practice. In addition, Edwardson said, the German medical education was shorter and therefore of less value than the Swedish one.17 When describing the situation for young Swedish doctors, Edwardson connected to a protectionist idea that had been widely discussed in a number of European countries throughout the past decade, in the wake of the Great Depression: namely that of an “academic proletariat,” groping for work they were actually overqualified for.18

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That same day, the evening daily Aftonbladet, which was known to be friendly towards the German regime, stated in quite openly antiSemitic terms that “the murky origins of the project to import Jewish doctors are clearing up – all traces lead to circles that stand very close to the [Royal] Medical Board!” The chairman of the Swedish Association of Junior Doctors (SYLF), Dag Knutson, who was also a member of the anti-Semitic and pro-German Manhem Society, expressed great scepticism about the prospective plan. On the contrary, Israel Holmgren, who was a professor emeritus of medicine, a former liberal member of parliament, and still a very active anti-fascist, called for “the greatest possible concession to political emigrants” and said that there was no reason to take their race into account. It would, however, be prudent to be selective in other ways – first-class brains should be a priority, Holmgren argued.19 The next day, SYLF’s ombudsman Peter Rousthöi made a statement in Svenska Dagbladet. Rousthöi confirmed Edwardson’s analysis of the situation for newly examined physicians and argued that at present it should be wiser to export physicians from Sweden than to import them. Behind closed doors, SYLF had even discussed the possibility of sending a number of Swedish doctors to South America. At the same time, Rousthöi admitted, the situation was somewhat paradoxical in that the select few who actually got employed as junior physicians had to work much too hard for long hours at a time. The secretary of the Swedish Association of Private Practitioners, Dr S. Radhe, said in the same article that the competitive situation was difficult for private practitioners too. He added, with an implicit allusion to the doctors’ Jewishness, that one could not ignore the danger that imported doctors would put profit in the first place and let that lead them astray in their work. If the foreign doctors proved to be less than perfect, Radhe warned that they, out of their “need to earn money would be tempted to write prescriptions for all sorts of coveted things: cocaine, morphine, etc.”20 A few days later, the surgeon Sten von Stapelmohr wrote in Svenska läkartidningen that it would be wiser to send young Swedish doctors abroad on scholarships in order to be trained as specialists than it would be to “import additional labour,” who would later find it difficult to find work and who, if they remained in the country, “would further complicate the existence of our own.” The editors of the journal added in a footnote that Sweden could hardly be said to suffer from a shortage of specialists, as the relatively small number of specialist physicians was more than well compensated by the general practitioners’ exceptional

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level of expertise.21 Svenska läkartidningen, which would play a crucial role in the following debates, was a journal with multiple purposes; it published scientific articles, travel reports, and conference reports but also – fulfilling its role as voice of the professional organization of Swedish physicians – quite a number of articles on professional issues. A few weeks later, the proposal that Axel Höjer had championed was made more concrete in a letter, addressed to the Board of the Swedish Medical Association, from the “Committee of fund-raising for exiled intellectuals” that was represented by the professors Göran Liljestrand, Jan Waldenström, and Gunnar Dahlberg. This might seem strange at first sight, considering that Gunnar Dahlberg, since 1936, had been the head of the Swedish Institute for Race Biology. However, Dahlberg – who has been characterized as a reform eugenicist or welfare state eugenicist – had already steered the institute in a direction quite different from that of his predecessor, Herman Lundborg. Dahlberg notably distanced himself not only from Lundborg’s outright racist ideas, but also from the concept of race altogether.22 In its letter, the committee pressed still harder on the humanitarianism of the medical corps than Axel Höjer had done. It suggested that ten to fifteen physicians in need of income and shelter, each from a different specialty, should be brought into the country from Germany and be allowed to practise in cities that lacked representatives from their respective specialty.23 Bollhusmötet and Its Immediate Aftermath The debate surrounding Axel Höjer’s statements became the immediate prelude to a series of student rallies against the immigration and licensing of foreign physicians. The most emblematic of those meetings, later known as Bollhusmötet (the Ball House meeting) took place in the university students’ tennis hall in Uppsala on 17 February 1939 – the very same day that the letter from the committee of fund-raising for exiled intellectuals was published in Svenska läkartidningen. At the Uppsala meeting, a smaller right-wing nationalist group managed to convince the majority of the assembled student body to sign a petition against the planned “imports.” The broad support for the right-wing petition has been explained by a spreading fear of overcrowding among academics, coupled with a more general increase in anti-Semitism.24 A few days later the student union of the Karolinska Institute in Stockholm arranged a similar rally that resulted in an almost unanimous protest against the reception of foreign physicians.25

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In Svenska läkartidningen, a number of physicians continued the attack on Axel Höjer and the committee proposal. Several opponents pointed out that it was important not to ignore the ethnic aspects of the issue. None of them wanted to identify themselves as anti-Semitic. Instead, they took more indirect advantage of the supposed surge in anti-Semitism when warning of the consequences of an influx of Jewish physicians. Axel Odelberg’s way of formulating the “problem” exemplifies this mode of reasoning, where anti-Semitism was highlighted as an unavoidable companion of the Jews, or at least those Jews who had not become naturalized as Swedes: The problem, in my opinion, can be formulated this simply: To date we have not had a Jewish question in our country: so, shall we obtain one? Our Swedish colleagues of more or less Semitic extraction have had the same ethical outlook as their comrades of pure Nordic descent, no antagonism has occurred, and many of them have served as excellent models for our profession and our society. We know, however, that in several countries, not only in Central Europe, similarly good conditions have not prevailed, and such has been the case long before the last five years’ sharpening of conflicts. This is the core of the question.26

In Odelberg’s argument, culture rather than race was problematized. Well-educated, naturalized Jews could obviously prove to be worthy citizens and valuable physicians. Nevertheless, anti-Semitism was formulated as a problem that had to do with Jews and Jewishness, and furthermore, something for which the victims themselves shared the blame. Pointing at the risk of importing anti-Semitism and a hitherto non-existent Jewish “question” into Sweden along with Jewish refugees was a fairly common gambit in Swedish debates in the 1930s and early 1940s, and similar arguments were heard in other countries with a comparatively small Jewish population.27 The Swedish Medical Association tried to resolve the issue by appointing a separate committee with representatives of both sides of the conflict. This committee would examine how refugee doctors could be assisted in a way that benefited both parties. Its primary recommendation, which was based partly on a proposal from the refugee opponent Fredrik Berg, was that Sweden should help exiled physicians to relocate to a third country, such as the United States. Second, this committee could consider accepting a small number of retired doctors in Sweden, on condition that they were unaccompanied by children.

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Possibly, a few eminent scientists might also be accepted. However, none of these categories would be given a licence to practise medicine.28 In the months that followed, physicians continued to battle over the situation for young physicians, or rather, over how to interpret their situation, but now without connecting this issue to the refugee question. The most active participant in this discussion was Stig Holm, a private practitioner. Ten years before, Holm, who was a conscientious objector, had published a book called Krig eller kultur? (War or culture?) together with Axel Höjer, including contributions from a number of more or less prominent intellectuals with a pacifist inclination. Stig Holm had begun debating the question about a proletariat of young doctors even before the debate over the import of physicians had started. His rhetoric was often harsh and sarcastic: “Is it unreasonable of junior physicians to wish for at least the same standard of living that is judged as reasonable for estimable groups of citizens such as for example statare [a category of agricultural labour that lived in semi-serfdom] or mjölkryktare [a kind of farmhand]?” When it came to the proposals on import of specialists, Holm supported Axel Höjer’s view in principle and also shared his analysis of the need of more physicians. Holm’s own calculations confirmed those of the Royal Medical Board and indicated a need of at least 1,000 new physicians over the next decade.29 At the same time, Holm protested loudly against the government’s decision (in 1939) to grant work permits to a couple of German-Jewish doctors with no particularly outstanding qualifications.30 Here as there, Holm put the immediate interests of junior physicians to the fore (later, he was named an honorary member of SYLF).31 The Primacy of Expertise The way in which the debate unfolded suggests that the issue of importing physicians was perceived as part of a larger set of challenges. This larger complex of competing interests, I will argue, provided the main motive behind Axel Höjer’s ardent campaigning for the import of Jewish specialist physicians. The fight was also aggravated by personal enmities between Höjer and leading members of the medical profession, and by disagreements on the principles for cooperation between the Swedish Medical Association and the Royal Medical Board.32 This is not to say that Höjer’s proclamation of humanitarian motives was false. By 1939, Axel Höjer had been publicly known as an antifascist for several years, and he was always keen to emphasize the

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humanitarian aspects of refugee protection.33 However, evidence suggests that Höjer, acting in his role as chief medical officer, prioritized Sweden’s future need of medical staff – or more specifically, medical expertise for the training of new generations of medical specialists. That such expertise was the decisive factor becomes, I would argue, apparent already in the design of the plan. The plan, as it were, included one or possibly two representatives from different specialties: the ten, twelve, or at most twenty specialists included in the program would thus be selected on the basis of their specialist knowledge, not on the basis of their need of protection. Axel Höjer also stressed that, thanks to the wide range of exiled physicians who were presently available, the plan provided unique opportunities to select first-class specialists instead of leaving the selection “to the element of chance, which consisted in the examination of incoming requests case by case.”34 The emphasis that was put on expertise is particularly telling given that it would probably have been more strategic to highlight humanitarian motives for receiving medical refugees. Even some of the harshest opponents agreed that the refugee issue had humanitarian aspects.35 The opponents’ interpretation of the labour market situation for physicians and other professionals, on the other hand, was quite the opposite of Axel Höjer’s. It tied to the idea of an academic and more specifically medical proletariat, and mirrors the protective attitude of the British Medical Association and its local branches towards immigrant doctors in Australia and New Zealand that Weaver portrays in his chapter in this volume. Höjer agreed that the situation was difficult for many young physicians in Sweden, and that many had to spend a long time waiting for specialist training. However, he said, this was an organizational problem, well on its way to being resolved. Again, he used other countries as comparative examples to show that Sweden, in fact, had a hidden need for more physicians. This need would also grow significantly if war broke out.36 Soon, war did break out. And before long, the war had drawn very close to Sweden. On 9 April 1940, Germany invaded Denmark and Norway. In that same month the question of physician migration once again ended up on the agenda of Svenska läkartidningen. This time, the president of the Swedish Medical Association, Curt Gyllenswärd, issued a word of warning, occasioned by that fact that yet another couple of Jewish physicians had applied for work permits in ­Sweden.37 If more work permits were approved, Gyllenswärd cautioned, the field would be left open to an “unbridled import of physicians.”

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Also, the reputation of the Swedish medical profession would be severely damaged. Gyllenswärd listed a number of objections, many of which revolved around either the questionable competence of the two physicians or the difficulties for Swedish physicians to provide for their own livelihood. He finished with a long passage about how unwise it would be to let a large number of unassimilated Jews gain influence over the Swedish medical profession. “Humanity towards the new arrivals can too easily turn into inhumanity against those who are already here and against citizens of Swedish origin,” was one of his arguments.38 Like Sten von Stapelmohr and nearly 200 other Swedish physicians, Gyllenswärd was a member of the Nazi-friendly Riksföreningen Sverige-Tyskland (the Sweden-Germany National Society).39 The year before, one of the Jewish doctors in question, Otto Ornstein, had applied for a position at the factories of the pharmaceutical company AB Astra, with the help of a letter of recommendation from, among others, Axel Höjer. The letter underscored that the employment of Ornstein would benefit Astra as a company as well as it would benefit Ornstein as a representative of refugees in need – without risking that Ornstein would “get in the way of a competent bacteriologist.” However, Ornstein had never got the position at Astra.40 On 20 May 1940, the Royal Medical Board turned down Otto Ornstein’s and Gerhard Wolff’s applications for licences to practise medicine in Sweden. Nor did the Royal Medical Board recommend licences for any of the other twenty-three foreign physicians with similar qualifications who were present in Sweden. In doing so, the Royal Medical Board (in stark contrast to how Höjer described the events in his memoirs) actually took a much more restrictive stance than the university chancellor Östen Undén, who wanted to grant licences to practise to the physicians in question. Much less liberally, the Royal Medical Board argued that no foreign physicians should presently be “incorporated into the Swedish medical profession,” because of national security, and because of the medical establishment’s general position on the matter. However, the board did open up for the possibility that the twenty-five physicians could be given some form of temporary work in different hospitals, where they could be monitored by senior physicians, and thus fill the gaps that appeared while many Swedish physicians were called into military service.41 This small detail opened up further debate. It was also hinted that Axel Höjer, in the early summer of 1940, had sent a circular letter to some senior physicians and “offered” them foreign physicians to

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replace those who were called into service.42 The conflict developed into a personal battle between representatives of the Swedish Medical Association, on the one hand, and on the other hand Axel Höjer and Torsten Thunberg. Thunberg, a professor of physiology in Lund, was an old friend and ally of Höjer and defended him in his own journal Hygienisk Revy.43 Höjer was also harshly attacked from parties outside of the leading circles of the Swedish Medical Association. The private practitioner Oscar Andersson accused him of being a dictator as well as a crypto-Communist, an opinion that according to Thunberg was “echoed” in fifty newspapers or more.44 The battle, however, hardly touched the original topic of debate. Since the Royal Medical Board had now come to the restrictive conclusion that any systematic import of physicians had been made impossible by the war situation, and since none of the foreign physicians who were already in the country was judged to be competent enough to qualify for any of the specialist positions that had been proposed originally, the question of an actual import of physicians had lost its significance. The question now was confined to the wisdom of giving temporary work under supervision for the twentyfive doctors who were already available in Sweden.45 For the foreign physicians who were stranded in Sweden, the media battle did not lead to any noticeable change. Some of the physicians were helped to migrate further away, to other countries, while others were forced to spend several years in Sweden. But they were still not allowed to work, or at least not practise medicine. Instead they were supported financially by contributions from a special refugee committee that was started on the initiative of Axel Höjer in the spring of 1940.46 Later in the 1940s the possibilities to work in Sweden were expanded for some foreign physicians, but then mainly physicians from the Nordic and Baltic countries.47 Public Health versus Public Danger In 1940, the debate about how to handle the foreign physicians continued to revolve around the exclusion of Swedish physicians and the supposedly inferior qualifications of foreign physicians. As more and more physicians were summoned to military service and a subsequent shortage of personnel made itself visible, the sceptics put more and more emphasis on national security, questioning foreign physicians’ loyalty to their country of refuge. Oscar Andersson pointed out that employment of foreign physicians in the current situation could c­onstitute

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a threat to national security – and especially so if the physician in question had the skills to initiate a bacteriological war.48 Curt Gyllenswärd even suggested – without a trace of irony – that German-Jewish physicians could prove to be Nazi spies.49 Although the question of importing physicians was no longer on the agenda of the medical authorities, the editor of Svenska läkartidningen Gunnar Myhrman followed Axel Höjer in using foreign examples to support his argument in this question. In contrast to Höjer, though, he used France as a shocking example of how an “alien invasion” had secretly undermined the indigenous medical corps of the country.50 The attacks against Axel Höjer were undoubtedly marked by a nationalistic and sometimes outright anti-Semitic rhetoric. But that does not necessarily mean that the battle between Höjer and the leaders of the Swedish Medical Association was founded primarily in their different perceptions of the importance of providing Jewish intellectuals a safe haven in Sweden – although Axel Höjer himself suggested this in his memoirs, written around 1970.51 In an interview in the right-wing daily newspaper Nya Dagligt Allehanda in the summer of 1940, Axel Höjer declared that his main interest lay in preventive health care, and that the point of the proposal to import physicians had been to strengthen the specialist skills in the Swedish health-care system: “You cannot exactly call this idea humane, but from a Swedish viewpoint it was probably wise, not least from a eugenic point of view. It is easy to see from our recent history, how the country has been benefited from eminent foreigners entering the country.” But Höjer questioned the terminology used while discussing these themes, as it was no longer a question about physicians being imported to Sweden. He himself, he declared, was currently mostly involved in providing refugee physicians a temporary haven before they could be transferred to “countries where they are more welcome than they are in Sweden.” Höjer also pointed out that only a handful of physicians from other countries, of which the majority were Swedes who had been living abroad, had been given permission to practise medicine in Sweden in recent years, and that the Royal Medical Board had no plans to become less restrictive. Here, the humanitarian side of things disappeared altogether. Höjer even mentioned Germany among the countries that he had studied to find solutions to the “the complex problems of healthcare” (the other countries he mentioned were Sweden’s immediate neighbours in Scandinavia, the “Western powers,” Italy, and Russia).52

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It should be noted that Nya Dagligt Allehanda was one of the most hostile newspapers on the question of refugees. Before and during the war, the newspaper directed several fierce campaigns against refugees from Third Reich Germany and against refugee-friendly groups in Sweden.53 The mere fact that Axel Höjer let himself be interviewed and quoted in such a context demonstrates how far he was prepared to go to promote his main interests. And those interests lay in the expansion and development of the Swedish health-care system in a more preventive and more pro-active direction, aiming at public health in a very ambitious conception. A Sort of Continuation In a review of the debates written in 1999, Uno Käärik, editorial secretary at Läkartidningen (the journal formerly known as Svenska läkartidningen), concluded that the discussions “deteriorated into peripheral questions on the political preferences of the various debaters, on socialization of healthcare, etc.”54 In contrast to Käärik, I would argue that this very “deterioration,” along with the further development of the debates, proves that such questions were anything but peripheral. While the debate about the foreign physicians in Sweden and/or a possible import of more refugee physicians fell practically silent after 1940, discussions on the future need for more physicians and on the existence of an academic proletariat continued in Svenska läkartidningen for the rest of the war period. Also, Höjer’s disagreement with the Swedish Medical Association would have a continuation later on, after the end of the war, when the personal antagonisms established in the late 1930s surfaced in another debate, with the “socialization” of health care at its very centre. In the spring of 1948, Höjer presented the report of a commission, led by Höjer himself, with ambitious suggestions on how to organize outpatient medical care in Sweden in the future. In the report, which Höjer referred to as his “testament,” his stated objective was that health care would be equally accessible to all citizens, and in particular that preventive health care would be expanded to the point that, in a long-term perspective, the treatment of diseases would be quite superfluous. This process, he claimed, could be made possible only through a publicly funded and publicly organized health-care system, with regular health examinations and publicly employed physicians on a fixed salary.55 While working with the inquiry, Axel Höjer was attacked by his old opponent Dag Knutson. In a speech at the annual general meeting of

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Swedish physicians in 1946, Knutson cautioned that “the creation of a welfare state – a so-called people’s home – in a more or less totalitarian spirit” was about to lead to “a growing state guardianship over an increasingly mainstreamed mass” and, perhaps worse, that the medical profession would be slave-bound as full-time civil servants in this dictatorial welfare state project. Ironically, Knutson, who had been German-friendly before and during the war, was now, a little more than a year after it was finished, fully prepared to use comparisons with Nazi ideology as a weapon against Höjer: “One can certainly talk about a survival and further development of the ideologies that the recently ended World War II was intended to crush together with its carriers, but that could not be crushed because they spring from a general spiritual development, shared by the victors and the vanquished. A plague, the aetiology of which will not be expanded on at this place.”56 Once published, Axel Höjer’s proposals met with even stronger opposition. Again, the harshest attacks came from the Swedish Medical Association. By then, Dag Knutson had been appointed as chairman of the association, which had also been reorganized in a manner that made it more powerful and influential than before. Knutson, J.P. Edwardson, and a range of other physicians claimed that the Höjer report formed a serious threat against medicine as an independent profession with control over its own services and charges.57 At first, the medical corps was quite successful in opposing the suggestions too, although eventually Höjer’s line of argument would prevail (from the 1960s, when Höjer himself was long gone as general director of the Royal Medical Board, the health-care system was reformed in a manner quite similar to the one Höjer and his commissioners had suggested).58 In their report, Höjer and his collaborators also prescribed a certain import of physicians from other countries, in order to be able to initiate the expansion of open health care within reasonable time. This suggestion stirred new opposition against the import of physicians, once again mostly from the Swedish Medical Association and allied press. This time the debate was focused more exclusively on the labour market. By now, no “Jewish question” was connected to the debate over physician migration to Sweden. Ethnicity did play a role in the new debate. The Höjer report said that Nordic physicians should be prioritized for linguistic and cultural reasons.59 Later on, Axel Höjer would also propose acceptance of physicians from Austria, Switzerland, and Scotland.60 Importantly however, by the late 1940s, ethnicity was neither

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highlighted as a problem by the opponents, nor found to be a reason for humanitarian action by the proponents. An April 1950 editorial in the conservative daily newspaper Svenska Dagbladet asserted that Höjer, in a verbal discussion with a representative from the Swedish Medical Association in 1948, had indicated that he would soon put forward a proposal about an organized immigration of physicians, which would prioritize “displaced persons.”61 And in a popularized version of his report (from 1949), Höjer mentioned the possibility of encouraging “refugee doctors” to immigrate. But he mentioned it only briefly, in a passage that concentrated on the overproduction of physicians in Switzerland, Scotland, and Austria.62 When he later went public with a more concrete proposal to import Austrian physicians, he mentioned no humanitarian motives. His line of argument was that the government of Austria, according to him, had put forward an offer so advantageous that Sweden could not afford to turn it down.63 According to Svenska Dagbladet, Höjer wanted to import 220 Austrian specialist physicians – the exact number that would cover the present shortage of expertise in Sweden. When, eventually, the available number of Austrian specialists willing to migrate proved to be next to zero, Höjer and the Royal Medical Board had to scale down their demands. The final recommendation from the Royal Medical Board, which was also promoted in the following governmental proposition, was pragmatic: in the absence of a surplus of specialists, 100 junior physicians should be imported from Austria. (Svenska Dagbladet took the changing plans of the Royal Medical Board as evidence that Höjer’s only interest lay in annoying the medical corps.)64 Nevertheless, the discussions show that, once again, and even more clearly this time, the primary interest of Axel Höjer and the Royal Medical Board, and what was promoted in the first place, was the kind of physician migration that would most effectively benefit the expansion of the Swedish health-care system, in the direction that Höjer supposed to be most desirable. Conclusion In Sweden, at around the beginning of the Second World War, there was a heated debate on the desirability of bringing Jewish physicians from Nazi Germany to Sweden. The outcome proved fruitless for those who promoted immigration: no Jewish physicians were imported, not even the dozen specialists suggested in the modest proposal that had ignited the debate in the early months of 1939, and none of the twenty-five

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German-Jewish physicians who had migrated to Sweden on their own initiative in the late 1930s were given a licence to practise in the medical profession. The debate was laden with xenophobic and at times outright anti-Semitic conceptions. But in terms of conflict, what was primarily laid bare was a strong disagreement on the question of the optimal health-care organization: its size, its forms, and perhaps even its objectives. This becomes apparent when analysing the debate as it unfolded in Svenska läkartidningen and other media, and not least so when analysing the moves of the most prominent actor on the pro-refugee side, the general director of the Royal Medical Board, Axel Höjer. Although Höjer saw and highlighted the humanitarian gains in allowing Jewish refugees from the Third Reich to practise medicine in Sweden, they were not a primary motive for him, but rather a secondary factor in his fight for other goals. His primary motive was the promotion of public health. And to pursue this objective, he prioritized the quality of health care over what he identified as the self-interest of the medical profession. Höjer’s unique position as head of the Royal Medical Board gave him a privileged opportunity to point at the immigration of medical experts as something that could benefit Swedish health care. He could draw on his own medical expertise when he so wanted, but when it did not suit him he had no need to oblige other physicians, as he no longer had to defend or fight for a position within the health-care system, nor within academia. His position set him apart from the representatives of the medical corps, who regarded the issue mostly from the protectionist – and sometimes also explicitly anti-Semitic – viewpoint of the medical labour market. Notes 1 Ingvar Svanberg and Mattias Tydén, Sverige och förintelsen: Debatt och dokument om Europas judar 1933–1945 (Stockholm: Dialogos, 2005), 86. 2 Ibid., 147–52. 3 Klas Åmark, Att bo granne med ondskan (Stockholm: Bonniers, 2011), 467–490; Svanberg and Tydén, Sverige och förintelsen, 157–8; Mikael Byström and Pär Frohnert, “Introduction I,” in Reaching a State of Hope: Refugees, Immigrants and the Swedish Welfare State, 1930–2000, ed. Mikael Byström and Pär Frohnert (Lund: Nordic Academic, 2013), 31. 4 Svanberg and Tydén, Sverige och förintelsen, 157–8; Lars M. Andersson and Karin Kvist Geverts, “Inledning,” in En problematisk relation? Flyktingpolitik

90 Annika Berg och judiska flyktingar i Sverige 1920–1950, ed. Lars M. Andersson and Karin Kvist Geverts (Uppsala: Opuscula Historica Upsaliensia, 2008), 11–13. Swedish authorities were also cautious about receiving communists as political refugees. Åmark, Att bo granne med ondskan, 471. 5 Hans Lindberg, Svensk flyktingpolitik under internationellt tryck 1936–1941 (Stockholm: Allmänna förlaget, 1973), 48–74; Svanberg and Tydén, Sverige och förintelsen, 158; Byström and Frohnert, “Introduction I,” 31. See also Ola Larsmo, “‘Bollhusmötet’ 1939: Konstruktionen av en rasistisk opinion,” in Sverige och Nazityskland: Skuldfrågor och moraldebatt, ed. Mattias Tydén and Lars M. Andersson (Stockholm: Dialogos, 2007), 198–200. 6 Åmark, Att bo granne med ondskan, 472–9. 7 Svanberg and Tydén, Sverige och förintelsen, 151–2; Lindberg, Svensk flyktingpolitik under internationellt tryck 1936–1941, 185–90; Annika Berg, Den gränslösa hälsan: Signe och Axel Höjer, folkhälsan och expertisen (Uppsala: Uppsala Universitet, 2009), 218. 8 Åmark, Att bo granne med ondskan, 473–4, 484. 9 John Weaver, “Pathways of Perseverance: Medical Refugee Flights to Australia and New Zealand, 1933–1942,” this volume. 10 See, e.g., Axel Höjer, “Ur J Axel Höjers minnen,” J.A. Höjers archive, National Archives of Sweden, Stockholm, 515–17, 545–6. A shortened version of this account is published in Axel Höjer, En läkares väg: Från Visby till Vietnam (Stockholm: Bonniers, 1975), 140, 148–9. 11 “Plan på läkarimport som väcker gensagor: 10–20 tyska emigranter skulle tas in,” Svenska Dagbladet (28 January 1939). According to Ola Larsmo, the idea had first been discussed by Professors Göran Liljestrand and Gunnar Dahlberg. However, Larsmo states no source for this information. Ola Larsmo, Djävulssonaten: Ur det svenska hatets historia (Stockholm: Bonnier, 2007), 13. In any case, it was Dahlberg and Liljestrand who, together with Jan Waldenström, signed the letter that was sent to the Swedish Medical Association on 9 February 1939, with the proposition to provide work for ten refugee physicians in Sweden. Göran Liljestrand, Gunnar Dahlberg, and Jan Waldenström, “Skrivelse från kommittén för insamlingen för landsflyktiga intellektuella: Till Centralstyrelsen för Sveriges Läkarförbund,” Svenska läkartidningen 36 (1939): 360–2. 12 “Plan på läkarimport,” 3, 14. 13 Berg, Den gränslösa hälsan, 138–40. 14 The First Ten Years of the World Health Organization (Geneva: World Health Organization, 1958), 459.

Public Health and Persecution  91  15 “Power, Knowledge and Acknowledgement of Expertise: Signe and Axel Höjer’s Strategies to Launch Public Health Ideas, 1919–1970,” in In Experts We Trust: Knowledge, Politics and Bureaucracy in Nordic Welfare States, ed. Åsa Lundqvist and Klaus Petersen (Odense: University Press of Southern Denmark, 2010), 188–90; Berg, Den gränslösa hälsan, especially chaps 1:4, 2:1, 2:4. 16 “Kvacksalveriets vackra skylt av vetenskaplighet och människokärlek rena bluffen,” Östergötlands Folkblad (16 April 1937): 12; “Samhället måste snart ingripa mot kvacksalveriet,” Norrköpings Tidningar (16 April 1937), 6–7; Axel Höjer, “Hälsoarbetare,” in En bok till Karl Hovberg på 50-årsdagen 24 mars 1943 (Malmö: Framtiden, 1943), 190–2. 17 “Plan på läkarimport.” In his memoirs, written around 1970, Axel Höjer mentioned Edwardson as “able” but “Nazi coloured” or “Nazi oriented” (“den duktige men nazistiskt färgade” or “den duktige men nazistiskt inställde”). Höjer, En läkares väg, 193; Höjer, “Ur J. Axel Höjers minnen,” 541. Edwardson would later become the first chairman of SACO, the trade union / central organization for Swedish academics. Ulf Schöldström, “Läkarförbundet under ett sekel,” in Ett sekel med läkaren i fokus: Läkarförbundet 1903–2003, ed. Nils O. Sjöstrand (Stockholm: Sveriges läkarförbund, 2003), 29. 18 Arnold. J. Heidenheimer, “Conflict and Compromises between Professional and Bureaucratic Health Interests 1947–72,” in The Shaping of the Swedish Health System, ed. Arnold. J. Heidenheimer and Nils Elvander (London: Croom Helm, 1980), 122. 19 “Läkarimportens dunkla källa klarlagd,” Aftonbladet (28 January 1939), 1, 15. On Knutson’s membership in Manhem, see Ulf Högberg, “Förtroendevalda läkares medlemskap i föreningar associerade till Tredje Riket,” Svenska läkartidningen 97 (2000): 3307. 20 “‘Export viktigare än import av läkare’: Yngre läkarföreningen har ögonen på utlandet,” Svenska Dagbladet, 29 January 1939. Peter Rousthöi was referred to as chairman of SYLF in the article, but was in fact ombudsman (chairman at this time was Dag Knutson). Gösta Tunevall, “SYLF under 3 decennier,” in SYLF – Sveriges yngre läkares förening, 65 år: 1921–1986, ed. Barbro Nordenhäll (Stockholm: SYLF, 1986), 3. 21 Sten von Stapelmohr, “Läkareimportförslaget,” Svenska läkartidningen 36 (1939): 265–7. 22 Gunnar Broberg and Mattias Tydén, “Eugenics in Sweden: Efficient Care,” in Eugenics and the Welfare State: Sterilization Policy in Denmark, Sweden, Norway, and Finland, ed. Gunnar Broberg and Nils Roll-Hansen, 91–5 (East Lansing: Michigan State University Press, 1996).

92 Annika Berg 23 Liljestrand, Dahlberg, Waldenström, “Skrivelse från kommittén för insamlingen för landsflyktiga intellektuella.” 24 Larsmo, Djävulssonaten, esp. 13–15. 25 Svanberg and Tydén, Sverige och förintelsen, 186. In his memoirs, Axel Höjer claimed that Crown-Prince Gustaf Adolf had summoned him and begged him to cancel the plans on import of physicians, in order to avoid public discord. Höjer, “Ur J. Axel Höjers minnen,” 488. 26 Axel Odelberg, “Läkarimporten,” Svenska läkartidningen 36 (1939): 422–3. See also Fredrik Berg, “Ett förslag i flyktingfrågan,” Svenska läkartidningen 36 (1939): 465–7; Eskil Kylin, “Läkarimporten,” Svenska läkartidningen 36 (1939): 507–13. 27 Åmark, Att bo granne med ondskan, 472–3, 484. 28 “Hjälp åt landsflyktiga läkare: Utdrag ur protokoll, hållet vid fullmäktiges för Sveriges Läkarförbund extra möte den 25 mars 1939,” Svenska läkartidningen 36 (1939): 1038–40; “Vädjan om bidrag till insamling för landsflyktiga läkare,” Svenska läkartidningen 36 (1939): 1284–5. The committee had to modify its plan when the war broke out and it became more difficult to send physician immigrants on to third countries. See “Flyktingkommittén vädjar till Sveriges Läkarförbunds lokalföreningar,” Svenska läkartidningen 36 (1939): 2138–9. Still, the lion’s share of the money was used to enable transmigration. In 1943, the committee was merged with another committee that had been formed on the initiative of Axel Höjer in the spring of 1940 to sustain emigrant physicians during the time that they were stranded in Sweden. See “Kommittén för hjälp åt emigrantläkare,” Svenska läkartidningen 42 (1945): 2063–4. 29 See various articles in Svenska läkartidningen, 1939. The quotation taken from Stig Holm, “Utredning av de underordnade läkarnas arbets-, löneoch bostadsförhållanden å Lunds lasarett och övriga sjukvårdsinrättningar inom Malmöhus läns landstingsområde,” Svenska läkartidningen 36 (1939): 165. See also Stig Holm and Axel Höjer, eds., Krig eller Kultur (Stockholm: Tiden, 1929). 30 Stig Holm, “Kommentarer till en landsflyktig kollegas ansökan om legitimation,” Svenska läkartidningen 36 (1939): 1122–5. The Royal Medical Board too objected to these work permits, but the government chose to follow the recommendations of University Chancellor Östen Undén (and, according to Axel Höjer’s memoirs, of Foreign Minister Richard Sandler). Compare Höjer “Ur J. Axel Höjers minnen,” 515. Note that Höjer does not mention the Royal Medical Board’s objections. 31 Uno Käärik, “Överskott på läkare främsta motivet för svenskt motstånd,” Läkartidningen 96 (1999): 5118.

Public Health and Persecution  93  32 Curt Gyllenswärd, “Läkarimporten [2],” Svenska läkartidningen 37 (1940): 1064–71. 33 On Axel Höjer’s engagement in the peace movement and against fascism, see Berg, Den gränslösa hälsan, 194–5, 216–17. 34 ”Plan på läkarimport,” 14. 35 See, for example, Sten von Stapelmohr, “Läkarimportfrågan,” Svenska läkartidningen 36 (1939): 565; Berg, “Ett förslag i flyktingfrågan,” 466; “Utredning begäres i importfrågan,” Svenska läkartidningen 37 (1940): 1302. 36 “Plan på läkarimport,” 14. 37 Curt Gyllenswärd, “Läkarimporten,” Svenska läkartidningen 37 (1940): 669–77. 38 Gyllenswärd, “Läkarimporten,” 669, 677. 39 Högberg, “Förtroendevalda läkares medlemskap i föreningar associerade till Tredje Riket,” 3307. 40 Gyllenswärd, “Läkarimporten [2],” 1072–3. The letter to AB Astra is reproduced on page 1072. 41 Gyllenswärd, “Läkarimporten [2],” 1076. The pronouncement of the Royal Medical Board is reproduced on pages 1058–61 in the article, my quotation taken from page 1060. So, just like the year before, University Chancellor Östen Undén was willing to grant licences to practise medicine to Jewish refugees – in contrast to the Royal Medical Board. The events were portrayed quite differently in Axel Höjer’s memoirs: “The Medical Board suggested, that Dr O. should be granted right to practice in Sweden … But the spokesmen of the medical corps initiated a great campaign with lies and insults and strong components of anti-Semitism, and thus the government rejected Ornstein’s application.” Höjer, “Ur J. Axel Höjers minnen,” 515. What may be of some interest in this context is that Otto Ornstein’s son later married Höjer’s daughter Boel. Signe Höjer, Mitt i livet (Stockholm: LT, 1982), 126, 158. 42 Oscar Andersson, “Indiskreta kommentarer till importfrågan,” Svenska läkartidningen 37 (1940): 1145. 43 Curt Gyllenswärd and the editor of Svenska Läkartidningen, Gustaf Myhrman, went on the fiercest attacks against Höjer, and against Thunberg when he entered the battle. Höjer also counted Stig Holm, Dag Knutson, Oscar J. Anderson, and J.P. Edwardson among his enemies. Gunnar Dahlberg reacted strongly against the attacks and, in a letter to Höjer of 17 July 1940, offered to try to get Edwardson dismissed as publisher of Svenska läkartidningen. Others who defended Höjer were Nils Silfverskiöld, Gunnar Inghe, and the Medical Society of Dalarna, as well as Vera Johnsson, a female physician whose interjections in the debate were

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4 4 45 46

47 4 8 49 50

5 1 52

53

54

refused by Svenska läkartidningen. Gyllenswärd, “Läkarimporten [2],” 1057–81; “Utredning begäres i importfrågan,” 1302–14; “Fortsatt diskussion i importfrågan,” Svenska läkartidningen 37 (1940): 1338–44; Gustaf Myhrman, “Pressreferat i Läkarimportfrågan,” Svenska läkartidningen 37 (1940): 1374–6; Myhrman, “Pressreferat: Läkarimporten i Frankrike,” Svenska läkartidningen 37 (1940): 1402–3; Myhrman, “Pressreferat: Läkarimportfrågan i Hygienisk Revy,” Svenska läkartidningen 37 (1940): 1497–1500; af Myhrman, “Pressreferat: ‘Den stora vreden i Läkartidningen,’” Svenska läkartidningen 37 (1940): 1557–62; Myhrman, “En protest från Dalarna,” Svenska läkartidningen 37 (1940): 1597; Dag Knutson, “‘Kalabaliken i Läkartidningen’: Några stillsamma reflektioner,” Svenska läkartidningen 37 (1940): 1685–88; “Pressreferat: Tankar om vår uppgift och framtiden,” Svenska läkartidningen 37 (1940): 1831–4; “Pressreferat: Läkarna och folkhälsan,” Svenska läkartidningen 37 (1940): 1872–4. Gunnar Dahlberg to Axel Höjer, 17 July 1940, Signe and Axel Höjer archives (Signe and Axel Höjers arkiv), National Archives of Sweden, Stockholm, 3a vol. 1. Compare Höjer, “Ur J. Axel Höjers minnen,” 515–16, 540–50. Andersson, “Indiskreta kommentarer till importfrågan,” 1145–50. Gyllenswärd, “Läkarimporten [2],” 1058–61. Fredrik Berg, “Hjälp åt landsflyktiga kolleger i vårt land,” Svenska läkartidningen 39 (1942): 47–8. After 1 February 1945, the refugees were supported by Utlänningskommissionen. “Kommittén för hjälp åt emigrantläkare,” 2063. Motzi Eklöf, Läkarens ethos: Studier i den svenska läkarkårens identiteter, intressen och ideal 1890–1960 (Linköping: Linköpings universitet, 2000), 147. Oscar Andersson, “Läkarimporten,” Svenska läkartidningen 37 (1940): 946–7. Gyllenswärd, “Läkarimporten,” 1304. Myhrman, “Pressreferat: Läkarimporten i Frankrike,” 1402–3. In a later issue of Svenska läkartidningen a referee, probably Myhrman, wrote with appreciation about the Vichy regime’s recently initiated “clean out” among those “medical improprieties.” “Pressreferat: Fransk nyorganisering,” Svenska läkartidningen 37 (1940): 1876. Höjer, “Ur J. Axel Höjers minnen,” 515–16. “Förebyggande hälsovård huvudintresset: Medicinalstyrelsens chef deklarerar: ‘Läkarimporten’ i ny belysning,” Nya Dagligt Allehanda, 9 August 1940. The campaigns were not softened when Nya Dagligt Allehanda’s Nazi-friendly editor-in-chief left the paper in 1936. Lindberg, Svensk flyktingpolitik under internationellt tryck 1936–1941, 41, 70–1. Käärik, “Överskott på läkare främsta motivet för svenskt motstånd,” 5118.

Public Health and Persecution  95  55 SOU 1948:14, Den öppna läkarvården i riket: Utredning och förslag. See also J. Axel Höjer, Hälsovård och läkarvård: i går – i dag – i morgon (Stockholm: KF, 1949). 56 Dag Knutson, “Läkaren som fri yrkesutövare eller sjukvårdstjänsteman: Inledningsanförande vid 24. Allmänna Svenska Läkarmötet,” Svenska läkartidningen 43 (1946): 2230, 2231. 57 An extensive debate took place in Svenska Läkartidningen 1948. See also Berg, Den gränslösa hälsan, chap. 2:3, esp. 250–7. 58 Urban Janlert, “Sjukvård efter kriget,” Motpol 56, nos 3–4 (1978): 5–8; Arthur Engel, “En hälsans, fredens och den sociala rättvisans missionär,” Läkartidningen 72 (1975): 1786. 59 SOU 1948:14, Den öppna läkarvården i riket, 310–11. 60 Höjer, Hälsovård och läkarvård, 74; Axel Höjer, “Den öppna läkarvården i riket,” Sveriges landstings tidskrift 36, no. 1 (1949): 3. 61 “När samarbetsviljan saknas,” Svenska Dagbladet, 29 April 1950. 62 Höjer, Hälsovård och läkarvård, 74. 63 Höjer, “Den öppna läkarvården i riket” [in Sveriges landstings tidskrift], 3. 64 “När samarbetsviljan saknas.” In the autumn of 1951, sixty Austrian physicians were working on trial in Sweden. Eklöf, Läkarens ethos, 147.

4 “A mysterious discrimination”: Irish Medical Emigration to the United States in the 1950s greta jones

The emigration of doctors was a constant feature of the medical scene in Ireland throughout the nineteenth and twentieth centuries.1 The vast majority went to Britain and the British Empire. After the Second World War, however, this pattern began to change. North America, and the United States in particular, became an attractive option for Irish medical graduates, as it did for medical graduates from the rest of Europe and the developing world.2 With a rise of immigration into the United States of foreign-trained physicians, the leading professional body, the American Medical Association (AMA), decided to issue a list of approved foreign medical schools that in their view provided a medical education equivalent to that of American schools. In this way, they hoped to influence American opinion about which graduates should be licensed in the United States. This proved to be a difficult system to maintain. It was not successful and was abandoned by the late 1950s. While it operated, however, it produced perturbation among those countries exporting medical graduates to the United States. Ireland was a case in point. The medical schools of the Republic of Ireland – though not the medical school of Queen’s University Belfast (QUB), which was still within the U.K. system – were not included in the AMA’s list of approved medical schools. What followed was an intense struggle involving diplomacy, doctor activism, and political intervention on both sides of the Atlantic. Ireland was not the only country discomfited by non-inclusion on the list. Many other case studies could be produced of negative reaction in other European countries and in Asia and South America. But Ireland shared language and cultural connections with the United States, and its exclusion was felt particularly badly. In addition, the whole episode raised questions about the management of its medical schools and the

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extent to which they had failed to adapt to new, predominantly American models of medical education in the twentieth century. Finally, it showed the degree to which national pride and medical education were intertwined. The controversy over medical education would eventually engage the attention of the Irish public and its political representatives at the highest level. Doctor emigration depended upon the acceptability of Irish medical qualifications abroad. As far as Britain was concerned, Irish medical schools were validated by the General Medical Council (GMC) of the United Kingdom from the nineteenth century and approved under the same system of periodic visitation applying throughout the British Isles. Thus, graduates of Irish medical schools were routinely entered on the medical register of the United Kingdom and eligible for all appointments requiring registration in Britain and the British Empire. This continued to be the situation for Queen’s Medical School in Belfast after the partition of Ireland in 1922. In the south, however, the new state set up at partition was deemed by the Irish government to require its own medical council and system of registration. The possibility then arose that Irish medical graduates might lose automatic access to the British Medical Register. This led to a brief but intense struggle between doctors and the state in 1925 and 1926. The conflict was resolved by a system of reciprocal registration. A new Irish medical council and register was created for Irish doctors, but the British GMC continued to inspect and approve Irish medical schools north and south as a condition of allowing Irish medical schools to register their graduates on the U.K. register.3 The Problem of Recognition and Licensure Irish medical schools in independent Ireland in 1945 comprised the National University of Ireland (NUI), which had three constituent colleges: University Colleges of Dublin (UCD), Cork (UCC), and Galway. In addition, there were three other medical schools in Dublin: the University of Dublin (Trinity College or TCD), the Royal College of Surgeons (RCS), and the Apothecaries Hall. The importance of emigration to Britain and the British Empire meant that changes in British medical education affected the Irish schools. On 14 December 1949, representatives of Irish and British medicine met in Dublin to discuss the proposed reforms in British medical education recommended by the Goodenough Report of 1944 and subsequently

98 Greta Jones

incorporated into the Medical Act of 1950 in the United Kingdom.4 Central to Irish concerns was the provision that every graduate, before acceptance on the British Medical Register, should have served one year of residency or internship in a hospital approved for that purpose by the GMC. This, according to the Eire Department of Health, “is of greater importance than any of the other proposals put forward by the British government for the amendment of the Medical Acts.”5 The Irish committed themselves to moving to this system but felt it would take time and be expensive, a view that was sympathetically received by the GMC. In response, an arrangement was made by which graduates of Irish medical schools would be admitted to the Irish Medical Register. However, until the condition of internship was fulfilled either in Britain or Ireland, they were given provisional status – ­designated by the letter P – on the U.K. Register. The issue of registration and licensure in the United States was, however, much more complex. Medical licensing in the United States was the responsibility of individual states, and the conditions were laid down by their legislatures. Many states accepted those who passed the exams of the National Board of Medical Examiners (NBME), but foreign medical graduates were not eligible to sit these exams. According to a survey of licensing practices for foreign medical graduates conducted for the AMA and published in 1949, the situation was “confusing and uncertain.”6 Some twenty-three states excluded all graduates from outside the United States and Canada from practice. In others, the regulations varied according to citizenship or immigration status, length of time in the United States, or other considerations. The AMA carefully monitored the numbers of foreign medical practitioners applying for licensure each year, producing annual tables of requests from foreign-educated doctors for admission to licensure and the success rates. The AMA expected that post-war doctor immigration into the United States would be largely from “displaced physicians” as a result of the political situation in Europe.7 For this reason, there was in fact substantial emigration to the United States after 1945. However, it was only in the 1950s that immigration began to rise substantially and, increasingly, this was from non-European nations.8 The AMA expressed its concerns about this immigration in terms of training and competency and this view was not entirely self-serving. The Flexner reforms in 1910 had significantly raised the level of medical education in the United States, and there was a tendency to look at medical education outside the United States very much through the prism of Flexner.9

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In addition, though many European schools retained a degree of respect in the United States, after the Second World War the view of the AMA was that twenty years of political turmoil, the devastation of war, and the relative isolation of many Continental medical schools had put back medical education in Europe.10 The AMA could not control licensing of foreign doctors directly. Therefore its aim was to influence political and public opinion about foreign medical education, which it attempted to do by producing for foreign medical schools an “approved list” rated by the same standards as American medical schools. They hoped this would influence attitudes about which foreign doctors could be safely licensed to practise. In the words of one commentator, “The policy of rating the school rather than the individual was an extension of a successful policy initiated by the Flexner Report of 1910.” In that writer’s view, however, “what had succeeded for American medical schools failed when applied to foreign medical schools.”11 The Committee on Foreign Medical Credentials – a subcommittee of the AMA’s Council on Medical Education and Hospitals – was set up by the AMA in the autumn of 1947 to examine doctor immigration. At the first full-scale meeting on 25 March 1949, representatives from the Association of American Medical Colleges, the Advisory Board on Medical Specialities, and bodies from the licensing world were present, including the NBME, the Federation of State Medical Boards, and the registration bodies of Connecticut, Illinois, and Wisconsin. These were all states with more than average experience of doctor immigration. New York – the state with most emigrant doctors – was invited but was unable to attend. Also present were government representatives from the U.S. Office of Education and international and charitable organisations including the Rockefeller Foundation. Three members of the Council on Medical Education and Hospitals were particularly important in the Committee on Foreign Credentials: Victor Johnson, H.G. Weiskotten, and Donald G. Anderson. It was Donald Anderson who, as secretary to the committee, would conduct the bulk of its business, along with F.R. Manlove, the assistant secretary. The committee was anxious not to appear restrictive. Its aim, it claimed, was to facilitate resettlement of physicians in America by removing prejudices against foreign graduates in the minds of state licensing boards. An approved list would encourage state boards to adopt “an enlightened view towards the foreign trained physician.”12 Nonetheless it believed that

100 Greta Jones the present high standards of medical practice in the United States has been the direct result of the recognition by the licensing boards, that evaluation of the school from which a physician graduates is equally as important as evaluation of the physician himself. Before this principle was generally recognised, the country was overrun with physicians who, armed with a degree from a low-grade school or outright diploma mill, succeeded in one way or another, in passing the examinations for licensure. The needless suffering and injury perpetuated by the incompetent and, at times, fraudulent practices of many of these inadequately trained men constitute a dark chapter in the history of medicine.13

The difficulties of producing reports on foreign medical schools soon became apparent. Annual visitation was the most satisfactory method but it was costly and time-consuming.14 Questionnaires might be substituted, but experience with them had not been encouraging.15 Eventually it was decided to seek detailed information about foreign medical schools in personal interviews “with qualified and disinterested persons who have knowledge of the school in question.” Examination of written reports on academic performance and, where appropriate, “the status of the school with the General Medical Council of Great Britain” also formed part of the strategy.16 It was particularly useful if information could be obtained by a visit. However, visitations could be arranged only on an informal and ad hoc basis when a member of the AMA happened to be in the vicinity. A small committee comprising Harold S. Diehl (chairman), Loren R. Chandler, and Stanley Dorst visited Great Britain in October 1949, returning in February 1950.17 Harold S. Diehl broke off the visit to Great Britain to visit Ireland, and it was on the basis of his observations that Irish schools were assessed. During the same period, Creighton Barker visited Copenhagen, Stockholm, Uppsala, and Oslo. Freddy Homburger of Boston contributed knowledge on medical education in Switzerland. Vernon Lippard, who had visited Italy recently, provided information on its schools.18 The Classification of Foreign Medical Schools was the basis of the list of “approved” foreign medical schools first issued in February 1950. The list comprised twenty-seven schools in, respectively, Denmark (one), Finland (two), Netherlands (four), Norway (one), and Sweden (three). The United Kingdom had sixteen approved schools: ten in England, four in Scotland, one in Wales, and one in Northern Ireland (QUB).19 The preliminary list, drawn up on 7 February 1950, contained the Irish

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medical schools. Subsequently, according to the deliberations of the Council on Medical Education and Hospitals, “the schools in Eire had been removed on the basis of later information.”20 Effectively from 1950 Irish medical schools, with the exception of QUB, were not recognized by the AMA. The reports on the medical schools presented before the council were brief, but something of their direction can be gathered from the guidance given to the delegation before it departed on the British visit. Crucial to the view of the AMA on the suitability of a medical school was affiliation to a university and clinical facilities at all stages of medical training. Laboratory facilities, the qualifications of the faculty, size of class, entrance qualifications, and state of the library were taken into account. Failure rates of the graduates of different foreign schools in American licensing exams was also an issue. Less tangible measures, such as appraisal of students and the reputation of the school, were included. Finally, competence in English was important.21 The Goodenough Report of 1944 had begun a process of change in British medical education that brought it closer to the American model. But reform of Irish schools was impeded by a number of factors. First, there had traditionally been a proliferation of medical schools in Ireland. During the Rockefeller visit to Ireland in the 1920s to assist reform in Irish medical education, it was pointed out that Ireland was oversupplied with medical schools.22 However, consolidation had proved impossible, partly because of historic rivalries that were often exacerbated by denominational conflict. But also the Irish medical schools depended for their survival on student fees and because they assumed that a good proportion of those they educated would leave Ireland, overproduction of graduates was built into their calculations. These factors together meant that resources for teaching and clinical instruction were squeezed. From 26 April to 23 May 1954, the General Medical Council of the United Kingdom visited the Irish schools, and their report illustrated the persistence of the problems, particularly those that arose from the unstructured relationship between hospitals and medical schools. Cork and Galway medical schools could negotiate programs of instruction with fewer hospitals in their respective cities. But, even there, the hospitals were often too small to accommodate enough variety of cases to permit the best standards of clinical training. No professor at an Irish medical school had a clinical department or laboratory in any hospital. Clinical pathology was particularly neglected, and there was a

102 Greta Jones

serious shortage of autopsy material. Libraries and museums lacked investment. The university calendars were often unreliable guides to the teaching programs. In both Cork and Galway they needed “drastic revision in order to tally with and confirm the information with which we were supplied.”23 There was a need for appointments in a number of areas where Irish medical schools were falling behind modern medical education.24 Shortages of posts in medicine and surgery were sometimes covered by re-designation of a teacher’s function at six-monthly intervals, a practice the GMC thought pedagogically unsound. Crucially, however, and in contrast to the AMA, the GMC did not withhold recognition. Reaction to the Approved List In discussions in 1949 with Paul Dompke, a U.S. State Department official, a representative of the AMA asked whether the issuing of a list of approved foreign medical schools would embarrass the United States. The answer was that “opinion was divided in the State Department. Some feared unwanted attention from the governments of the unlisted schools; others were in favour of taking a calculated risk. But it was not discussed at the highest level in the State Department.”25 In fact, considerable “unwanted attention” arose, and Irish schools were not the only ones discomfited by their non-inclusion on the approved list. The AMA, at a meeting of the Committee on Foreign Credentials in 1952, was informed that “the Diplomatic services of France, Italy and the Irish Free State have protested the absence of schools in these countries from the lists. Other representations indicate that there are schools in Mexico and India which desire to be included in the list.”26 By 1953, the AMA had received requests for visits from medical schools in West Germany, Italy, South America, and China. The prospect opening up was not only pressure for first-time visitation, but also follow-up visitations from disappointed medical schools. Since, as was pointed out in one meeting, there were approximately 566 medical schools in the world, this was a daunting vista.27 With regard to Ireland, the AMA Council on Medical Education and Hospitals was told in December 1950 that “the medical schools of Southern Ireland are disturbed that they have not been recognized by the Council. Considerable correspondence has been received from the Schools and other interested agencies.”28 From 1950 to 1953, a campaign of politico-medical lobbying took place on behalf of Irish medical schools to reverse the AMA’s decision.

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The Department of External Affairs (DEA) of the Republic of Ireland (later Department of Foreign Affairs) became involved. Most of the extant correspondence between the AMA and interested parties in Ireland has survived primarily in Irish government files.29 Successive reports on the position of Irish medical school graduates in the United States were commissioned by the DEA from Ireland’s consul generals in New York and Chicago and relayed to Ireland via the Irish Embassy in Washington. The Irish Medical Association – the Irish equivalent of the British Medical Association – and the Medical Registration Council of Ireland entered into correspondence with the AMA. Luminaries from the U.S. Roman Catholic Church intervened, as did Irish immigrant doctors in New York and Chicago, organizing themselves into a loose grouping called the Irish Universities (Medical) Club of America. For a time the Irish sought a backdoor means of evading the consequences of non-listing by the AMA. This was by securing recognition of Irish medical schools by the New York State Licensing Board. In May 1951, a report was sent from the Irish consul general in New York to the DEA via the Republic of Ireland’s office in Washington. A friend of the consul general, Leo Kelly, a Brooklyn doctor, had visited him to talk about Dr Maurillo, a member of the Board of Regents of New York, who reputedly got Swiss and Italian schools recognized by New York.30 They believed that a visit by Dr Maurillo to Europe was imminent in June 1951 and that he might become an ally of Irish medical schools. A proposal to defray his expenses for a visit to Ireland was sent to the AMA by the Irish Medical Association. But Dr F.R. Manlove, assistant secretary of the AMA’s Council on Medical Education and Hospitals, turned down the offer on the grounds that “since Dr Maurillo was not known to the Council on Medical Education and Hospitals of the AMA, a report furnished by him would not be accepted as a basis for the Council’s decisions.”31 The proposal to use the New York Board of Regents persisted into 1952. A representative of Cardinal Spellman, the Most Reverend William A. Scully, chairman of the National Catholic Welfare Committee of New York, suggested to Ambassador Matthews – the U.S. ambassador to Ireland – in January 1952 that “an unofficial visit to the Irish medical schools by a Catholic member of the Board of Regents of Education in New York” could be arranged. This was intended to be preliminary to a second official visit by the Board of Regents. Mr ­Christianson of the United States Embassy believed, according to Irish officials, “that, as the other States of the Union practically always took their medical standards from

104 Greta Jones

New York, recognition by the New York Board of Regents must automatically mean recognition throughout the USA.”32 Since New York was by far the most significant recipient of immigrant doctors applying for licensure, as can be seen from table 4.1, this was a fair point. In 1955, New York State, along with Ohio, Illinois, and California, had the largest number of graduates of foreign medical schools applying for licensure. In spite of the pressure, the AMA held out for two years. The 1950 list was reissued in 1953 in Choice of Medical School, which contained a section on foreign medical schools. The list of approved schools had risen to thirty-nine and now included Brazil (one), Belgium (four), Lebanon (one), Switzerland (five), and China (one). But Irish schools were still not included.33 Between 1950 and the issue of the second list in 1953, however, there was evidence of the strain produced on the AMA by the controversy over the approved list. In 1953, the preamble to the section on foreign medical schools contained a warning that the results were not amenable to lobbying: “No foreign medical schools can be included in the list solely on the basis of information furnished to the two Councils by the school itself, by its graduates or by any foreign government or agency … nor can they accept from foreign schools offers to subsidize inspections by representatives of the councils.”34 However, after a discussion described as “robust” at a meeting of the Committee on Foreign Credentials of the AMA on 25 April 1952, the principle of a second visit to Ireland was accepted. According to  the minutes, “Dr Anderson said it was planned at the first opportunity to again review the programs in the Irish schools.”35 By 6–7 June 1952, the AMA had agreed that the occasion of the Second World Table 4.1.  States with the Highest Number (over 100) of Foreign Graduates Presenting Themselves for Licensure in 1955 State

Number

Passed

Failed

% Failed

New York Illinois Ohio California Virginia Connecticut New Jersey

383 362 225 181 89 29 4

159 157 160 135 54 13 3

224 205 65 46 35 16 1

58.4 56.6 28.9 34.1 – – –

Source: Medical licensure statistics, Journal of the American Medical Association 161 (26 May 1956): 364–9.

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Conference on Medical Education to be held in London in late August and early September of 1953 should be used for a repeat visit to the Eire schools: “After discussing the status of the medical schools in Eire and the tremendous pressure from many sources to approve these schools, it was agreed that Dr Anderson should survey these schools while he is in Europe in the summer of 1953 to participate in the International Conference on Medical Education.”36 The Second Visit by the AMA The second visit of the AMA to Irish medical schools took place in September 1953 and the report was produced at the end of November. The headline in the Irish Times of 30 November was “Irish Medical Schools Not Condemned in Report of US Doctors: Different Methods Stressed.” Indeed, the language of the AMA report was conciliatory in referring to Irish medical education as in a “state of transition.” In reality, however, criticisms of the first visitation were upheld in greater detail, and approval was not given to Irish medical schools. There was much disappointment and defensiveness in the reception to the second report. Michael Tierney, president of University College Dublin, the largest of the three colleges that made up the National University of Ireland, felt that “there seems to me to be here a mysterious discrimination against Ireland which the Report does nothing to explain.” His view was that “one of the conclusions to be drawn, in my opinion, from the Report is the un-wisdom of any attempt on our part to train for practice under American conditions.”37 Alfred O’Rahilly, president of University College Cork, maintained that “whilst we are anxious to help Irish medical graduates in the USA, it is not the primary job of our medical schools to equip doctors for America.”38 The Irish Times believed that a generation ago, “rightly or wrongly Dublin was supposed to rank with Edinburgh and Vienna … Is it conceivable that our schools have been resting on their laurels complacently disregardful of modern advances in the science and practice and medicine, while the schools of Great Britain and Northern Ireland studied and toiled to keep abreast of the times? We do not believe it for one moment.”39 Underlying all these comments, nonetheless, was apprehension, particularly about a forthcoming inspection by the GMC scheduled for 1954. On 1 December 1953, the Irish Times reported, “Whilst the heads of Irish medical schools are considering the report of the American doctors, they are preparing for what one doctor suggested yesterday is a

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much more important visit.”40 Fortunately for the Irish medical schools, the GMC Report of 1954 did not withhold recognition. Nonetheless, the criticisms it made of Irish medical education were similar to those of the AMA the year before. The combination of the AMA report of November 1953 and the subsequent GMC report in 1954 began, if not immediate change, a recognition that it must eventually take place. One contributory factor was the widespread public interest and concern that the AMA’s list had generated and that brought home forcibly to Irish politicians the importance of addressing the question. Between 1955 and 1956, Eamon de Valera, leader of the chief opposition party in the Republic of Ireland and soon to become, once again, Taoiseach (Prime Minister), asked his office, in his capacity as chancellor of the National University of Ireland, to contact the Taoiseach (John Costello). This was to inform him that “the situation regarding the deficiencies of the medical schools of the constituent colleges of the National University of Ireland had become extremely serious and that there was a danger of grave developments in the early future. Mr de Valera stated that further inspections of the medical schools from abroad are expected and that the time available in which to prepare for such inspections is only about a year.”41 De Valera believed that “a bad name given to us now by such bodies as the American Medical Association and the General Medical Council would be hard to outlive. It would not only have a disastrous effect on our reputation abroad but would tend to lower our proper self-esteem and our domestic standards … I trust, therefore, that you will give your personal attention to the claims of the Colleges of the University for financial aid, particularly for their medical schools and see that any short-comings here as regards medical teaching cannot be attributed to state indifference or neglect.”42 Divisions in Irish Medical Education In Ireland, the failure of Irish medical schools to make the approved list caused considerable agitation. In a letter to the AMA in 1950, President Tierney of UCD described the decision as “an undeserved and unexpected slur” and “invidious treatment.” A letter protesting the decision was also received from Dr J.W. Bigger of the Medical Faculty of the University of Dublin (Trinity College, Dublin).43 Despite this sense of national resentment, Tierney was ironically inclined to hide behind recognition by the GMC of Irish medical schools. UCD’s medical degrees,

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he claimed, were “accepted for immediate admission to the British Medical Register. Its Extern Examiners are among the most distinguished teachers in British University Medical Schools, and its examinations and curricula are in entire conformity with the Regulations of the British General Medical Council.”44 However, this was not seen by the AMA as circumventing the difficulty. According to the AMA’s report of its discussions in 1952, “Dr Manlove pointed out that should graduates be accepted whose qualifications are recognised by the General Medical Council of Great Britain, this would include graduates of schools in Eire, Australia, South Africa and India. From the information on file, he stated there was doubt as to the quality of training offered in some of the schools in these countries.”45 But not all Irish medical educators and doctors were of the same mind as Tierney or Bigger. One effect of the AMA intervention was to encourage Irish critics of their medical education to make their views known. A letter to the AMA from James O’Donovan, dean of University College Cork’s medical school, stated the failed inspections “will have an exceedingly good result in shaking the Governing authorities out of their Rip van Winkle sleep … it gives some of us who are willing to do the right thing a weapon with which to castigate those who were obstructing us and whom our personal and local weapons were not powerful enough to hurt.” O’Donovan included with his letter his own memorandum for educational reform, drafted in 1941, to illustrate the point that “we are not all unaware of the discrepancies between our standards and those required by modern medical teaching. No notice whatever has been taken of this report but I have now published it to my students and, armed with the results of your recent inspection, I think that we shall succeed in effecting the necessary reforms.”46 O’Donovan was joined by a number of Irish medical graduates in the United States. The Irish Universities (Medical) Club of America, largely comprising doctors from Chicago and New York, were also critical of the medical education they had received in Ireland. They drafted a letter in November 1952 which included a memorandum, circulated to the Irish Consulates at Chicago and New York. In their covering letter, the authors of the “Chicago” memorandum claimed to be addressing the concerns of the majority of Irish emigrant doctors, not just the signatories. They urged “the Irish government and the Irish Medical Association to hold public inquiries at an early date to expose and correct the abuses which have brought our universities and the Irish medical profession into world-wide disrepute.” In particular, they wanted to

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ensure that “the Irish medical schools assume control and supervision of the clinical teaching of their students in the same fashion as European, British and American medical schools.”47 The letter elicited angry responses in speeches at the winter gradua­ tions of the NUI in December 1952 from both the president of UCD (Dr Tierney) and of UCC (Alfred O’Rahilly). Tierney described the letter and the allegations in the memorandum as “so erroneous as to be in some cases positively grotesque. Certain of them are of such a character that they could constitute grounds for an action for slander.”48 A threat was made to expunge the names of the signatories from the list of graduates. In January 1953, Tierney announced a small victory in the Irish Independent newspaper that four of the signatories claimed never to have seen the memorandum or letter, much less signed it. Two others claimed to have been told of it but had had insufficient time to study it.49 This was something of a pyrrhic victory. Four months later the Irish Universities (Medical) Club of America issued a second letter, this time on the authority of their associate club in New York. The letter was published on 23 May 1953 in the Western People, a newspaper widely read in the west of Ireland. It contained new signatories as well as some from the first letter. The object of the second letter was to take issue with Tierney’s and O’Rahilly’s comments at the winter graduations and “not to let the conferring address go unchallenged.”50 Inadvertently the attack at the winter graduation on the Irish Universities (Medical) Club of America increased publicity for their second intervention.51 Widespread reporting of it in the Irish newspapers led the government of the Irish Republic to commission its first full-length account of the preceding three years of negotiations: “The Minister spoke to me on Saturday 23 May, regarding an editorial and a letter from the Irish Universities Medical Club of America which appeared in the issue of the Western People of that date and instructed me to prepare, for the information of the Taoiseach, a memorandum setting out the developments in the recent controversy between the Irish doctors in America and the Universities and Medical Profession here on the subject of the non-inclusion of the medical schools of the Irish Universities in the approved list of schools issued by the American Medical Association.”52 The rhetoric of the emigrant doctors who drafted the letter and memorandum was rather overblown and they were guilty of inaccuracies and carelessness in presenting their case. Tierney’s attack on them was not, as they claimed, “still reverberating around Ireland and the civilised

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world.”53 They were, as the government account of the events stated, a rather fluid and amorphous body, lacking a solid organizational centre that could validate memoranda issued in their name. Nonetheless, they gave voice to real discontent about the inadequacies of Irish medical education. Each of the two letters had twenty-three signatories, but seven doctors signed both letters. These seven doctors are traceable. They were slightly older than the other generally younger signatories. They were in their thirties and, with two exceptions, licensed to practise in America. The two exceptions belonged to the 1950 cohort of graduates of NUI. Subsequently, they received their licences in 1956 and 1957 respectively. One of the double signatories, in his fifties, was Thomas E. Hardy, the only one who had not gained his medical degree at NUI. He was awarded a BA in 1915 but emigrated to Chicago, where he obtained an MA at Loyola and then an MD from the University of Chicago in 1925. Of the remaining doctors – comprising the sixteen who signed the Chicago letter and another different sixteen who signed the New York letter some months later – only twenty were traced. Of these, most were in their twenties and the rest in their early thirties – the eldest was thirty-six at the time of the letter.54 They were recent graduates, and all but three had graduated after 1945. Fifteen of the twenty-seven signatories, whose licensing details can be found, were unlicensed at the time the letters were written. Several were not subsequently licensed until the late 1950s or early 1960s.55 The views of the Irish Universities (Medical) Clubs of Chicago and New York on Irish medical education repeated many of the criticisms of the AMA and GMC. They referred to the lack of teaching of basic science, the poor facilities of UCD dissection rooms, and the overcrowding and understaffing. They also complained that much of this arose from the annual export of doctors, which led to overcrowding and strain on resources: “At least 300 students were graduated yearly from the Irish medical schools – a number three times as large as that graduated yearly in any corresponding population area in England or the United States.”56 Their greatest provocation was, however, that they laid the fault firmly at the door of the Irish medical establishment. The refusal of the deans of medical schools to listen to their complaints and answer letters indicated “cynical and callous indifference.” They claimed there was “a small group of permanent officials who have a vested interest in medical education and are chiefly concerned with keeping the student body at a numerical level to insure their continued employment.”57

110 Greta Jones

Noticeably there were no Trinity College graduates among the protesters and very few from the Royal College of Surgeons in Dublin, even though the strictures directed against Irish medical education also applied to these institutions. The protesting doctors were overwhelmingly from the predominantly Catholic NUI and most from UCD, the largest medical school of the NUI. This reflected a shared experience of undergraduate medical education but also the cultural, religious, and political divisions in Ireland.58 The Abandonment of the Approved List In the early years of its operation, optimistic reports on the adoption of the approved list for foreign medical schools appeared in JAMA.59 But by 1956, the AMA was moving towards the abandonment of the list. Only around 25 per cent of state licensing boards were using it. “Thus for more than half of all state medical licensing boards the listing has either been of no use or has lent itself to an unintended use.” Moreover, 75 per cent of all licensed foreign graduates were from unlisted schools.60 There were two reasons for its abandonment. The assessment procedures upon which the approved list was based had faults from the start.61 At the same time, the anxieties of the AMA about medical immigration were diminishing. By the mid-1950s, many American states were desperate to find medical personnel, particularly for state-run institutions and hospitals, and foreign medical graduates were entering the United States through the intern and residency system.62 The use of residencies to facilitate immigrant doctors climbed steadily throughout the 1950s and eventually became the predominant route that medical emigrants to the United States would take.63 The AMA also came to accept the idea that the approved list unfairly penalized good individuals because of the state of the medical school in which they received their education. By 1954, the AMA was moving to a system that assessed individual competence.64 In 1956, it announced an examination to be offered by an AMA-run body – the Educational Commission for Foreign Medical Graduates (ECFMG) – which was to devise and set examinations for individual foreign medical graduates. Success in these exams amounted to accreditation by the AMA. The scheme opened on 1 October 1957, with the first exam scheduled for March 1958 and the second for the following August.65 The abandonment of the approved list and the substitution of the ECFMG eased the pressure on Irish medical schools. Some additional

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resources were also provided in the form of a series of one-off subsidies by the Irish government to the universities in the late 1950s, mainly for accommodation. Also there was a drop in recruitment of medical students to Irish schools in the late 1950s, which was carried out in anticipation of reduced demand for medical manpower in Britain predicted by the Willink Committee in 1957.66 In fact, demand in Britain for Irish medical graduates remained buoyant. Meanwhile, whatever public protestations were made, in private there was a consensus between medical schools and government that reform in Irish medical education was long overdue. The Commission on Higher Education appointed by the Irish government in 1960 recommended reforms very much along the lines recommended by the AMA. The commission believed the relationship between hospitals and medical schools had improved over the previous decade because of a number of ad hoc changes that had taken place.67 But they also recognized that, given the historical situation in the Irish Republic, it would be a protracted process: “The hospitals used for clinical teaching are not the property of the medical schools and their management and government lie with their own authorities.”68 Thus, “it seems, therefore, that medical school / teaching hospital relationship must continue on the basis of separate ownership and management of the medical school and the hospital.”69 Conclusion The “approved list” exemplifies the extent to which American hegemony in medical education was exported across continents in the twentieth century. In many cases, it was the funding bodies such as Rockefeller that spread the gospel of Flexner. In the case under examination here, it was the issue of migration across borders of medical graduates. This was by no means the only protracted negotiation over qualifications and eligibility to practise that medical immigration gave rise to. The Irish government itself was asked by the secretary of state of foreign affairs on behalf of the Supreme Sanitary Council of Austria in 1925 whether Austrian medical graduates would be permitted to practise in Ireland; its replies were discouraging.70 The visits to medical schools by the AMA are, in themselves, a fascinating exemplification of this medical hegemony in practice. They also show the complexity of the process that brought into play different medical cultures, the economics of medical schools, and the cultural assumptions held in a society about medicine.

112 Greta Jones

But the Irish case also shows that the issue could resonate throughout the political establishment. They reveal the point at which medical education met diplomacy, economics, national pride and the deployment of national resources. The AMA was perhaps naive about the extent to which national passions would be stirred up by the approved list experiment and Ireland was not the only nation which protested their exclusion. How other countries reacted to AMA visitation and recognition, or non-­ recognition, in the early 1950s deserves closer attention from historians. The Irish example suggests complex cultural and political factors at work in reaction to the “approved list.” There was also an additional political dimension in Ireland. In the 1950s, the 26 counties of Ireland had been independent for only three decades. Many of those in power in universities in the 1950s were the elite of the revolutionary generation and owed their advancement to the political turmoil from 1916 to 1922, which led to the establishment of the southern state. The Ireland of the 1940s and 1950s was their creation and criticism of any aspect of their nation elicited fear that the whole nationalist project itself was under attack. Hence the extraordinary sensitivities aroused by this episode and the reference by Tierney to “mysterious discrimination” which implied broader political rather than professional motives in the critics of Irish medical education. Notes 1 For figures on this, see G. Jones, “The Rockefeller Foundation and Medical Education in Ireland in the 1920s,” Irish Historical Studies 120 (1997): 564–80, table 1, 57. The figures are based on a survey of cohorts from the main medical schools in Ireland every five years from 1860 to 1960. 2 Of the individuals who went to the United States, only two did so before 1920. Fifteen went between 1920 and 1940, and thirty-nine between 1945 and 1960. This is not, of course, the total number of emigrants to the United States but the figure from the selected cohorts. The figure also excludes a further sixty-one who went to Canada during the period. Because of reciprocal registration agreements between Canada and the United States, Canada was often a first stop before moving to the United States. Of the cohorts who moved to practise outside Ireland from 1950 to 1960, 19 per cent were in North America. This was less than the 60 per cent emigrating to Great Britain in the same period, but more than for any other destination.

“A mysterious discrimination”  113  3 Jones, “Rockefeller Foundation and Medical Education.” 4 Discussion of 12 October 1944, Royal College of Surgeons in Ireland (hereafter RCSI) Council Minutes (December 1938–60), index G, 113. 5 National Archives Dublin (NAD), Office of the Taoiseach, file S11589, appendix A, part 11, Medical Education and Registration, 2. 6 C. Barker and G. Mooney, “Licensing of Foreign Medical Graduates in the United States,” Journal of the American Medical Association 140 (7 May 1949): 12. 7 J. Brunot, “Resettlement of Displaced Physicians: A New Approach,” Journal of the American Medical Association 145 (7 April 1951): 1059–62. 8 In 1955, 37.7 per cent of all medical emigrants presenting themselves for licensure in the United States were from Western European countries and, if one adds the total from the United Kingdom, Australasia, South Africa, and Ireland, it was 42.6. By 1960, this figure had fallen to 27.3 per cent and 35.7 per cent respectively. Calculated from “Medical Licensure Statistics,” JAMA 161 (26 May 1956): 364–9. Figures based on foreign-educated physicians presenting themselves for licensure. 9 See T.N. Bonner, Iconoclast Abraham Flexner and a Life in Learning (Baltimore: Johns Hopkins University Press, 2002); K.M. Ludmerer, Time to Heal: American Medical Education from the Turn of the Century to the Era of Managed Care (Oxford: Oxford University Press, 1999). 10 American Medical Association (hereafter AMA) Archives, Chicago, Minutes of Meeting of the Committee on Foreign Medical Credentials, 25 March 1949, in Minutes of the Business Meeting of the Council on Medical Education and Hospitals, 8–9 February 1949, appendix H, 5. 11 AMA Archives CHM5926/1971, Melvin Lurie, “Physician Licensing Policy,” First National Congress on Health Manpower sponsored by the Council on Health Manpower of the AMA (22–4 October 1970), 92. 12 AMA Archives, appendix H, 6. 13 AMA Archives, Minutes of the Meeting of the Committee on Foreign Medical Credentials, 25 March 1949, 4; appendix H to the Minutes of the Business Meeting of the Council on Medical Education and Hospitals, 8–9 February 1949. 14 It was calculated at $60–90,000 a year. AMA Archives, Minutes of the Council on Medical Education and Hospitals, 8–9 February 1949, 25. 15 The Federation of State Medical Boards, the World Medical Association, and the Committee on Displaced Persons had sent out 350 questionnaires but only 150 were returned. Of 300 sent out by the Department of State, only 132 were returned. 16 AMA Archives, Council on Medical Education and Hospitals, appendix G of the Minutes of 20, 22, 23 October 1949. This would, of course, be relevant

114 Greta Jones

1 7 18

19

20 21 22 23 24 25

26 27

28 29 30

only to schools within the jurisdiction of the GMC, but in 1949 this included a number in former or remaining British colonies in Africa and Asia. A report was mailed back to the council and received in December 1949. AMA Archives, Business Meeting of the Council on Medical Education and Hospitals, Minutes, 4 and 5 December 1949. Freddy Homburger was a native of Switzerland and obtained his medical degree there. He headed the Cancer Research Unit at Tufts. Vernon W. Lippard was president of the Association of American Medical Colleges and in 1952 became dean of Yale Medical School. AMA Archives, Meeting of the Council of Medical Education and Hospitals, 3–8 February 1950. The medical school in Belfast was still within the United Kingdom. AMA Archives, Council on Medical Education and Hospitals, Minutes, 3–8 February 1950, appendix B, 14. AMA Archives, Minutes of the Council on Medical Education and Hospitals, 20, 22, 23 October 1949, appendix G. Jones, “Rockefeller Foundation and Medical Education in Ireland in the 1920s,” 571. General Medical Council (hereafter GMC) Visitation Reports V/M./1 and V/S./1, 9. Radiology, dental disease, anaesthesiology, and general practice were all cited. AMA Archives, Minutes of Business Committee of the Council on Medical Education and Hospitals, 5 December 1949, appendix G, 4. Interviews, 16 November 1949, and a subsequent telephone conversation, 28 November 1949. AMA Archives, Minutes of the Meeting of the Committee on Foreign Medical Credentials, vol. 1 (25 April 1952), appendix F, 11. AMA Archives, Minutes of the Business Committee of the Council on Medical Education and Hospitals, 29–30 November 1953. Dr Turner pointed this out. AMA Archives, Minutes of the Meeting of the Council on Medical Education and Hospitals, 2–4 December 1950, 24–5. Preserved in NAD, Office of the Taoiseach, file S 14402B, “Undergraduate and Postgraduate Medical Training.” He is referred to in the documents produced by the Irish government as Dr Vincent Maurillo, but in the New York Times as Dr Dominick Maurillo. See “Four Medical Schools in Europe Studied,” New York Times, 14 September 1951. His name is also occasionally spelt as Mauriello in Irish government documents.

“A mysterious discrimination”  115  31 NAD, Office of the Taoiseach, file S 14402B, Memorandum on the History of AMA and Irish Medical Schools, May 1953, 7–8. 32 NAD, Office of the Taoiseach, file S 14402B, 11. Ambassador Mathews was Francis P. Mathews, U.S. ambassador to Ireland, 1951–2. In November 1952, the Irish Universities (Medical) Club of New York was still urging the claims of Dr Maurillo, who had “approved the graduates of the medical schools of twenty Italian universities and of the University of Paris as acceptable for licensure in New York.” File S 14402B, annex C, Present Condition of Medical Education in the Republic of Ireland, 1. Report attached to a letter from the Irish Universities (Medical) Club of Chicago to the consul in Chicago of the Republic of Ireland, November 1952. 33 “Medical Licensure for 1953,” JAMA 155 (29 May 1954): 472. 34 AMA Archives, Appendix on Foreign Medical Schools, 3, in Choice of Medical School, published by the AMA in 1952. The two councils mentioned were the Executive Council of the Association of American Medical Colleges and the Council on Medical Education and Hospitals. 35 AMA Archives, Minutes of the Meeting of the Committee on Foreign Medical Credentials, vol. 1, appendix F (25 April 1952), 11–12. 36 AMA Archives, “Medical Schools in Eire” Business Meeting of the Council on Medical Education and Hospitals, 6–7 June 1952, 32. 37 “Statement by Dr Tierney,” Irish Independent, 30 November 1953, 9. 38 “Not the Primary Object of Medical Schools to Equip Doctors for America,” Irish Times, 3 December 1953. 39 “Editorial: Irish Medicine,” Irish Times, 30 November 1953. 40 “Medical Schools Await Visit No. 2,” Irish Times, 1 December 1953. 41 NAD, Office of the Taoiseach, file S 13258B, “University College Cork: Financial Assistance,” letter 10 Mean Fomhar (September 1956). It refers to de Valera’s phone communication of “July last.” 42 NAD, Office of the Taoiseach, de Valera to the taoiseach, John Costello, 7 November 1955 (original in file S 14402B). 43 AMA Archives, Minutes of the Council on Medical Education and Hospitals of 22–4 June 1950. J.W. Bigger represented Ireland on the General Medical Council, 1936–41. He was professor of bacteriology at Trinity College, Dublin. 44 AMA Archives, Tierney to Donald Anderson, 13 September 1950. Copy in NAD, Office of the Taoiseach, file S 14402, annex B. The existence of a federal Ireland might have come as a shock to the Republic of Ireland’s citizens, given that legislation enacted in 1949 finally severed any remaining – and largely symbolic – connections with the United Kingdom.

116 Greta Jones 45 AMA Archives, Minutes of the Meeting of the Committee on Foreign Medical Credentials, vol. 1 (25 April 1952), 8. 46 AMA Archives, Minutes of the Meeting of the Council on Medical Education and Hospitals, 28–30 November 1953, appendix H, “Reports on Medical Education in Ireland,” letter, James M. O’Donovan, dean of the Medical Faculty of Cork, 3 October 1953. 47 NAD, Office of the Taoiseach, file S 14402B, annex C, “Present Condition of Medical Education in the Republic of Ireland,” 1. Report attached to a letter from the Irish Universities (Medical) Club of Chicago to the consul of the Republic of Ireland, November 1952. 48 “Alleged Abuses in Medical Schools, UCD President’s Denial,” Irish Times, 20 December 1952. See also Alfred O’Rahilly, “Attack on Irish Medical Schools ‘Unjustified,’” Irish Times, 22 December 1952. 49 “Doctors Repudiate Document,” Irish Independent, 3 January 1953. 50 “Irish Doctors in America,” Western People, 23 May 1953. 51 “US Medical Club Replies to Dr Tierney,” Irish Times, 25 June 1953. 52 NAD, Office of the Taoiseach, file S 14402B, “TVC” to Mr Fay, accompanying Memorandum on the History of AMA and Irish Medical Schools,” 30 May 1953. 53 “Irish Doctors in America.” 54 Eight signatories to the Chicago letter – excluding those who signed both letters – whose age can be found, were in their twenties. Twelve new signatories to the New York letter who can be detected were all aged between twenty-six and thirty-six. 55 These have been traced where possible using the AMA Directories and the American Directory of Medical Specialists, which give dates of first licensure. 56 NAD, Office of the Taoiseach, file S 14402B, annex C, “Present Condition of Medical Education in the Republic of Ireland,” 1, Irish Universities Medical Club of Chicago to the consul of the Republic of Ireland, November 1952. 57 Ibid., 2. 58 Trinity was largely Protestant and, officially, at this time Catholics were banned by the Roman Catholic archbishop of Dublin. The College of Surgeons was a non-denominational school that was also not looked upon favourably by those close to the Catholic Church, like Michael Tierney and Alfred O’Rahilly. See J.A. Gaughan, Alfred O’Rahilly, vol. 3, “Controversialist,” part 2: Catholic Apologist (Dublin: Kingdom Books, 1993), 174–88. 59 “Editorial: Licensure of Foreign-Trained Physicians,” JAMA 146 (26 May 1951): 377–8. They reported that in 1950, fourteen states and the National Board of Examiners had accepted the list.

“A mysterious discrimination”  117  60 “Medical Education in the US and Canada,” JAMA 161 (25 August 1956): 1637–8, 1661. The pass rate for graduates from approved schools was, however, higher than for graduates from unapproved schools – 68 per cent of all entrants from the approved list, as opposed to 46 per cent from the unapproved schools. 61 AMA Archives, Minutes of the Council on Medical Education and Hospitals, 25 March 1949. 62 According to calculations made by the AMA, 7.3 per cent of residents and fellows in 1950–1 and 11.6 per cent of interns were foreign-born non-citizens. In 1952–5, the percentage among interns had risen to 19.4. These were not spread evenly over the states. In New Jersey, it was 64 per cent compared with 3.5 per cent in Maine. W.S. Wiggins, “Report of the Conference on Foreign Medical Schools Held in Washington 30 April 1954,” AMA Archives, Minutes of the Meeting of the Council on Medical Education and Hospitals, 17–19 June 1954, appendix L. 63 “Approved Internships and Residencies,” JAMA 171 (10 October 1959): 151–63, figure 2. 64 Both Dr Manlove and Dr Blauch raised this issue at the meeting of the Committee on Foreign Credentials, AMA Archives, vol. 1 (25 April 1952), appendix F. 65 The number taking this exam was around 1,000 in 1958, and over 2,000 applications had been received to enrol for the exam by February 1959. See T. Stewart “Foreign Medical Graduates,” JAMA 169 (28 March 1959): 1513. 66 “The Report of the Committee to Consider the Future Numbers of Medical Practitioners and the Appropriate Intake of Medical Students in Britain,” chair, Henry Willink (London: HMSO, 1957). 67 Reform took place ad hoc. For example, negotiation between the NUI and St Vincent’s and the Mater Hospitals had led to the establishment of a number of professors nominated by NUI who were then confirmed as hospital appointments. A cache of beds for teaching were reserved for them. TCD and the RCSI had also made individual arrangements with hospitals of a similar nature. 68 Commission on Higher Education 1960–7, 260. 69 Ibid., 263. 70 NAD, Taoiseach’s Office, file S 4611, Admission of Austrian Nationals.

5 A System of Exclusion: New Zealand Women Medical Specialists in International Medical Networks, 1945–1975 john armstrong

During the two to three decades that followed the Second World War, approximately three-quarters of all New Zealand doctors, and up to 90 per cent of New Zealand medical specialists, spent a period of years at the start of their careers living and working overseas for the purposes of obtaining postgraduate experience and qualifications.1 The main impetus for this mass migration was New Zealand’s small domestic population, which was unable to provide the volume of “clinical material” needed to sustain specialist training programs, or to provide the volume of experience that trainees needed to attain competency.2 In the 1950s and 1960s, overseas travel was practically obligatory for the growing number of New Zealand doctors aspiring to specialty status. Sources suggest that by the mid-1960s, more than a fifth of New Zealand’s entire active medical workforce and more than one-third of its hospital-based practitioners were working overseas, mostly in postgraduate training positions, at any given time.3 During this period, the vast majority of New Zealand’s medical migrants travelled to Britain.4 Paradoxically, Britain’s status as the main venue for New Zealand postgraduate training derived largely from Britain’s poorly developed postgraduate training infrastructure. Mainly as the result of the British medical establishment’s longstanding suspicion of specialized medicine, almost all specialist t­ raining was delivered on an informal, ad hoc basis “on the job,” rather than through any formal training programs.5 Obtaining specialized training was therefore much less competitive than it was in Continental Europe or the United States, and New Zealand doctors had only to secure an appointment in a British hospital to commence specialized training. As Laurence Monnais and David Wright point out in their introduction

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to this volume, the exodus of British-born doctors from the National Health Service to the United States, Canada, and Australia after 1948 ensured that many such opportunities were available. Some New Zealand doctors pursued jobs in London, attracted by that city’s status as the most populous city in the world, and by the specialized hospitals that provided both unrivalled learning opportunities and valuable professional prestige. Many others sought training experiences in the specialty departments of English and Scottish provincial hospitals, which sometimes offered a greater range of opportunities to obtain “handson” experience than did the large London institutions, even if the associated prestige was less. The migrations of New Zealand’s trainee specialists were underpinned by the many cultural, familial, and professional structures that connected New Zealand and British societies, which in turn derived from New Zealand’s status as a former British colony. In the field of professional medicine, the migrations of New Zealand doctors to Britain were enabled by the mutual recognition of undergraduate medical qualifications, and – as John Weaver discusses in his contribution to this book – by an organizational infrastructure that was dominated by British medical institutions, such as the royal colleges and the British Medical Association. However, perhaps the most important mechanism underpinning this international medical migration was a strong and largely self-perpetuating system of informal interpersonal relationships between New Zealand doctors and their British colleagues. New Zealand doctors routinely obtained the British jobs that they needed through guidance and contacts provided by their medical school lecturers and senior hospital colleagues, who had in turn often obtained their own training in British hospitals. Informal, interpersonal links played a key role in facilitating post–Second World War medical migration, and in promoting the careers of the vast majority of New Zealand specialist doctors active during this time. This chapter argues that these international connections, and particularly the network of informal professional relationships that underpinned medical migration after the Second World War, were also heavily gendered. As such, this network could also function as a mechanism for exclusion, or at least for heavily proscribed forms of inclusion. For women doctors and those of non-white ethnicity, the interaction of cultural norms, individual attitudes, professional structures, and employment opportunities could powerfully inhibit access to this network of informal relationships, and by extension, to participation in

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professional medicine.6 Through the use of recorded interviews, the analysis of twentieth-century New Zealand medical autobiographies, and the database analysis of New Zealand medical obituaries, this chapter examines the participation of New Zealand graduates in international networks of connection, but recognizes that the nature of that network – effectively an “old boys” club – represented a significant challenge for many of the New Zealand women who worked to forge careers as medical specialists in the years following the Second World War. Further, it will suggest that this gendering of medical migration may have been further shaped by the particular nature of training in various medical specialties. Prior to the establishment of New Zealand’s first medical school in 1875, all New Zealand doctors trained overseas, with the vast majority graduating from institutions in the British Isles.7 For the first eight years of its existence, the Otago Medical School was not licensed to provide a full course, and its students were obliged to complete the final years of their degrees overseas, usually in Britain, and often at Edinburgh.8 Even after Otago began to offer a complete medical curriculum in 1883, many of its students continued to leave part way through the course in pursuit of more prestigious British qualifications. Between 1883 and 1893, twenty-one Otago medical students remained in Dunedin to complete the course, while sixty-five left after one or two years in order to graduate in Britain.9 However, in the early decades of the twentieth century, the Otago Medical School established its credentials more firmly and began to retain most of its enrolees for the duration of the course. By the early 1920s, a majority of New Zealand’s medical practitioners were registered with a locally obtained qualification. Yet overseas migration remained an integral part of the New Zealand medical experience. In part, this was the result of growing emphasis on postgraduate medical training. Around the turn of the twentieth century, leading British medical figures began to suggest that a basic medical degree was no longer a sufficient basis upon which to found a life-long medical career, but needed to be continually augmented by informal reading and formal postgraduate courses. Although some New Zealand centres attempted to establish postgraduate training courses, their success was inhibited by the relatively small number of medical practitioners in any one place, and by the challenge of convincing doctors from rural areas or other centres to travel long distances to attend courses of uncertain worth. At a time when the growing status of the Otago Medical School’s degree was lowering the rate of undergraduate medical migration to Britain, the

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growing emphasis on postgraduate training, and New Zealand’s inability to provide it, meant that New Zealand doctors continued to visit Britain almost as a matter of course. As the introduction of this volume notes, the multi-directional flow of both undergraduate and postgraduate students between Britain and its colonies ensured the continuing exchange of professional traditions and practices. A critical moment in this shift from undergraduate to postgraduate migration came with the outbreak of the Second World War, during which at least one-third of all practising New Zealand doctors engaged in overseas military service.10 This large-scale migration of qualified doctors generated numerous contacts with British colleagues that, on many occasions, led to job opportunities in British hospitals after the conflict ended. The desire to make the most of these opportunities meant that New Zealand doctors usually made positive impressions on British medical colleagues and administrators, which in turn eased the way for subsequent New Zealand applicants. By the 1950s, New Zealand doctors had established networks of peer support in Britain that were to a large extent self-perpetuating. New Zealand doctors working in British hospitals helped other New Zealanders to find jobs, to secure accommodation, and to study for the notoriously difficult examinations of Britain’s various royal colleges of medicine and surgery. New Zealand doctors gave each other invaluable social support, and their spouses looked after each other’s children. In addition, those doctors who returned to New Zealand as specialists provided a vital link for the following “generation” of graduates seeking to travel to Britain. Veterans of the British experience were able to offer promising New Zealand graduates advice about the practicalities of the migration experience, to provide personal introductions to prominent British practitioners, and on some occasions, to organize them jobs even before they left New Zealand. In many ways, informal relationships were the key to accessing the world of specialized medicine.11 However, not all young graduates who began their careers in the years following the Second World War enjoyed the benefits of collegial support, or at least, not to the same degree. Support networks took time to establish, with the result that some New Zealand graduates who chose to pursue careers in emerging specialty fields remembered doing so with very little help, informal or otherwise. Other doctors recalled being denied networking opportunities because of personality differences with senior practitioners, or because of an unwillingness to conform to the unwritten rules of deference that sometimes characterized

122  John Armstrong

professional medical relationships. Some New Zealand doctors attributed their failure to obtain beneficial sponsorship to their social backgrounds, and in particular, to a lack of any pre-existing familial links to the medical profession. However, for many doctors, a key reason for their inability to access professional medical networks was their failure to conform to the medical profession’s traditional ethnic and gender demographics. In the context of the post–Second World War British Commonwealth, the “ideal” medical practitioner was indisputably white, heterosexual, middle class, and male. Such doctors dominated the profession in numerical terms and held a virtual monopoly on leadership positions. Until at least the 1970s, medical journals and texts used masculine personal pronouns by default. Numerous studies have illustrated the ways in which medical education and medical socialisation have reflected and reinforced Eurocentric and masculine norms, ideals, and knowledges in the medical profession.12 This had profound ramifications for the participation of women in professional networks, in overseas migration, and, by extension, in specialized medicine. Women in Medicine To a large extent, the entry of New Zealand women into professional medicine during the late nineteenth century followed a path already laid by campaigners in Britain. Legislative precedents had been set, and philosophical and moral debates had already been conducted and largely won.13 There was little professional objection to the granting of medical degrees to women in New Zealand, and at no time had Otago University placed limits on the number of women enrolling in medicine.14 Between 1893, when Eliza Frikart became New Zealand’s first registered woman doctor, and 1919, fifty-three women registered to practise medicine in New Zealand. As in Britain, the First World War led to a significant increase in the number of women practitioners. Between 1920 and 1929, eighty more women registered as doctors in New Zealand.15 Women’s participation then increased rapidly during the 1960 and 1970s, lifted on the rising tide of second-wave feminism. Between 1961 and 1983, the number of women enrolling in ­British medical schools increased by 250 per cent, compared to a 50 per cent increase for men. By 1983, about 38 per cent of Britain’s medical graduates were women.16 Similar changes occurred in New Zealand. In just fifteen years from 1974, the proportion of women among

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New Zealand’s medical graduates increased from less than 15 per cent to approximately half.17 As early as 1948, the British Medical Women’s Federation had felt able to comment that they were “relatively content” with the position of women doctors.18 By the late 1980s, the achievement of numerical parity in both British and New Zealand medical schools looked like a watershed for women’s participation in the medical profession. However, achieving numerical parity in medical schools was not the same thing as achieving professional equality. Gaining a basic qualification in medicine was only the first of many steps required to establish a successful career. For many women doctors, the sternest professional challenges appeared only after they had graduated.19 There is no doubt that medical school was a difficult experience for many women. For almost a century after the first women entered Britain’s medical schools, students both there and in New Zealand faced discriminatory selection, segregated lectures, exclusion from extracurricular social events, and treatment from lecturers and fellow students that could only be described as harassment.20 However, such experiences were not universal. Dr Frances Preston recalled that while some of the Otago Medical School’s lecturers regarded women with disapproval or at best “tolerance,” others were very encouraging of women students.21 Caroline Stenhouse, an ophthalmologist who graduated from Otago in 1923, recalled that “as students, [women] were simply accepted as part of the student body, and those of us who showed signs of exceptional brilliance … received just as much encouragement and help as their male counterparts.”22 Professor Barbara Heslop also felt no strong sense of discrimination at the Otago Medical School during her attendance there in the early 1940s, although she recalled that “things were said which could hurt if you let them hurt.”23 All of these women, and many others, faced far greater difficulties after leaving medical school. Dr Frances Preston noted that although most women students worked very hard at medical school, and some excelled, all were aware that “opportunities for advancement” were rare for New Zealand women after graduation. Preston struggled to obtain even a basic house-officer job, because hospital boards claimed to be unable to provide suitable accommodation for a woman doctor.24 Dr Alice Bush was declined a house officer position at Auckland hospital in 1937 for the same reason, despite her quite exceptional academic credentials. Bush had passed the primary examination of the Royal College of Surgeons during her second year at medical school

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and was described by Auckland Hospital’s superintendent as “probably the most brilliant student we have had at the hospital” during her sixth-year placement. Bush eventually secured a position at Auckland Hospital after a family friend and hospital board member arranged for her to stay in a family home nearby.25 Dr Caroline Stenhouse’s recollection of life after medical school could hardly have been more different in tone from her positive memories of undergraduate life at Otago. She remembered that “after we graduated, the medical school washed its hands of us. We were thrown out into a cold, hard post-war world equipped with a medical education that was largely theoretical, since little opportunity had been given us for practical work.”26 Dr Barbara Heslop did manage to secure a junior hospital position after graduating, but she also recalled feeling excluded by her male peers. On one occasion, she discovered that her colleagues had intentionally excluded her from a journal club they had established. When confronted, they claimed that their wives were uncomfortable with them associating with a woman colleague after hours.27 Dr Eleanor McLaglan faced overt discrimination when a hospital superintendent admitted to rescinding her house officer appointment solely because of her gender.28 Dr Doris Gordon recounted one occasion in which a woman house surgeon had lost her hospital appointment after feeling obliged to claim responsibility for a surgical error that had in fact been made by a male colleague.29 Even after women began to enter medicine in greater numbers from the late 1960s, professional success remained elusive. New Zealand’s medical leadership, for example, remained exclusively male. In 1973, the New Zealand Department of Health’s four divisional heads and its eighteen senior medical officers of health were all men. Every member of the New Zealand Medical Council and the Medical Research Council was a man, as were all office-holders in the Medical Association of New Zealand and its various subcommittees. Men occupied all fifty-two of the Otago Medical School’s professorial or associate professorial chairs, the presidencies of every specialist association, and all of the “dominion head” positions within every British Royal College. The medical superintendent of every major New Zealand hospital was a man.30 “Women’s Specialties” Women also struggled to achieve the other widely accepted marker of success in professional medicine: specialist status. Of the 100 obituaries of women doctors published in the New Zealand Medical Journal between

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1939 and 2008, 32 described their subjects as specialists, compared to 41 per cent of the 714 obituaries of male doctors analysed for this chapter. In 1976, women comprised about 14 per cent of New Zealand’s medical workforce, but only 5 per cent of its registered specialists.31 Eight years later, the proportion of women in the medical workforce increased to almost 20 per cent, but the proportion of women among New Zealand’s registered specialists remained disproportionately low, at just under 10 per cent.32 These low figures translated into an even greater paucity of women in the upper ranks of specialized medicine. In 1971, about a quarter of New Zealand’s medical specialists were recognized as senior practitioners by virtue of their placement on the “additional steps” salary grade. All of these were men.33 By 1976, just three of the fifty-six registered women specialists (5 per cent) were on the additional steps, compared to 325 (or over 30 per cent) of the 1,056 male specialists. In 1984, women made up just over 10 per cent of New Zealand’s medical specialists, but less than 1 per cent of its recognized senior specialists.34 In addition to their overall underrepresentation in specialized medicine and their relative absence from the upper ranks of specialized medicine, women also appeared to be restricted in the particular specialty areas in which they practised.35 The attitudes, discourses, and structures that characterised professional medicine seemed to generate not only a “glass ceiling” that curtailed vertical movement into senior clinical or leadership roles, but “glass walls” that limited horizontal movement into particular specialties. The concentration of women in specialties such as obstetrics, “child health,” and “family medicine” (general practice) was often explained by the supposed “natural inclination” of women to care for other women and for children.36 During the first half of the twentieth century, a handful of other specialties also emerged as important areas for New Zealand women, which included psychiatry, geriatrics, anaesthetics, radiology, and public health.37 To a degree, the concentration of women doctors in these specialties reflected their low statuses relative to more prestigious or lucrative fields, which made them unattractive to many male doctors and thereby provided women with greater opportunities.38 Elsewhere in this volume, Joanna Bornat, Parvati Raghuram, and Leroi Henry note a similar gathering of South Asian doctors in geriatrics in Britain’s NHS. Jobs in government medical services were also available to women largely by default. “State medicine,” as it was sometimes derisively called, was held in low esteem by a profession that had long treasured its autonomy and resisted the involvement of third parties in the doctor–patient relationship.39

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Studies of medical schools and workplaces have shown that overt discrimination and discouragement from male colleagues also had a role to play in influencing the career decisions of women doctors. Demeaning jokes, insults, and disrespectful communications sometimes discouraged women from pursuing specialties that men considered to be their domain.40 Some male doctors refused to engage women students or colleagues in conversation or in informal learning experiences.41 Overall, however, those studies suggest that overt discrimination was relatively rare in the medical profession.42 Much of the literature on women’s participation in medicine foregrounds women’s agency as the main determining factor in their career trajectories.43 However, the conviction that women’s lives were shaped primarily by their own actions has also been used to assert that women must also be “responsible for their own lack of progress” in professional medicine.44 A typical manifestation of this idea appeared in a 1973 New Zealand Medical Journal editorial, which argued that the lack of women in leadership positions in New Zealand was probably due to women’s tendency to be “deflected into a different destiny, that of children,” rather than to any “intrinsic bar to the top,” the existence of which was explicitly denied.45 Three years later, and in a similar vein, the New Zealand Medical Council wrote that women’s underrepresentation in specialized medicine was due to the fact that “most women in medicine have in the past adopted a passive approach towards their professional careers. About half of those who marry, marry doctors, and in most instances the husband’s career comes first. Many opt out completely for long periods in favour of family responsibilities, and have difficulty in finding the confidence to return to even relatively undemanding medical work. Few fulfil their early academic potential, few hold top professional or administrative posts, and few play an active role in professional colleges and specialist societies.”46 This passage, and many others like it, paints a bleak picture of the ability, determination, and initiative of medical women. It also paints a misleading picture, to the extent that it overlooks the influence of external factors and structures in shaping – and usually limiting – the choices that were available to women doctors.47 Professional Networks, Migration, and Specialization Most research into the participation of New Zealand women in specialized medicine in the twentieth century highlights the prevalence of full-time training programs and the challenges that this presented to

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women with families as the most significant factors in both the participation and distribution of women in specialized medicine. However, medical migration and the networks that sustain them have never been considered as factors in the careers of New Zealand women specialists active during the latter half of the twentieth century. A 1978 New Zealand Department of Health report into the factors that shaped women’s participation in medicine, for example, discussed in detail the restrictive effects of full-time training regimes without once acknowledging that, for much of the previous thirty years, most of that training had been delivered in British hospitals.48 Given the critical importance of overseas training to the careers of New Zealand specialists during this period, this is a significant oversight. Research carried out for the thesis from which this chapter is drawn suggests not only a relationship between the overall migration rates of men and women doctors and their relative rates of specialization, but a possible correlation between migration patterns and the particular medical specialties that women doctors worked in after the Second World War. Overall, migration rates were lower among New Zealand women doctors than they were among their male colleagues. The analysis of post-war New Zealand medical obituaries suggests that just over threequarters of New Zealand–born male doctors, and just over 90 per cent of male specialists spent some time training overseas. In comparison, just over 50 per cent of women doctors’ obituaries included references to medical migration, while fewer than three-quarters of women specialists migrated. While there is no doubt that this difference reflected the preferences and aspirations of women doctors, it is again necessary to consider those preferences in the context of the professional conventions, structures, and expectations within which they were formed. For aspiring specialists, one key structure was the network of interpersonal relationships that underpinned both the network of postgraduate migrations that facilitated their training and their subsequent careers. One consequence of systems of mentorship is that they tend to replicate and preserve the ethnic, gender, and class make-up of the groups in which they operate.49 The American sociologist Judith Lorber has argued that within the male-dominated medical profession, this replication is often motivated by a desire to foster a culture of shared beliefs, values, vernacular language, jokes, and ultimately, behaviours, which together form the basis of workplace trust and collegiality.50 The tendency of medical mentors to select mentees similar to themselves contributed to the perpetuation of associated professional patterns.51

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The extreme scarcity of women surgeons, for example, meant that very few women mentors were available to encourage later generations of women into that area of work. The particular avenues through which junior doctors formed congenial relationships with their seniors also reflected masculine norms and behaviours. Knowledge and ability in sport is one example. Caroline Dyhouse notes that during the interwar period, senior consultants in some of London’s major teaching hospitals resisted the entry of women students out of fear that they would compromise their institutions’ sporting traditions.52 Michael Belgrave has argued that for New Zealand doctors, sporting prowess was “as much a mark of personal distinction as social service, and [was] often regarded as a complement to professional acclaim.”53 Sociologist Haida Lukes found evidence for this among junior Australian doctors, several of whom suggested that being able to display a knowledge of sports such as cricket and rugby was an important skill when “catering” to senior doctors.54 Rosemary Pringle’s study of British and Australian women doctors also found that some struggled to form friendly relationships with senior consultants because they lacked sufficient interest in sport to engage in such conversations, while those who did have knowledge still tended to be excluded.55 Similar issues seemed to arise around alcohol consumption. New Zealand pathologist Barbara Heslop remembered that, although women attendees at medical conferences and society meetings were officially invited to dinners and other social occasions during the 1960s, they were often “taken aside” and informally asked to refrain from attending. Heslop speculated that this was due to a heavy drinking culture among male New Zealand doctors, and to their desire to socialize in this way without the “stifling” presence of women colleagues.56 Some of Rosemary Pringle’s interviewees also remembered that male consultants were generally unwilling to invite women juniors out for a social drink.57 Although this probably reflected current social mores as much as professional discrimination, the effect was the same: women doctors found it much harder to establish the friendly relationships that were critical to entering into and succeeding within the international postgraduate network.58 “Demographic” and “Organ” Specialties The masculine nature of informal medical networking almost certainly contributed to the lower rates of migration among medical women,

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cited above, and by extension, to a slightly lower overall rate of specialization among women doctors (about 30 per cent) compared to men (about 40 per cent). Women doctors who were excluded from social interactions and who struggled to form friendly relationships with senior colleagues were clearly at a disadvantage when it came to obtaining contacts in British hospitals, and by extension, specialized training. However, this chapter posits that the particular distribution of women doctors among the specialties might also be attributable in part to postgraduate migration systems, and in particular to the differing importance of postgraduate migration for trainees in the medical and surgical specialties. The importance of “hands on” experience in training differed from specialty to specialty, which meant that, in the New Zealand context at least, the need to access large populations, and therefore to migrate, also differed. It may be useful in this regard to consider medical specialties in two broad categories, which for the purposes of this discussion will be called “demographic” and “organ” specialties.59 The differentiation is not intended to be absolute, but might instead be viewed as a way of characterizing two halves of a conceptual spectrum. On one side are the demographic specialties, which deal with conditions associated with particular demographic groups or life stages, such as children (paediatrics), pregnant women (obstetrics), and the elderly (geriatric medicine), or with medical techniques that are broadly applicable across a range of conditions, such as anaesthetics and the diagnostic specialties of radiology and pathology. The broad range of conditions that general practitioners deal with also places them within this category. Organ specialties, on the other hand, deal with particular conditions and illnesses in particular parts of the body, or involve provision of specific medical or surgical techniques. On the basis of this definition, organ specialties include ophthalmology (eyes), otolaryngology (ear, nose, and throat), and the vast majority of surgical specialties, including urology, orthopaedics, gynaecology, and reconstructive surgery. Specialties such as gynaecology and urology would probably sit somewhere near the middle of this spectrum, as they relate to particular bodily systems, but also involve a high quantum of work with patients at particular life stages. Psychiatry could similarly be placed in either category. The crucial difference between these two broad categories of medical specialty is that the absence of large clinical populations was less limiting for trainees in demographic specialties than it was for doctors aspiring to one of the organ specialties. Because young, pregnant,

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and elderly people make up a significant proportion of any healthy population, even a sparsely populated country like New Zealand was able to provide sufficient “clinical material” to facilitate the necessary experience in trainee practitioners. Similarly, the broad applicability of anaesthetics, radiology, and pathology allowed training in these areas to occur in any reasonably sophisticated hospital. By contrast, having access to a large population was imperative in the training of specialists in areas such as ophthalmology and otolaryngology, where obtaining and maintaining the necessary technical skills, particularly in rarer conditions and procedures, was almost impossible in the context of New Zealand’s small populations. Acquiring technical skill through repetition was particularly important in surgical disciplines, where manual dexterity and “feel” could be achieved – quite literally – only through “hands-on” practice. For surgeons in small population centres, obtaining the necessary “feel” was difficult to acquire without migrating.60 The differentiation of specialties in this way is the result of an observation, derived from the database analysis of 880 New Zealand medical obituaries, that the rate of postgraduate migration was much higher among practitioners of the “organ” specialties than it was among those doctors who worked in “demographic” specialties. Column 2 of table 5.1 enumerates the proportion of specialists in each field whose obituaries contained references to overseas postgraduate migration. It is particularly interesting to note what appears to be a strong inverse relationship between the migration rates associated with the specialties and the corresponding gender participation rates. The specialties with the highest proportion of women practitioners tended to be those with the lowest rates of migration. Invariably, these fall into the category of “demographic” specialties. Column 3 of table 5.1 gives the average participation rates of women practitioners in specialties between 1967 and 1983. The two most obvious anomalies in the overall pattern are obstetrics and gynaecology (O&G), and internal medicine. In contrast to the overall trend, O&G had a high associated migration rate and a relatively high proportion of women practitioners, while internal medicine had relatively low migration rates and few women practitioners. In the case of O&G, this anomaly is almost certainly due to the failure of the manpower surveys that provide these figures to differentiate between “pure” obstetricians, many of whom were women, and obstetrician/gynaecologists, whose work contained a greater surgical load and whose practitioners were more often men.61 All of the twenty-three doctors described as obstetrician/gynaecologists or

A System of Exclusion  131  Table 5.1.  Rates of Migration and Gender Participation by Specialty Specialty

Rates of postgraduate migration in New Zealand Medical obituaries, 1939–2008 (%)

Average % women practitioners, 1967, 1975, and 1983 combined

Paediatric medicine Anaesthetics Psychiatry Obstetrics & gynaecology Pathology General practice Radiology Ophthalmology* Dermatology* Internal medicine* Otolaryngology* Surgery**

86 76 71 95 79 68 85 100 100 84 100 94

25 24 19 16 12 10 7 7 6.5 5 1.6 0.5

* Organ specialty ** This figure combines the migration rates for general surgeons, orthopaedic surgeons, and urologists, as does the corresponding category in the gender participation rates. Sources: The Employment of Medical Practitioners in New Zealand: A Report on the 1967 Questionnaire Survey of the Medical Council of New Zealand (Wellington: Medical Council of New Zealand, 1968), 20–1; Medical Manpower in New Zealand: Report of a Planning Workshop Held at Wairakei, 19–23 April 1976 (Wellington: Division of Hospitals, 1976), 40, 49–67; and Health Manpower Resources, 1983 Data (Wellington: Department of Health, 1983), tables 19.7–20.2, 60–77.

“pure” gynaecologists in their obituaries were men. In comparison, four out of the eleven “pure” obstetricians were women. When calculations are adjusted to acknowledge this difference, the respective migration rates correlate much more closely with the trends observable in column 3: 80 per cent of the doctors who specialized in obstetrics alone travelled overseas, compared to 96 per cent of those whose work included a gynaecological element. The other slightly anomalous finding, in internal medicine, is probably explained by the fact that by the early 1980s, between 14 and 18 per cent of New Zealand specialist geriatricians – who were included in the “internal medicine” category in manpower surveys – were women.62 If this specialty is treated separately, the rate of migration among the database’s remaining physicians rises to almost 90 per cent. With these clarifications in mind, the figures in table 5.1 seem to demonstrate clear relationships among the three variables under

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consideration: the differences among demographic and organ specialties, overseas migration rates, and women’s participation rates. Particular features of post–Second World War international medical networks, outlined earlier in this chapter, provide plausible explanations of the relationships among those variables. First, I have suggested that the difficulties that women faced in entering informal professional networks may have limited their ability to facilitate overseas migrations, and therefore to specialize. Second, as discussed above, I contend that the differing importance of large population centres in specialized training contributed to different migration rates among the practitioners of demographic and organ specialties. Finally, I suggest that the relationship between the remaining pair of variables can be derived logically from these first two arguments. Women may have gravitated towards the demographic specialties because they were, in general, less able to access the interpersonal networks that facilitated the migrations that were a critical part of beginning a career in an organ specialty. This is not to discount the possibility that women doctors may have simply preferred not to travel overseas. However, for those New Zealand women who chose to remain in New Zealand but still aspired to specialist status, the range of specialties to choose from would have been significantly narrower than for their migrant colleagues. The interaction of these variables does not necessarily provide a completely explanatory framework for the specialty choices of all women doctors. Similar patterns of distribution among the specialties could be found among British women doctors, for example, who of course had no need to migrate. These shared patterns can be attributed largely to other factors common to both jurisdictions, such as medical economics. Regardless of where they were practised, demographic specialties tended to be less prestigious and less remunerative than the organ specialties. Surgical specialties in particular were often more profitable than non-surgical ones because private patients were more willing to pay for tangible and observable “procedures” than for courses of medicine that were often slow to produce results. As a result, training positions in less lucrative demographic specialties tended to be less competitive, and therefore more accessible to women.63 Yet the contention that the careers of women doctors in New Zealand and Britain could be limited by the same factors is, in many ways, the central argument of this chapter. International networks did not only facilitate the movement of doctors between New Zealand and Britain, but also transmitted attitudes, discriminatory practices, and restrictive

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professional conventions. Because certain British institutions functioned as hubs for their respective specialties both domestically and for the Commonwealth as a whole, it is plausible to view the difficulties that New Zealand women faced getting access to the jobs that they needed to obtain specialist experience as long-distance versions of the very same challenges that British women faced. All of these women needed access to the same British institutions if they were to become specialists, but all struggled to access and negotiate the interpersonal networks that enabled that access. Together, these shared challenges contributed to the decision-making contexts of both women in Britain and in New Zealand. Conclusion Despite their position on opposite sides of the planet, the New Zealand and British medical establishments were in many ways parts of a single system. Understanding the history of New Zealand medicine therefore demands the adoption of an international frame of reference. It also demands acknowledgment of the complexity and variation of international systems of exchange. In 2007, Sasha Mullally and David Wright called for historians of medical migration to augment their analysis of macro-data, broad trends, and policy documents with investigations of the subjective experiences of physicians, through techniques such as oral history interviewing and analysis of life writing. Several chapters in this book demonstrate the value of this approach. The present chapter suggests that such investigations into the experiences of practitioners provide not only can provide invaluable insights into the important and relatively unstudied informal relationships and mechanisms that underpinned “medical” migration in the broadest sense, but may also provide insights into the structures and history of specialties within the broader medical profession. For professional medicine, the twentieth century was the century of specialization. For some observers, this development was viewed as fragmentation, characterized by a shift towards increasingly focused areas of practice and professional isolation. To paraphrase one doctor interviewed for this study, specialization made it increasingly difficult to “talk to the bloke in the next office” about the specifics of day-today patient management across specialties.64 However, it is clear that this same process was also responsible for the creation of professional links. Specialization did not diminish the need for peer support, and

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in order to generate it, specialists and sub-specialists often had little choice but to look to practitioners doing similar work in other institutions, regions, or even countries. Specialists organized meetings and conferences, initiated international research programs, established international journals, and formed supra-national societies, which, like the disease-control initiatives discussed in the introduction to this volume, often spanned several national jurisdictions. In short, specialists travelled. This chapter has considered one aspect of twentieth-century specialized medical migration, in a limited geographical context. Further studies in other jurisdictions will provide further insights into the experience of medical migrants, the history of specialties, and the process of specialization itself. Notes 1 This chapter is drawn from my PhD thesis, “The Common-Health and Beyond: New Zealand Trainee Specialists in International Medical Networks, 1945–1975.” I gratefully acknowledge the assistance and mentoring of my PhD research supervisors at the University of Waikato, Professor Catharine Coleborne, Dr Rosalind McClean, and Dr James Beattie. I would also like to thank Professor David Wright at McGill University and Professor Laurence Monnais at the University of Montreal for facilitating my involvement in the 2012 “Twentieth Century Physician Migration” workshop in Montreal. The figures quoted here come from the database analysis, conducted as part of this thesis research, of 770 obituaries published in the New Zealand Medical Journal between 1939 and 2008. Of the 597 obituaries of doctors born in New Zealand, 447, or 74.8 per cent, either mentioned a specific overseas training program or cited a postgraduate qualification that could be obtained only overseas. Of the 246 obituaries of New Zealand–born doctors identified as specialists, 219, or 89 per cent, mentioned overseas migration. The full thesis is available online at http://researchcommons.waikato.ac.nz/handle/10289/7848. 2 During the 1960s, New Zealand’s domestic population grew from 2.3 million to 2.8 million. 3 In March 1969, the New Zealand Medical Register listed 4,435 doctors, of whom only 3,400 were described as active within New Zealand. The difference was accounted for in a “medical manpower” survey the following year, which reported that 990 New Zealand graduates were working overseas. See “Staffing,” Appendices to the Journal of the New Zealand

A System of Exclusion  135  House of Representatives, vol. 4, section H-31, 58, and “The Government’s Answer,” New Zealand Medical Journal 69 (December 1970): 405–6. 4 Of the 307 obituaries that included a reference to the destination of their subject’s postgraduate migration, 287, or more than 93 per cent, specified England and/or Scotland. 5 For discussions on the development of medical specialization in Britain, see George Weisz, Divide and Conquer: A Comparative History of Medical Specialization (New York: Oxford University Press, 2006); Weisz, “Medical Directories and Medical Specialization in France, Britain, and the United States,” Bulletin of the History of Medicine 71, no. 1 (March 1997): 23–68; Weisz, “The Emergence of Medical Specialisation in the Nineteenth Century,” Bulletin of the History of Medicine 77, no. 3 (2003): 536–75; Lindsay Granshaw, “Fame and Fortune by Means of Bricks and Mortar: The Medical Profession and Specialist Hospitals in Britain, 1800–1948,” in The Hospital in History, ed. Lindsay Granshaw and Roy Porter (London: Routledge, 1989), 199–220; and Christopher Lawrence, “Incommunicable Knowledge: Science, Technology and the Clinical Art in Britain 1850– 1914,” Journal of Contemporary History 20, no. 4 (October 1985): 503–20. 6 I recognize that the term women doctors, used throughout this chapter, carries an implication that the normative term doctor is therefore masculine. In the context of this chapter, however, the distinction is necessary, and to a degree also recognizes the unequal challenges that the chapter describes. 7 The most comprehensive discussion on the origins of New Zealand’s medical profession can be found in Michael Belgrave, “‘Medical Men’ and ‘Lady Doctors’: The Making of a New Zealand Medical Profession, 1857–1941” (PhD diss., Victoria University of Wellington, New Zealand, 1985). 8 Rex Wright-St Clair, A History of the New Zealand Medical Association: The First 100 years (Wellington, NZ: Butterworths, 1987), 34. 9 See Dorothy Page, Anatomy of a Medical School: A History of Medicine at the University of Otago, 1875–2000 (Dunedin: Otago University Press, 2008), 478; and R.G. Robinson, “The Otago Medical School, 1875–1975,” British Medical Journal 1, no. 5954 (15 February 1975): 379. 10 For different reasons, the outbreak of the First World War was also significant in the development of medical specialization, and the migration patterns of New Zealand doctors. My thesis discusses these developments in detail. 11 Qualitative information on the workings of this medical network have been gleaned from medical biographies and obituaries, selected medical

136  John Armstrong journal content, oral history interviews, reports of overseas study trips, and a long series of semi-formal guides for prospective migrants, published by the Otago Medical School during the study period. A collection of more than three hundred letters written by a New Zealand medical graduate, Dr Colin Fenton, back to his parents during his six years in Britain in the mid- to late 1950s has been of particular value. These letters have provided invaluable insights into the experiences of New Zealand medical graduates overseas. I thank Dr Fenton for his generosity in lending his collection to me. 12 For a useful discussion of the “maleness” of medicine, see Patricia Gerald Bourne and Norma Juliet Wikler, “Commitment and the Cultural Mandate: Women in Medicine,” Social Problems 25, no. 4 (April 1978): 430–40, and particularly the open section. Although the article examines medicine in the United States in particular, its insights are applicable to other Western jurisdictions. See also Agnes Miles, Women, Health and Medicine (Milton Keynes: Open University Press, 1991); and Rosemary Pringle, Sex and Medicine: Gender, Power, and Authority in the Medical Profession (Cambridge: Cambridge University Press, 1998). 13 Michael Belgrave, “A Subtle Containment: Women in New Zealand Medicine, 1893–1941,” in Women Doctors in New Zealand: An Historical Perspective, 1921–1986, ed. Margaret D. Maxwell (Auckland: IMS, 1990), 204. 14 Barbara Heslop, “Women’s Suffrage Day Lecture, 1987,” in Women Doctors in New Zealand, 232. 15 Rex Wright-St Clair, “Women in New Zealand Medicine before 1930,” in Women Doctors in New Zealand, 180. 16 The number of women graduates more than tripled over this period, from 445 in 1961 to more than 1,300 in 1983. The proportion of women graduates increased from less than a quarter in 1961 to well over a third in 1983. See Mary Ann Elston, “Women Doctors in the British Health Services: A Sociological Study of their Careers and Opportunities” (PhD disss, University of Leeds, 1986), tables 4.2, 4.3, and 4.4, 105–7. 17 Department of Health, Health Manpower Resources, 1983 Data (Wellington: Department of Health, 1983), 57. 18 Report on Medical Women’s Federation Symposium, “Women Doctors in the British forces, 1914–1918 War,” Journal of the Medical Women’s Federation 49 (1967): 89, cited in Elston, “Women Doctors in the British Health Services,” 383. 19 See Jill McIlraith, “Introduction,” in The Goods Train Doctors: Stories of Women Doctors in New Zealand, 1920–1993, ed. Jill McIlraith (Dunedin: New Zealand Medical Women’s Association, 1994), 4–6.

A System of Exclusion  137  20 Examples of discrimination are discussed several times in McIlraith’s Goods Train Doctors. See in particular Susi Williams, “Sober Suits and Flat Heels – And Don’t Dare Be Pregnant,” 6–8. See also Belgrave, “Subtle Containment,” 206–7. 21 Frances I. Preston, Lady Doctor, Vintage Model (Wellington: A.H. & A.W. Reed, 1974), 12. 22 Maxwell, Women Doctors in New Zealand, 156–7. 23 Interview with Barbara Heslop, 16 February 2011. 24 Dr Preston was unequivocal in describing this as an “excuse.” Preston, Lady Doctor, 12. 25 Maxwell, Women Doctors in New Zealand, 105–6. 26 Ibid., 156–7. 27 Interview with Barbara Heslop. 28 Eleanor McLaglan, Stethoscope and Saddlebags (Auckland: Collins, 1965), 121–3. 29 Doris Gordon, Back Blocks Baby Doctor (London: Faber and Faber, 1960), 98–100. On another occasion, Gordon recalled watching an overconfident but under-qualified male junior surgeon face no repercussions after removing the wrong rib from a newborn baby. After the incident she recalled not wanting “to see another pair of trousers for the rest of the day.” Gordon, 90. 30 Barbara Heslop, “For Better or for Worse? Women Doctors at the End of the Decade,” in Women Doctors in New Zealand, 254. Originally published in New Zealand Medical Journal 100, no. 820 (25 March 1987): 176–9. 31 The New Zealand Specialist Register included 1,112 doctors in 1976, 56 of whom were women. Heslop, “For Better or for Worse?,” table 1, 226. The lack of any formal specialist registration system in New Zealand before 1968 means that few data are available on the situation of women specialists before that time. 32 Ibid.; Department of Health, Health Manpower Resources, 1983 Data (Wellington: Department of Health, 1984), 7. 33 From 1968, New Zealand doctors with recognized postgraduate qualifications could formally register as specialists and were assigned a salary grade based on their qualifications and experience. Doctors with advanced professional experience or expertise could be placed on “additional steps,” which allowed them to be remunerated at a level beyond that stipulated by the normal specialist grades. 34 Heslop, “For Better or for Worse?,” table 1, 226. In 1984, there were 1,572 male specialists (of whom 436, or 27 per cent, were on the additional steps) and 169 women specialists and just 15 senior specialists (8.9 per cent).

138  John Armstrong 35 The question of whether this apparent marginalization was “forced” on women or the result of their own agency is discussed later in this chapter. 36 For references to early women practitioners, see Barbara Ehrenreich and Deirdre English, Witches, Midwives and Nurses: A History of Women Healers, 2nd ed. (New York: Feminist, 2010); Hilary Bourdillon, Women as Healers: A History of Women and Medicine (Cambridge: Cambridge University Press, 1988); and Johanna Geyer-Kordesh, “Women and Medicine,” in Companion Encyclopedia of the History of Medicine, ed. W.F. Bynum and Roy Porter, 888–914 (London: Routledge, 1997). 37 Specialties that were practised primarily in publicly funded New Zealand hospitals, such as anaesthetics, pathology, and radiology, were also often unattractive to ambitious male practitioners after the Second World War. As these specialties became increasingly technology-reliant after the war, they became increasingly expensive and therefore difficult for practitioners to perform in the private setting. A number of the biographies and autobiographies of New Zealand medical women describe the process whereby low-status jobs in psychiatric institutions or in state services were sometimes the only remaining option for paid medical work after failing to become established in private or hospital practices. See, for example, Fay Hercock, Alice: The Making of a Woman Doctor, 1914–1974 (Auckland: Auckland University Press, 1999), 97; Cecil Manson and Cecelia Manson, Doctor Agnes Bennett (London: Michael Joseph, 1960), 40; Maxwell, Women Doctors in New Zealand, 119; McLaglan, Stethoscope and Saddlebags, 122–4; Preston, Lady Doctor, 122; Patricia Sargison, Notable Women in New Zealand Health: Te Hauora ki Aotearoa: Ōna Wāhine Rongonui (Auckland: Longman Paul, 1993), 25, 27, 30. I recognize that specialties such as anaesthesia were more lucrative in other medical jurisdictions. 38 The prevalence of multifaceted and persistent illness among the elderly and the mentally ill often made for frustrating and unrewarding work, while the need for long-term and often institutionally based care regimes, combined with the high proportion of economically marginalized patients within their particular demographics made private psychiatric or geriatric practice almost impossible. The obituary of the Auckland psychiatrist Donald Henry Ashdown Blackley commended him for retaining his “understanding and sympathy” while contending with “the tedium of dealing with people with vague and difficult problems.” See “Obituary: Donald Henry Ashdown Blackly,” New Zealand Medical Journal 63 (May 1964): 319–21. 39 A workforce survey conducted by the Medical Council of New Zealand in 1967, for example, found that more than 60 per cent of the Department

A System of Exclusion  139 

40

4 1 42

43 44

45 46

4 7 48 49 50

of Health’s field medical officers were women. Thirty-one of New Zealand’s forty-nine medical officers were women. These figures do not include doctors employed by the Department of Health to work in one of the country’s state-run mental institutions. Of these, three out of twenty (15 per cent) were women. Employment of Medical Practitioners in New Zealand, 1967, 20–1. Most New Zealand women doctors profiled in McIlraith, Goods Train Doctors, spent at least a portion of their careers in the School Medical Service or in the Family Planning Association. For a summary of findings relevant to the period under discussion, see Bourne and Wikler, “Commitment and the Cultural Mandate.” For a discussion in the New Zealand context, see J.C. Van Rooyen, Women in Medicine, Department of Health Occasional Paper, no. 9 (Wellington: Department of Health, 1978): 10–12. Bourne and Wikler, “Commitment and the Cultural Mandate,” 430–1. See, for example, Morag C. Timbury and Maria A. Ratzer, “Glasgow Medical Women 1951–4: Their Contribution and Attitude to Medical Work,” British Medical Journal 2, no. 5653 (10 May 1969): 372–4; Barbara Heslop, Robyn J. Molloy, Hendrika J. Waal-Manning, and Ngaire Walsh, “Women in Medicine in New Zealand,” New Zealand Medical Journal 77, no. 491 (April 1973): 219–29. Judith Lorber, Women Physicians: Careers, Status, Power (New York: Tavistock, 1984). Mary Roth Walsh, “Doctors Wanted: No Women Need Apply”: Sexual Barriers in the Medical Profession, 1835–1975 (New Haven, CT: Yale University Press, 1977), xvii–xviii. To clarify, this quote does not summarize Walsh’s position, but is used in her introductory survey of the historiography of women in medicine. “Editorial: Women in Medicine,” New Zealand Medical Journal 77, no. 491 (April 1973): 258–9. Medical Manpower in New Zealand: Report of a Planning Workshop Held at Wairakei, 19–23 April, 1976 (Wellington: New Zealand Medical Council, 1976), 34. The Medical Council also argued that “medical women have greater difficulty than men in making up their minds about career objectives,” 79. Elston, “Women Doctors in the British Health Services,” 41. Van Rooyen, Women in Medicine. Lorber, Women Physicians, 4–5. Ibid., 4–7; and Haida Lukes, Medical Education and Sociology of Medical Habitus: “It’s Not All about the Stethoscope”! (Dordrecht: Kluwer Academic Publishers, 2003), 74.

140  John Armstrong 51 Robert A. Nye, “The Legacy of Masculine Codes of Honor and the Admission of Women into the Medical Profession in the Nineteenth Century,” in Women Physicians and the Cultures of Medicine, ed. Ellen S. More, Elizabeth Fee, and Manon Perry (Baltimore: Johns Hopkins University Press, 2009), 149. 52 Caroline Dyhouse, “Women Students and the London Medical Schools, 1914–39: The Anatomy of a Masculine Culture,” Gender and History 10, no. 1 (April 1998): 113, 125–7. 53 Belgrave, “‘Medical Men’ and ‘Lady Doctors,’” 385. Belgrave’s comment is borne out by the post–Second World War Two obituaries of New Zealand doctors, almost half of which refer to the sporting interests and achievements of their subjects. Of the 714 obituaries of male doctors, 319 (45 per cent) made some reference to a sporting interest. 54 Lukes, Medical Education and Sociology of Medical Habitus, 74–80. 55 Pringle, Sex and Medicine, 87. 56 Barbara Heslop, “Postgraduate Training: The Eternal Tug of War for Women and How It Has Got Tougher,” in McIlraith, Goods Train Doctors, 11. 57 Pringle, Sex and Medicine, 87. 58 Ibid., 117. See also Isobel Allen, Doctors and Their Careers (London: Policy Studies Institute, 1988); M.L. Johnson and M.A. Elston, “Medical Careers: An End of Grant Report Prepared for the Social Science Research Council,” 1980; Rosemary Hutt, Richard Parsons, and David Pearson, The Determinants of Doctors’ Career Decisions (Brighton: Institute of Manpower Studies, 1979). 59 The phrase organ specialties comes from D.S. Cole, “A Single Medical College for New Zealand,” New Zealand Medical Journal 72, no. 463 (September 1970): 191. 60 See S.D.H. Wilde, “Practising Surgery: A History of Surgical Training in Australia, 1927–1974” (PhD diss., University of Melbourne, 2003), 177. Chapter 5 of my thesis describes in detail the benefits that some New Zealand doctors felt while working in London and other large British population centres. 61 Elston, “Women Doctors in the British Health Services,” 55. Rosemary Pringle asserts that modern gynaecology has, as a specialty, been “extraordinarily hostile to the presence of women.” Pringle, Sex and Medicine, 44. 62 New Zealand Medical Manpower Statistics, 1983 (Wellington: Department of Health, 1984), 78. 63 D.W. Carmalt-Jones: A Physician in Spite of Himself, ed. Brian Barraclough (London: Royal Society of Medicine Press, 2009), 132. For discussions of

A System of Exclusion  141  medical economics, see Glenn Gritzer and Arnold Arluke, The Making of Rehabilitation: A Political Economy of Medical Specialization (Berkeley: University of California Press, 1985); Eliot Freidson, “Client Control and Medical Practice,” American Journal of Sociology 65, no. 4 (January 1960): 374–82. See also Pringle, Sex and Medicine, 76. 64 Interview with Peter Rothwell, 8 August 2007.

6  From Zebra to Motorbike: Transnational Trajectories of South Asian Doctors in East Africa, ca 1870–1970 margret frenz

He was a man that one only encountered once in a while in the practice of medicine, an ardent doctor and an equally ardent fighter for his people. The same fiery spirit was applied to both … His practice was not confined to them, he was also very acceptable to the European and African, whom he treated with the same courtesy and punctiliousness.1

Introduction In 1870, Dr Francisco da Piedade Paixo Noronha was appointed to the service of the sultan of Zanzibar. Building on the example of this pathbreaker, the first identifiable South Asian doctor in East Africa, other doctors from South Asia began to practise in East Africa in the late nineteenth century. They established themselves in government service or in their own practices in the twentieth century and by the middle of the century were prominent members of the emerging East African South Asian professional class. Not only did they excel in their profession, but they were also visible in the public arena as supporters of social welfare projects and as political activists, in some cases as journalists. South Asian doctors in East Africa provide an apt case study to explore issues raised at the confluence of several academic fields: migration studies, imperial and global history, networks of empire, and the history of medicine. In most of these fields, South Asian doctors are under-researched and an untapped resource for historical analysis. For instance, in the East African context, John Iliffe does not look at South Asian doctors in his pioneering history of doctors in East Africa, but focuses solely on East Africans, whereas Anna Crozier in her study

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concentrates on the British colonial medical service. So one might say that only the outer ends of the whole spectrum have been looked at, but not the centre – and this chapter is the first to address this gap.2 South Asians came to East Africa in large numbers from about the 1890s: as traders, as workers on the railways (both indentured and free), and as recruits for the newly established colonial administration. Mostly, South Asians came from the Punjab and Gujarat, with about 10 per cent of them hailing from Goa.3 When the British proclaimed the East Africa Protectorate in 1895 and subsequently established the colonial administration, they adopted and reinforced racial preconceptions and ideas prevalent at the time and attempted their implementation in the economic, social, and political infrastructure of East Africa. For instance, they increasingly chose to create segregated facilities and living quarters for Europeans, Africans, and Asians. In addition, the social, educational, and medical infrastructure was organized largely along racial lines.4 This also created problems in the recruitment of doctors, who were employed along racial categories. Furthermore, while facilities to study medicine in East Africa emerged in the 1920s, the first internationally recognized degree was awarded only in 1957. In consequence, there was a shortage of doctors throughout East Africa, as was noted in the early 1960s: “East Africa is severely under-doctored.”5 This chapter analyses the roles played by South Asian physicians in British East Africa as medical doctors and community activists who used their entrepreneurial skills to open up new medical and political opportunities. It is based on multi-sited archival and oral history fieldwork, informed by interdisciplinary research methods, particularly critical historical enquiry and anthropological and sociological methods of conducting interviews and undertaking direct observation in multiple sites.6 My goal is to create a dialogue between these different sets of material, to access diverse voices and perspectives of the same historical experience, and to arrive at a richer reconstruction of the past. I argue that South Asian doctors constituted an interstitial subaltern group, in some respects privileged (as doctors) but in others (as members of a specific ethnic group) they were marginalized and excluded. South Asian doctors brought with them notions of how to run not only hospitals and clinics but also schools and other social institutions. They adapted them to local conditions, at the same time as some of them became active politically to challenge the distinctions made between members of different ethnic groups by a government that based its policies on racial categories, within which they worked and lived, whether as public or private doctors, men or women.

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South Asian Doctors in East Africa The main features of transformation through time in the experiences of South Asian doctors in East Africa relate to migration patterns, educational facilities, practice facilities, and job opportunities. I establish three rough phases for the analysis of this history: first, an early colonial phase until approximately the First World War, second the high colonial phase from the First World War to independence in the early 1960s, and third, a postcolonial phase from independence until the present day. As I briefly characterize these phases I will illustrate each with examples of South Asian doctors practising in East Africa. Since their medical careers spanned up to as much as fifty years, I have included these examples in the period when the doctors began their practice. Parallel to these phases, facilities for medical training in East Africa were slowly established at Makerere College in Uganda, which started as a technical college in 1922 and in the following decades widened the scope of subjects that could be studied. To begin with, all those with Western-style medical training came from outside East Africa. Higher education for East Africans, including the option to study medicine, appeared only in the early 1920s and only at Makerere, which became a university college affiliated to the University of London in 1949. But the numbers trained were inadequate to the need.7 In June 1963, M ­ akerere – with the Royal Technical College Nairobi and University College Dar es Salaam – was established as the University of East Africa, awarding its own degrees.8 Students of Indian, Arab, and European descent were officially admitted to Makerere from 1951 onwards, when the college was declared open to everyone, irrespective of race, though African students remained the large majority.9 Medical education at Makerere started in 1923–4 with two-year courses aimed at underpinning practical education with some theoretical framework. This was later transformed into a full five-year syllabus on a “Western” medical school model. Between thirty and thirty-five African students undertook medical training at Makerere per year in the 1940s, their numbers rising to around 50 per year in the mid-1950s.10 But not until February 1957 was the Licentiate in Medicine and Surgery (East Africa) recognized by the General Medical Council of Great Britain and the decision was celebrated as “a landmark in medical education in Africa.”11 The first African woman to be awarded the LMS (EA) was Josephine Namboze, who received her certificate on 20 February 1959.12 By the early 1960s, the number of male medical students was

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around 160, with only five women per year.13 The first – part-time – member of staff of Indian origin at the medical school appears in the academic year 1960–1, as do students as winners of prizes. By the 1950s, some of the prizes were sponsored by Indians. For instance, Muljibhai Madhvani donated prizes in medicine, in veterinary science, and in education.14 The first full-time member of staff of Indian origin began to teach at Makerere in 1962.15 With Makerere having full university status from 1963, the medical school introduced the qualifying degree of MB ChB.16 Even so, it remained attractive to go abroad, particularly for further studies, for both East Africans of South Asian origin and East Africans alike. The Indian government offered various scholarship programs for African students to study medicine in India from 1947.17 Until well into the mid-twentieth century, then, all those with full medical training either went abroad for training and returned, or migrated to East Africa having their qualifications in place. Doctors who came from British and Portuguese India to East Africa usually undertook their medical degree either at Goa Medical College Panjim or at Grant Medical College Bombay. Medical colleges were established across the Indian subcontinent throughout the nineteenth century, but their graduates faced increasingly stiff competition for government posts as well as for private practice. Indian doctors looked for opportunities abroad as the British Empire spread across the globe.18

The Early Colonial Phase In East Africa until the First World War, there were very few doctors trained in so-called Western medicine, an absence of hospitals, and the need for doctors to work with minimal facilities. Mostly, doctors practised privately and catered to all communities (if they were accepted). In Zanzibar, doctors often worked in the service of the sultans, as well as providing medical services to others in the sultanate. In Zanzibar, Goan doctors attended first and foremost to the sultan’s health, and that of his family and members of his court. As early as 1870, Dr Francisco da Piedade Paixo Noronha and in his footsteps Dr Braz Antonio de Souza (from 1880),19 and Dr Rodolpho de Mello (from 1895), came to Zanzibar and took care of the medical needs of the Goan community there besides attending to the sultan’s health needs. Dr L.A. Andrade is mentioned as the physician and surgeon at Zanzibar’s medical hall, together with his assistant R. Valladares.20 Later on, Dr Eugene Menezes, on invitation, joined as a physician to the sultan.

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He was followed by Dr Manuel Albuquerque, who acted as the sultan’s doctor and again invited another Goan doctor, Valente de Souza, to support him in his work, serving the sultan, which he did during the 1930s and early 1940s. However, de Souza moved on to be medical officer in charge of Magadi Hospital in Kenya.21 An example of a doctor whose trans-imperial trajectory denotes a four-way circulatory migration, from Portuguese Goa to British India, to Great Britain, to British East Africa, and back to Portuguese Goa, is Manõel Francisco de Albuquerque, also known as Dr Manuel Francis Albuquerque. He was born in Anjuna in Bardez, northern Goa, in 1871.22 His career spanned the early colonial period and into the period of high colonial rule. After his primary and secondary education, he left for Bombay to obtain a medical degree at Grant Medical College, probably around 1890, where he read surgery, anatomy, midwifery, medical jurisprudence, and pathology. Moreover, de Albuquerque undertook practical training at various hospitals and medical institutions, including the J.J. Hospital and the royal dispensary in Bombay. In 1896, de Albuquerque obtained the final degree of Licentiate in Medicine & Surgery at the University of Bombay. It is not known how and why he decided to undertake further studies in the United Kingdom. He passed his exam at the Royal Colleges of Edinburgh on 29 October 1899.23 De Albuquerque then moved on to new shores and worked as the personal physician to the sultans of Zanzibar, Hamud bin Muhammed (1896–1902), Ali bin Hamud (1902–11), and Khalifa bin Harub (1911–60). For more than four decades, Zanzibar became de Albuquerque’s home. His professional life flourished; in 1901 he discovered that one of the deadly diseases riddling the island was bubonic plague and that preventive measures could save hundreds if not thousands of lives. For his services to the sultan, and particularly for detecting and fighting bubonic plague, de Albuquerque received the Order of the Brilliant Star of Zanzibar. Two further honours were conferred on him by the sultans: the Order of Hamoudieh and a Golden Sword. In the 1923 Medical Directory of the United Kingdom, his address is given as the Surgical Hall of Zanzibar.24 Apart from his medical practice, he was employed by the Portuguese government as the Portuguese consul in Zanzibar from 1916 to 1923 and from 1926 to 1933.25 For his services to the Portuguese government, he was awarded the Cavaleiro da Ordem de Cristo. De Albuquerque returned to Goa in 1946 and died ten years later, on 8 April 1956. Fifty-five years after his death, in March 2011, a marble

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statue of him was unveiled by the dean of Goa Medical College to honour his memory.26 At around the turn of the nineteenth to the twentieth century, a slightly less travelled medical practitioner set up practice in Nairobi: Dr Rosendo Ayres Ribeiro, described throughout the literature as the pioneer physician in Nairobi who treated patients from all communities. Ribeiro was born in Goa in 1870 and completed his MBBS at Goa Medical College Panjim.27 After a brief stint in Mombasa from 1898, he moved to Nairobi in 1899. Apparently, he lived in a tent on Whitehouse Road (on the spot in which in the mid-twentieth century the Whitehouse Bakery was situated) for the first year or so of working in Nairobi before moving to the Indian bazaar area. Ribeiro used to ride a zebra on his visiting rounds to patients when he was not too busy in his practice and therefore was known as the “doctor on a zebra.” In Nairobi, he was the first to notice the plague epidemic in 1900–2, which he reported to the British medical officer. The officer overreacted and had the Indian bazaar burned down – which meant that Ribeiro lost his home and clinic. In recognition of his report, though, the British government gave him a plot of land in Victoria Road, where he built a new home and clinic in the local bungalow style. It seems that Ribeiro was quite well known to all communities through the manufacturing of “Dr Ribeiro’s anti-malaria pills.” Apart from his professional work, he actively supported social welfare and educational facilities. For instance, the Goan school opened its doors in the early 1930s and was named after him. Moreover, he acted as the Portuguese vice-consul from 1913 to 1924.28 Ribeiro was honoured with the Grau de Benemerência by the Portuguese government and made an OBE by the British government.29 Ribeiro married Margarida Candida Lourenco in 1908. Two of Ribeiro’s sons became doctors: the elder, Ayres Lourenco Ribeiro, studied medicine in the United Kingdom and became police surgeon for Kenya, and his younger son, Manuel Ribeiro trained as a doctor in Bombay and practised in Nairobi (see below).30 The South Asian doctors who started their practice in East Africa in the early colonial period could be seen as dedicated doctors and entrepreneurs in several respects, particularly as they created new medicines. They engaged in “establishment” politics, with both de Albuquerque and Ribeiro becoming Portuguese consuls, and played notable roles as community philanthropists, activists, and donors. They were regarded by those who followed them in heroic mode, as pioneers opening up new opportunities.

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The High Colonial Phase After the First World War and until independence in the early 1960s, the characteristics that determined much of the professional work for doctors in East Africa changed significantly. One factor was the beginning of efforts at professionalization through the establishment in East Africa of medical boards, which were set up in Kenya and Uganda around 1914, and in Tanganyika in 1920.31 In the high colonial phase, the number of Indians in East Africa rose rapidly – and with this increase, the communities’ perceived need for more health-care facilities at their disposal, mainly in the major cities of East Africa. As East Africa was governed along racial lines, hospitals (and other institutions of social infrastructure such as schools) built by Europeans and open to Europeans were closed to Indians and Africans alike. If members of these communities wished to be treated adequately, they had to initiate and build new hospitals, the funding of which was sometimes matched by the government, sometimes not. Often, Indian businessmen donated significant sums towards building a hospital, or donations were collected by individuals such as the de Sousas (see below).32 In this context of unfilled demand, Indian doctors were entrepreneurs and raised funds, set up practices, and thus took advantage of government failure to provide adequate medical facilities for all inhabitants of the colony. Their numbers rose steeply.33 But still, although the British colonial government in Kenya ran several recruitment campaigns in newly independent India in the 1950s and 1960s, the acute dearth of Asian doctors and nurses persisted until Kenya’s own independence in the early 1960s.34 South Asian doctors faced many challenges in Nairobi in the high colonial phase. I illustrate them by looking at one male and one female doctor, who were married to each other, and not only established themselves in the medical field, but also involved themselves in the improvement of the medical – and the educational – infrastructure for South Asians in Kenya, as well as in the political arena. They took on responsibilities in the colonial government structures, but also in alternative, anti-imperial forums such as journals and newspapers. Dr Alex Caetano Lactancio de Sousa was born in Goa in 1883. He went to Grant Medical College Bombay, where he took his degree in 1914, moving to Kenya in 1915. There, he was appointed government medical officer in Mombasa, then moved to Kisumu for some years. In 1919, de Sousa returned to Bombay, married his college friend Dr Mary Mathilda de Sousa, and opened a private practice with her in Nairobi by the end of

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that year. In the 1920s, R.A. Ribeiro and the de Sousas were the only doctors for the Indian community in Nairobi; their professional lives were highly demanding, as they had to perform all-round duties and had to be “nurse, dietician, health educator, dispenser and even ambulance driver,” as well as be on call during the night.35 A.C.L. de Sousa was described as treating everyone equally, irrespective of caste, creed, or race – as the epigraph at the beginning of this chapter shows.36 In contrast to Ribeiro, who did his rounds on a zebra, de Sousa rode a motorbike. A.C.L. de Sousa was an initiator, staunch supporter, and founder of the Lady Grigg Indian Maternity Home – an initiative he shared with his wife (see further below). The “Lady Grigg” was both a maternity hospital and midwife training school. Furthermore, A.C.L. de Sousa was a member of the Indian Medical and Dental Association, a member of the Welfare League, which was established in 1926, and chief representative of the Asian community at the events of the Welfare League. He also was politically active as a member of East African Indian National Congress, and a member of the Goan Overseas Association. In addition, de Sousa was acting Portuguese vice-consul in 1921, and in the 1920s, he became a member of the Legislative Assembly in Nairobi. Within the Goan community, he pushed forward the agenda to establish Goan schools in East Africa. In community publications, he has even been called the “father of Goan education.”37 He also supported the project of building the Goan Housing Estate, which – on completion – was named after him. He played a significant role in establishing the Desai Memorial Hall in memory of Manilal A. Desai, an outstanding Indian politician of the 1920s and a personal friend of the de Sousas. His political views became widely circulated in the Goan Voice, which he founded and edited for the nearly twenty years of its existence. In addition, de Sousa was president of the Goan Institute Nairobi for ­several years. As a colleague remembered de Sousa after his death, “It will not be wrong or even an exaggeration to say that Dr. A.C.L. de Sousa was an institution in Nairobi in the old days, and when I first came to Nairobi there were only two other Indian doctors practising, one was the old Dr. Ribeiro, a very old fashioned and very sound practitioner, and Dr. A.C.L. de Sousa and his wife, who were both doctors, who used to practice what would then be considered modern medicine.”38 South Asian female doctors hardly worked in East Africa before the 1920s. Even then, they were very rare: one was Mary de Sousa, who practised during the high colonial phase, from the early 1920s to the

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late 1940s. The main article in her memorial brochure is titled “The Passing Away of a Great Woman,” hinting at the high esteem in which she was held across the communities. Furthermore, it stated, “Never before in the history of Nairobi did Goans, Indians and Europeans attend a funeral in such great numbers. The mass of flowers laid on her coffin were the greatest ever seen at a funeral.” Interestingly, Africans appear in the memorial brochure only as her servants. Mary Mathilda de Sousa (1890–1953) grew up in Bombay as one of fourteen children. She studied medicine at Grant Medical College and graduated in 1914 as LM&S (Licentiate in Medicine and Surgery). She received two prizes: the Medical Prize of Rs 250 in the name of Sir Jamsetjee Jeejeebhoy and the Bai Hirabai Cama Gold Medal for Midwifery. After her studies, she worked as a medical officer in the Medical Department of Bhavanagar, followed by a stint in Chota Udaypur before returning to Bombay to work at the Kerrawala Maternity Hospital. In 1919, she married Dr Alex Caetano Lactancio de Sousa, who was on leave from Nairobi. By the end of 1919, she moved to Nairobi with him and started to work as a doctor and midwife in Nairobi.39 She was the very first Asian female doctor in Nairobi – possibly even in East Africa – and took up the challenge of improving the rudimentary medical facilities for Asian women. There was no maternity hospital; only simple medical facilities could be used at the K.A.R. Hospital, but mostly deliveries happened in the homes of families. Mary de Sousa involved herself with the Lady Grigg Welfare League, or rather, its Asian wing, in order to lobby for a proper maternity home for Asian women.40 She initiated fundraising through flag days and public gatherings, such as at the Theatre Royal, which were attended by an unusually high number of Asian women, who otherwise rarely left their houses for outings. However, once the Lady Grigg Indian Maternity Home41 was completed (with all the donations from the Indian community), Mary de Sousa rejected the offer to sit on the Board of Governors, as the constitution of this new institution did not provide for a balanced representation of Indians and Europeans on the committee. Her husband, who had supported the Lady Grigg Indian Maternity Home with her, took the same step. Besides her involvement for the improvement of medical facilities, Mary de Sousa was engaged in the Indian Education Board, in the Girl Guides and in the Boy Scouts, as well as profoundly supporting her husband’s political life. She was active herself and had attended the Lahore session of the Indian National Congress in 1919 before coming

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to Nairobi. Once there, she hosted all the major Indian visitors to East Africa, such as Sarojini Naidu, who presided over the annual meeting of the East African Indian National Congress twice, in her house. In the mid-1940s, Mary de Sousa became very ill and was mostly confined to the house during the last decade of her life.42 Mary de Sousa’s obituary highlights her significant contributions to the improvement of health facilities in Nairobi, especially for women: “The late Mrs de Sousa, by her sincere hard work became a household figure in the practice of obstetrics in Nairobi. Infants born in her hands, in some cases today, have passed the third decade of their life-span and have become grandmothers, who respectfully acknowledged her services to their families. She was primarily instrumental in starting the Indian Maternity Hospital, on Ngara Road, Nairobi, under the kind patronage of Lady Grigg – the wife of the then Governor of Kenya Colony. This institution is a living symbol of her services to the Indian Community.”43 The de Sousas left a deep impression on colleagues, friends, and patients: “The lady doctor was a boon to the community and this medical couple in a very short time earned a reputation in their professional services, especially, by their kind and humane attitude towards their patients … While she was mainly engaged in ‘her service of the sick,’ her husband a versatile doctor, engaged himself in political activities of the Indian community.”44 South Asian doctors in East Africa in the high colonial phase were highly committed to their profession, supported patients, and tried to engage with the colonial authorities from positions of equality – ­however limited by the political system. The ones described here took clear political stances, not always supported by other South Asians in East Africa, both strengthening their own social status – for example, continuing to accept roles as Portuguese consuls – and engaging in political activities that challenged colonial racial hierarchies and patterns of discrimination.

The Postcolonial Phase After the independence of the countries of East Africa in the early 1960s and the introduction of “Africanization” policies in all East African countries in the late 1960s, the number of South Asian inhabitants steadily decreased – with a particularly steep decline through the forceful expulsion of Asians from Uganda in 1972, which triggered further emigrations out of Kenya and Tanganyika.45 This decline was also

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reflected in the medical profession and medical institutions. Moreover, their prominence and visibility in the political arena declined. African private practice was still in its infancy at independence in all East African countries. East African doctors mostly remained aloof from politics, except for Ugandan doctors, of whom several entered the political arena. They took over “the institutions of colonial medicine – the ministries, international representation, disciplinary bodies, and professional associations – although again unevenly.”46 With independence, new medical schools were founded in Nairobi and Dar es Salaam as well as in Kampala. Otherwise, “medical changes at independence, apart from the Africanisation of senior posts, were largely cosmetic.”47 Numbers of East African and South Asian doctors are difficult to establish because there is only fragmentary documentation of medical practitioners at the time, but according to rough estimates, in 1961, there were about 100 government medical officers in Kenya, and 300 qualified private practitioners, of which “probably at least” two-thirds were South Asian. Half of the private practitioners seem to have practised in Nairobi.48 For later years, it is again hard to establish numbers – and particularly, for the South Asian minorities. As mentioned above, both Dr Ribeiro’s sons – Ayres Lourenco Ribeiro (died Ngong, Kajiado District, Kenya 1985), and Manuel Ribeiro (died Nairobi 1952) – became doctors. Ayres Lourenco Ribeiro studied medicine in London and was a member of the Royal College of Surgeons and a licentiate of the Royal College of Physicians.49 On returning to East Africa, he became a police surgeon and later Kenya government pathologist. Apart from his medical practice, A.L. Ribeiro published in academic journals. Of particular interest is his very brief discussion of “multiracial practice” in Nairobi, in which he argues that medical knowledge alone did not suffice when encountering the diversity of communities in Nairobi, and that knowledge of human nature and background cultural information were essential in interacting with and treating patients.50 In 1971, he was made an officer of the Order of St John.51 His brother, Dr Manuel Ribeiro, graduated from the University of Bombay and practised in Nairobi as well. Manuel Ribeiro was president of the Goan Gymkhana in the early 1940s; he opened its new building on Ngara Road in 1943. He died young, in the early 1950s. Salome Vaz, born in Dar es Salaam around 1930, is an example of a female doctor who began her practice at the end of the high colonial period. For her secondary education she was sent to Goa, and then to Bombay for her medical studies. Her father had obtained a scholarship

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for her from the British government, probably because he worked in the colonial administration – otherwise, the family could not have afforded to support her through her medical training. In 1953, she returned to Dar es Salaam and worked there until 1971 in various hospitals, including Princess Margaret Hospital, where patients were graded from grade 1 to 4 according to their financial capability. Salome Vaz specialized as a gynaecologist; she oversaw the maternity ward catering mainly to African women. When she started her job in the early 1950s, they had about 150 deliveries a month, and about 1,500 per month when she left in the early 1970s.52 Salome Vaz had to work under difficult conditions: for instance, the one ambulance and one anaesthetist in Dar es Salaam had to be shared among hospitals; proper blood banks for transfusions did not exist; and operating facilities were available only in the main hospital. This meant that patients had to be ferried around – even for a Caesarean section. In general, hospital staff had to treat patients under a constant lack of medicine and medical equipment. Vaz mentions British doctors and nurses only fleetingly – they all left by 1961. She worked closely with African nurses and midwives, particularly after independence. In the postcolonial phase, South Asian doctors faced intensifying challenges: improvements in working conditions came at the cost of increasing uncertainties after independence in all the East African countries in the early 1960s, the establishment of new nation states, and the profound transformations that followed. Particularly in Uganda, with the expulsion of Asians in 1972, it rapidly became impossible for them to practise medicine. Thus, many South Asian doctors moved on to the United Kingdom and to Canada – their story still needs to be told.53 As I illustrate in the next section, throughout the period under consideration, South Asians contributed significantly to expanding the very limited medical and educational infrastructure in British East Africa. South Asian doctors tended to work in private practice or communityfunded hospitals and privately established dispensaries because they were excluded from the British Medical Service. And, as with all other medical professions at the time, only very few women practised. Experiences of South Asian Doctors The case studies have illustrated the opportunities and challenges South Asian doctors encountered in their professional careers in East Africa. Throughout the changes and transformations of their working life that

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occurred over the course of the century considered here, several aspects characterize their professional, social, and political agency and engagement, albeit at varying degrees and with changing consequences in respective periods. The most decisive aspects, arguably, were race, status, and gender. These could have a profound impact on choosing a job, setting up a practice, treating patients, getting involved in political action, or even in deciding to emigrate.

Race The growing presence of the colonial administration and the decision of the colonial government to base the majority of structures and policies on a perceived difference between individuals of different races had profound repercussions in all areas of life: although people interacted in the economic and political spheres, boundaries were established and clearly marked, and in the social and cultural spheres, hardly any interaction took place. Segregation was the norm; it was much less pronounced in Uganda, Tanganyika, or Zanzibar than in Kenya, where it permeated almost every sphere of work and every cross-community relationship. In the health-care sector, the divisions between races were clearly spelt out: hospitals were reserved for a particular group of the population. For instance, the European Hospital (today Nairobi Hospital) in Nairobi was reserved for Europeans.54 Increasingly, representatives of the South Asian communities felt the need to build hospitals for themselves, but this was a slow process, as the funds had to be found from within the community. Some “Asian” hospitals were built with the money of donors, or through the collection of small donations by dedicated individuals such as A.C.L. and Mary de Sousa (see above), and sometimes matched by government through a grant-in-aid. Particular examples were the Lady Grigg Indian Maternity Home, the Aga Khan and the Shah Hospitals, all in Nairobi. In Mombasa, the Pandya Memorial Clinic was built in memory of Jagannath B. Pandya, an Indian entrepreneur, and supported by a significant donation from his family.55 For Africans, the Native Civil Hospital in Mombasa and the Native City Hospital in Nairobi existed since the early twentieth century. Before Asian hospitals were built, sick Indians were often referred to the “native” hospitals. The boundaries between the hospitals seem to have been rigidly maintained. The following statement reflects one of many reports of Asians or Africans not being treated in a European hospital: “One day

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one of my brothers had a motorcycle accident and was rushed to the European hospital. When the hospital came to find out he was from a Goan family they wanted him transferred to the Indian hospital. Only because Father was adamant that he was too ill to be moved did they let him stay. The British wanted nothing to do with us.”56 This segregation of individuals also affected the career options of South Asian doctors, who had little chance to work in European hospitals. The available evidence suggests that their only option was to open their own private practice or be an employee in one of the Indian hospitals or in the service of local rulers such as the sultan of Zanzibar. Even when Indian hospitals existed, their facilities were not as sophisticated as in the European hospitals, which were, for instance, the only ones where many specific tests could be done. In many respects, South Asian doctors were seen as “subordinate” to European doctors for this reason.57 Several prominent South Asian doctors expressed their criticism of the racial segregation in the high colonial phase, such as the de Sousas, who refused to be on the board of the Lady Grigg Indian Maternity Home, as it did not give Indians adequate representation. The rationale for segregated living quarters was provided by Dr William Simpson who travelled in Kenya, Uganda, and Zanzibar in 1913 and 1914. In his pseudo-scientific report he recommended the segregation between races as essential to maintain the “hygienic” standards in the colony.58 The administrative service was organized in a three-tiered system which placed the Europeans at the top, Asians in the “middle ranks,” and Africans on the lowest level. This hierarchy was reflected not only in professional positions and opportunities for promotion, but also in the facilities available in public buildings.59 Thus, the issue of race permeated all spheres of life, from office to home, from job opportunity to leisure activity, from the coast to the interior. For Indians, this frequently was an ambivalent experience, as becomes clear in the many interviews I conducted with East African Asians: being in the “middle” meant that they were open to criticism from both sides. However, South Asians were not only subject to prejudice, but subscribed to racial stereotypes themselves. In part, they were reflecting the inevitable ambivalence of the person in the “middle” of a racialized hierarchy, though prejudices based on skin colour exist in the Indian subcontinent. In the same way as patients realized that their entitlements and exclusions resulted in large measure from their racial categorization (though money also played a part), Indian doctors understood their position in a pecking order that opened up some opportunities while closing off

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others. The state was faced with establishing everything in triplicate, based on its politics of racial hierarchy, even if the facilities for those at the lower end of the spectrum were minimal at best. Racial segregation also posed problems for the professional services: it prevented their smooth development and the recognition and reward of merit.60 Europeans were often adamant that they would not serve under a non-­ European or be treated by one. In a nutshell, racial issues affected everyone and played out at different levels – the interaction between patient and doctor and between doctors of different backgrounds, the running of hospitals, and the policies of the city and colony for medical facilities. In the postcolonial phase, South Asian doctors had close working relationships with African doctors and nurses, but few of them survived upheavals of independence. Many South Asian doctors left East Africa as the new nation states established policies such as Africanization and nationalization. They moved with their relatives and friends to countries in the global north, particularly the United Kingdom and Canada, but also other European countries and the United States, sometimes joining kin who had moved there already. From the mid-1990s, Australia became an attractive destination.

Status Where did the South Asian doctors in East Africa come from? What backgrounds did they have? The ones I have chosen as case studies for this chapter came primarily from the upper classes in Goa, were Roman Catholic, and could afford a medical education – either in Goa or in nearby Bombay. Their opportunities for adequate jobs in Goa or in British India were exceedingly limited, and therefore East Africa offered considerable attractions. In the early colonial phase, South Asian doctors became pioneers and entrepreneurs in practising medicine. They also occupied prestigious posts, working as the sultan’s physicians, or being vice-consul of the Portuguese government in British East Africa.61 These public roles extended to include leadership positions within the community or in the wider population of East Africa, for instance on administrative boards and political bodies such as the Legislative Assembly. However, they did not occupy positions in which they could make major decisions – their voices were heard only in a consulting function, and their advice was not necessarily followed. At the same time, some of them criticized the colonial undertaking and became active in anti-imperial circles. In

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contrast, the postcolonial era saw a distinct decline in the public appearance of South Asian doctors. This reflects the profound transformations that occurred with the establishment of the new nation states. Most of these doctors earned a good living and represented a higher class than the average South Asian in East Africa. Yet, South Asian doctors were not homogeneous internally. The ones who appear in this chapter were more prominent, more visible, more easily researchable, and they have left more documentation, such as obituaries, memoirs, and even texts or letters written by the doctors themselves. These obituaries and memoirs were often hagiographies rather than critical assessments, challenging historians to discover how far our knowledge of these doctors is socially constructed in ways that are not always visible. In other documentation, South Asian doctors simply do not appear. Since the evidence shapes the context of the chapter, the extreme difficulties of finding alternative evidence is problematic.62 In the available secondary literature, the careers and opportunities of Indian doctors are compared to those of European or African doctors. This leaves out the internal comparison: even within the South Asian community, there was a diversity among practitioners.

Gender In the early colonial phase, there does not seem to have been a single female Indian physician in East Africa. Highly qualified women doctors arrive only in the high colonial phase, with Mary de Sousa being one of the most prominent representatives. The first female doctors graduated from medical school in India in 1878 and gained an LM&S from the 1880s. There was slow growth in their numbers, with only twenty or so a year graduating from medical colleges, and under fifty a year from medical schools, in the early 1920s.63 Those who practised in East Africa – like those who stayed in India – had to overcome perceptions and prejudices of the time that women should not go to university. (See also the history of female students of medicine at Makerere outlined above.) Many more female doctors and nurses came to East Africa in the postcolonial phase. This pattern reflects the general development of women entering the professions over time in the twentieth century, but they continued to face more hurdles than men in taking up medical work. All the female doctors I encountered in written documents or in oral history interviews specialized in gynaecology and obstetrics; until recently, the same has often been the case in India itself. This suggests

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they had more opportunities to practise successfully because first, midwives and nurses were scarce, and the patients who came to see them usually had husbands who would not have approved of their wives being seen by a male gynaecologist. However, some female doctors faced major challenges in their practice; apart from long hours and demanding medical work, at times their community did not approve of a woman being an independent professional. These views were often linked to their religious affiliation, especially women with a Hindu, Sikh, or Muslim background. Conclusion This chapter has illustrated that South Asian doctors in East Africa inhabited an ambivalent position, being marginalized members of a professional, Western-educated elite and, at the same time, leaders of an interstitial subaltern group. This ambivalence is crucial to understanding their social and political positions, which are captured neither by describing them as “handmaidens of empire” nor by seeing them simply as a “subordinate labour force.” The case studies presented here – mostly of Goan doctors – provide the first step towards looking at the broader South Asian community of doctors in East Africa. While the chapter has limited scope, most of the characteristics and experiences highlighted here reflect those of the wider community. Even with respect to religion, Goans as Catholics – like Hindus, Parsis, Sikhs, Jains, and Muslims – remained outside the dominant discourse of the Anglican Protestant social ethos established by the British in East Africa. With this work, I contribute new perspectives to three strands of literature: migration history, imperial and global history, and the history of medicine. To the first a new lens opens the view to multistage migration history and the shifts between colonial and postcolonial settings, allowing the researcher to establish a bridge across this rather artificial divide, whose political significance has often hindered the appreciation of its effects on economic and social processes. Further, my research provides a more nuanced understanding of how processes of migration and circulation created empires and the modern global world, and the role of professionals therein. Last but not least, this chapter transcends the national focus of many studies in the history of medicine by investigating the role of South Asian doctors in East Africa for the first time. Such doctors have so far been neglected, despite playing a significant role in establishing the profession. In this way the chapter creates a

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deeper understanding of the medical services and their trans-imperial and transnational interfaces. By focusing on individuals rather than institutions, their lived experience is also taken into account. South Asian doctors moved between countries of the global south; they helped build the empire from below through their migration, but were then trapped in a segregated colonial system that shared characteristics with those established in India itself, as well as having its own peculiarities. Within their communities, their high visibility as professionals made them community icons, so their stories might seem to embody those of the interstitial economic, social, and political South Asian communities in East Africa. The example of these doctors demonstrates that “imperial globalization” took different forms for different ethnic and religious groups. For South Asian doctors, “powerful exclusionary tendencies not only skewed the distribution of the economic gains that came from the British World, they ensured that the globalising forces of the pre–First World war era were circumscribed by geography and culture.”64 The “connected histories”65 and “intersecting local contexts”66 of these marginal professionals highlight the ambiguities and slippages of empire. Notes Acknowledgments: The ideas for this article were developed during a sabbatical in 2010–11 at the Institute for Advanced Studies in the Humanities, University of Edinburgh, which provided a congenial intellectual atmosphere. I am grateful for comments by the 2012 conference participants, and by two anonymous reviewers. Most importantly, though, I wish to thank all those who so generously shared their stories and experiences with me. 1 G.V.W. Anderson, “Dr de Sousa as a Medical Practitioner,” in In Memoriam: Dr A.C.L. de Sousa, comp. Anonymous, 26–7 (Nairobi: n.p., 1959). 2 John Iliffe, East African Doctors. A History of the Modern Profession (Cambridge: Cambridge University Press, 1998); Anna Crozier, Practising Colonial Medicine: The Colonial Medical Service in British East Africa (London: I.B. Tauris, 2007). For an overview of current patterns of physician emigration from India, see Fitzhugh Mullan, “Doctors for the World: Indian Physician Emigration,” Health Affairs 25, no. 2 (2006): 380–93. For South Asian doctors in the United Kingdom in the twentieth century, see Aneez Esmail, “Asian Doctors in the NHS: Service and Betrayal,”

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3

4

5

6

7

British Journal of General Practice 57 (2007): 827–34; see also the chapters by Simpson, Snow and Esmail, and Bornat, Raghuram, and Henry in this volume. For an overview of the history of South Asians in East Africa, see, for instance, the “classics”: Robert G. Gregory, India and East Africa: A History of Race Relations within the British Empire, 1890–1939 (Oxford: Oxford University Press, 1971); Jagjit S. Mangat, A History of the Asians in East Africa c. 1886 to 1945 (Oxford: Oxford University Press, 1969). For a history and an overview of how cities became “split sites” and segregated, see Carl H. Nightingale, Segregation: A Global History of Divided Cities (Chicago: University of Chicago Press, 2012). Faculty of Medicine, Makerere University College Medical School (Kampala: Faculty of Medicine, Makerere University College, n.d.), 4. This was the case in French and Portuguese Africa as well: Samuël Coghe, ‘InterImperial Learning and African Health Care in Portuguese Angola in the Interwar Period,” Social History of Medicine (2014), doi: 10.1093/shm/ hku063, 1–21; Elise Huillery, “History Matters: The Long-term Impact of Colonial Public Investments in French West Africa,” American Economic Journal: Applied Economics 1, no. 2 (2009): 176–215; Elliot J. Berg, “The Economic Basis of Political Choice in French West Africa,” American Political Science Review 54, no. 2 (1960): 391–405; Fitzhugh Mullan; Seble Frehywot, Francis Omaswa, Eric Buch, Candice Chen, S. Ryan Greysen, Travis Wassermann, Diaa ElDin ElGaili Abubakr, et al., “Medical Schools in Sub-Saharan Africa,” The Lancet 377, no. 9771 (2011): 1113–21. Mullan has no historical references but describes the very low numbers of doctors all across Africa, and the absence of much literature about them in French. In general, I provide a pseudonym, the location and date of the interview. The names of all interviewees have been changed to protect their privacy. For the methodology of oral history, historical enquiry, and multi-sited fieldwork, see Paul Thompson, The Voice of the Past. Oral History, 3rd ed. (Oxford: Oxford University Press, 2000); Jörn Rüsen, Grundzüge einer Historik, 3 vols (Göttingen: Vandenhoeck & Ruprecht, 1983–9); David Parkin, “Epilogue: Fieldwork Unfolding,” in Anthropologists in a Wider World: Essays on Field Research, ed. Paul Dresch, Wendy James, and David Parkin, 259–73 (New York: Berghahn, 2000). Makerere College, The University College of East Africa, Report for the Year 1956–1957 (Kampala: Makerere University College, [1957]), 1. For further details on Makerere in general, see Margaret Macpherson, They Built for the Future: A Chronicle of Makerere University College, 1922–1962 (Cambridge: Cambridge University Press, 1964); for the background of

From Zebra to Motorbike  161  students attending Makerere, see John E. Goldthorpe, An African Elite: Makerere College Students 1922–1960 (Nairobi: Published on behalf of the East African Institute of Social Research by Oxford University Press, 1965); for the Medical School, see Iliffe, East African Doctors, 60–91. 8 Makerere University College, Report for the Year 1962–1963 (Kampala: Makerere University College, [1963]), 1. 9 Makerere annual reports, 1946 to 1960. The report of 1959–60 lists 797 African, 6 Arab, 69 Asian, and 9 “Other” students across the university. Makerere College, The University College of East Africa, Report for the Year 1959–60 (Kampala: Makerere University College, [1960]), 134. See also Goldthorpe, African Elite, 12–13. 10 Reports 1946, 1949, 1950s. 11 Makerere College, University College of East Africa, Report for the Year 1956–57 (Kampala: Makerere University College, [1957]), 1. All individuals who had graduated with this award since 1951 were retrospectively recognized as LMS (EA); see Macpherson, They Built, 128. 12 Makerere College, University College of East Africa, Report for the Year 1958–59 (Kampala: n.p., [1959]), 1. Namboze was granted a Rockefeller Scholarship to pursue further studies in paediatric health in London and in the United States; see Macpherson, They Built, 128. 13 Makerere Annual Reports until 1963. 14 Makerere College, University College of East Africa, Report for the Year 1960–61 (Kampala: Makerere University College, [1961]), 48, 133. 15 Makerere University College, Report for the Year 1961–62 (Kampala: Makerere University College, [1962]), 43, 66. 16 Faculty of Medicine, Makerere University College Medical School (Kampala: Makerere University College, n.d.), 5. 17 See, for instance, the report on two successful young East Africans, who were awarded their medical degrees from the Medical Colleges of Bombay and Patna respectively. Goan Voice 592 (12 April 1958), 2. 18 Roger Jeffery, The Politics of Health in India (Berkeley: University of California Press, 1988), 75–102, provides numbers of medical students and estimates of medical practitioners in India for the nineteenth and early twentieth centuries. 19 See Teresa Albuquerque, Goans in Kenya (Mumbai: Michael Lobo Publishers, n.d.), 27. Piedade Paixo Noronha is mentioned as a medical practitioner in a list of Europeans and Goans living in Zanzibar in 1894, Zanzibar National Archives (ZNA) (AB33/10). De Souza seems to have worked in the Military Hospital in Zanzibar: Amina A. Issa, “‘From Stinkibar to Zanzibar’: Disease, Medicine and Public Health in Colonial

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20

21 22

23 24

25

26

27

28

29

Urban Zanzibar, 1870–1963” (PhD diss., University of Kwa-Zulu Natal, 2009), 162. ZNA AB33/10. According to the Zanzibar Protectorate Staff List, Andrade (born in 1865) came to Zanzibar in the early 1890s and first worked as a veterinary officer (ZNA DI1/8). Andrade is also mentioned as the owner of a plantation. R.N. Lyne, Zanzibar in Contemporary Times (1905; London: n.p., 1987), 259. The Official Gazette of the Colony and Protectorate of Kenya 57, no. 53 (29 September 1955), 241. Interview with Pascal, United Kingdom, May 2005. According to the Royal College of Surgeons Edinburgh Final TQ Examination Schedules 1897, de Albuquerque was born on 21 August 1871, but the author TNN of “Star of Zanzibar Set to Shine in Anjuna,” Times, 27 March 2011, claims that he was born on 14 August 1869. College Records of the Royal College of Surgeons Edinburgh, 20 October 1897–1 July 1908, 20. He is listed as “De Albuquerque, Manuel Franciso, Surgical Hall, Zanzibar, East Africa, LRCP, LRCSEd, LRFPS Glas 1897” in Royal Society of Medicine, The Medical Directory 1923 (London: [Churchill Livingstone], 1923–4), 1604. Ministério dos Negócios Estrangeiros, Anuário Diplomatico e Consular Portuguez. Relativo dos Annos de 1916–1917 (Lisbon: Ministério dos Negócios Estrangeiros, 1917), and following issues through to 1933. Arti Das, “A House Full of Memories,” Navhind Times, 25 March 2011; and Paul Fernandes, “Star of Zanzibar Set to Shine in Anjuna,” Times of India, 27 March 2011. Dr Rosendo Ayres Ribeiro is registered under the Medical and Dentists Ordinance of 1910 as a practising doctor in East Africa. Several issues of The Official Gazette of the Colony and Protectorate of Kenya. After his death in 1951, R.A. Ribeiro was remembered in an obituary in the East African Medical Journal, a rare occasion for a non-European doctor. “Obituary,” East African Medical Journal 28, no. 1 (1951): 91. Ministério dos Negócios Estrangeiros, Anuário Diplomatico e Consular Portuguez. Relativo dos Annos de 1914 (Lisbon: Ministério dos Negócios Estrangeiros, 1915), and issues through to 1925. Albuquerque, Goans of Kenya, 36. Until shortly after independence, a road was named after Ribeiro and Campos, another prominent Goan. Official Gazette of the Colony and Protectorate of Kenya 27, no. 1042 (11 November 1925): 1106. In the Kenya Gazette 102, no. 27 (12 May 2000), Ribeiro House is mentioned but it is not clear when it was so named.

From Zebra to Motorbike  163  30 Dr Ayres Lourenco Ribeiro, MA (Cantab) LRCP MRCS (England). See also Shanti Pandit, Asians in Central and East Africa ([Nairobi]: Panco Publications, [1963]), 91. See below. 31 Iliffe, East African Doctors, 121; Roger Jeffery, “Allopathic Medicine in India: A Case of Deprofessionalization?,” Social Science & Medicine 11, no. 10 (1977): 561–73; Terence J. Johnson, Professions and Power (London: Macmillan, 1972) describe how similar initiatives were taking place in India at the same time. 32 For an overview of philanthropic Indians in East Africa, see Robert G. Gregory, The Rise and Fall of Philanthropy in East Africa: The Asian Contribution (New Brunswick: Transaction Publishers, 1992). 33 Iliffe, East African Doctors, 121. 34 See the MOH series in the Kenya National Archives. For more detail on the recruitment of Indian nurses, see Margret Frenz, Community, Memory, and Migration in a Globalizing World: The Goan Experience, c. 1890–1980 (New Delhi: Oxford University Press, 2014), 129–32. 35 Anderson, “Dr de Sousa as a Medical Practitioner,” 26–7. 36 ”His practice was not confined to them, he was also very acceptable to the European and African, whom he treated with the same courtesy and punctiliousness.” Ibid. 37 See, for example, [Souza, Cherylde, ed.], Centenary: A Journey through Time … The Nairobi Institute (Formerly “The Goan Institute”) 1905 to 2005 (Nairobi: n.p., 2005). 38 S.D. Karve, “Dr. de Sousa: The Politician,” in In Memoriam: Dr A.C.L. de Sousa, comp. Anonymous, 21–2 (Nairobi: n.p., 1959). 39 Mary Mathilda de Sousa was registered under the Medical Practitioners and Dentists Ordinance of 1910 to practise in Nairobi / East Africa on 25 November 1919. Official Gazette of the East Africa Protectorate 21, no. 684 (3 December 1919): 916. 40 Susan Williams, Ladies of Influence: Women of the Elite in Interwar Britain (London: Allen Lane, 2000), 84–106. 41 Situated at Ngara. The Lady Grigg African Maternity Home was opened in 1926 and was located in Pumwani. 42 Anonymous, In Memoriam: The Late Dr Mary M. de Sousa (Nairobi: n.p., n.d.). Courtesy Cliff Pereira. 43 V.V. Patwardhan, “An Appreciation,” in In Memoriam. Dr A.C.L. de Sousa, comp. Anonymous (Nairobi: n.p., 1959), 29. 44 Ibid. 45 See Margret Frenz, “Global Goans: Migration Movements and Identity in a Historical Perspective,” Lusotopie 15, no. 1 (2008): 183–202; Margret

164  Margret Frenz

6 4 47 48

49

50 5 1 52 53 54

5 5 56 57

58

59

60

Frenz, “Migration, Identity, and Postcolonial Change in Uganda: A Goan Perspective,” Immigrants and Minorities 31, no. 1 (2013): 48–73. Iliffe, East African Doctors, 113–18. Ibid., 130. 1961 Tanganyika: 403 registered doctors, 182 of them private practitioners; over 80 per cent Asians. 1955 Uganda: 79 Asian, 9 African, 4 European private practitioners, 124 government doctors in post; influx of Asian doctors in the late 1950s. Iliffe, East African Doctors, 121. Official Gazette of the Colony and Protectorate of Kenya 58, no. 12 (19 March 1956): 246. He was awarded the degree in 1942. Kenya Gazette 90, no. 2 (15 January 1988): 34. Ayres Lourenco Ribeiro, “Multiracial General Practice in Nairobi,” British Medical Journal 2, no. 4894 (1954): 979–81. London Gazette, 7 September 1971, 9669. Interview with Salome Vaz, Goa, February 2006. Bornat, Raghuram, and Henry in this volume consider only Indian doctors who have come to the United Kingdom directly. In the Official Gazette of the Colony and Protectorate of Kenya 33, no. 781 (21 July 1920), 586, three hospitals are listed: the European Hospital, the K.A.R. Hospital, and the Native Civil Hospital. Gregory, Rise and Fall, 97–102. Cynthia Salvadori, We Came in Dhows (Nairobi: Kul Graphics, 1996), 24. South Asian doctors thus had to find niches in which to practise in colonial British East Africa as did South Asian doctors in the NHS. See Bornat, Raghuram, and Henry in this volume. Fredrick Omolo-Okalebo, Inga Britt Werner, Hannington Sengendo, and Tigran Haas, “Planning of Kampala City 1903–1962: The Planning Ideas, Values, and Their Physical Expression,” Journal of Planning History 9 (2010), 157–8; William J.R. Simpson, “Report on Sanitary Matters in the East African Protectorate, Uganda, and Zanzibar,” as quoted in Philip Curtin, “Medical Knowledge and Urban Planning in Tropical Africa,” American Historical Review 90, no. 3 (1985), 611. For instance, in the Government Secretariat, the toilet facilities were segregated: Europeans used the toilets provided within the building, Asians the outhouses, and Africans were expected to use a far corner of the compound. Interviews with Roberto, United Kingdom, December 2004; and Sabrina, Canada, September 2012. For instance, Iliffe claims that “African medical training profited greatly from European hostility to Indians.” Iliffe, East African Doctors, 63. And Crozier reports that a highly qualified South Asian doctor who earned the

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61

62

6 3 64

65

66

degrees of BSc (Bom), LRCP, LRCS (Edinburgh), and LRFPS (Glasgow) and published in the BMJ, was nevertheless given only a subordinate position in the colonial medical service. In contrast, one of his British contemporaries with a MBBS (Bom) “had a long career as a member of the Colonial Medical Service in Tanzania and Uganda from 1924 onwards despite having no British qualifications.” Crozier, Practising Colonial Medicine, 125. See Margret Frenz, “Representing the Portuguese Empire: Goan Consuls in British East Africa c. 1910–1950,” in Imperial Migrations: Colonial Communities and Diasporas in the Portuguese World, ed. Eric Morier-Genoud and Michel Cahen, 191–210 (New York: Palgrave Macmillan, 2012). In one instance, a collection of papers and so-called grey literature in a family home that I was offered to investigate was apparently destroyed by a family member. Therefore, the opportunity to procure alternative evidence has become very unlikely. Jeffery, Politics of Health, 90. Gary Magee and Andrew Thompson, Empire and Globalisation: Networks of People, Goods and Capital in the British World, c. 1850–1914 (Cambridge: Cambridge University Press, 2009), 62, restated on 231. Sanjay Subrahmanyam, ‘Connected Histories: Notes towards a Reconfiguration of Early Modern Eurasia,” Modern Asian Studies 31, no. 3 (1997): 735–62. Robert Harms, The Diligent: A Voyage through the Worlds of the Slave Trade (New York: Basic Books, 2002), xix.

7 Draft Doctors: The Impact of the Vietnam War on the Migration of Foreign Doctors to Canada david wright, alex ketchum, and gregory marks

Sarge, I’m only eighteen, I got a ruptured spleen And I always carry a purse I got eyes like a bat, and my feet are flat, and my asthma’s getting worse Yes, think of my career, my sweetheart dear, and my poor old invalid aunt Besides, I ain’t no fool, I’m a-goin’ to school And I’m working in a DEE-fense plant. Phil Ochs, “Draft Dodger Rag”1

The vietnam War has figured prominently in the historiography of twentieth-century american medicine. a robust literature now interweaves analyses of medical service during the war itself with the psychological legacy after the return to civilian life. for example, there is now considerable documentation on the experience of the estimated 10,000 vietnam War nurses.2 Lynn hampton has analysed their personal memoirs, whereas Doreen Spelts has written passionately about the women who perished abroad during their service.3 Natasha Moulton has demonstrated the independence and skills nurses gained while working abroad; however, that freedom of practice often vanished when they returned to the home front and male doctors relegated them to positions of less power within civilian hospitals.4 Carol Jean Sundling focused on the more recent experiences with post-traumatic stress disorder (PTSD) of vietnam veterans and places it within a historical context.5 The close relationship of the vietnam War with the emergence of PTSD has prompted some authors, like allan Young, to posit the “invention” of PTSD as a psychiatric diagnosis within a specific political and social context.6 Others, like Dean and Bremmer, see PTSD as merely the most recent manifestation of a long history of

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trauma and war, by comparing Vietnam veterans to the experiences of veterans of the American Civil War.7 Although the era will be forever in the shadow cast by the impact of the Vietnam War itself, the 1960s and early 1970s was also a turning point in the history of health services in the United States. With the return of a Democrat, John F. Kennedy, to the presidency in 1960, health reform once again appeared under the spotlight, after unsuccessful gambits in the 1950s. Abandoning attempts to introduce universal health insurance, health policy reformers in the United States moved on to a more targeted approach. The elderly quickly rose to the forefront, as the health of one of America’s most vulnerable demographic groups became the topic of debate.8 Both Democrats and Republicans had vested interests in seniors’ health. For the Democratic Party, healthcare programs for the aged could serve as a strategic building block in the creation of a more comprehensive national health system. Republicans also viewed the elderly as an important electoral constituency. Some also believed that, if the elderly were provided with health insurance, the Democratic Party’s arguments for health-care expansion to the entire population would lose momentum.9 Although excellent studies have analysed the evolution of health policy in the United States during the post–Second World War era, this is the first examination of the impact of the Vietnam War on the transnational migration of physicians into and out of the United States and Canada. Of course, the emigration of an estimated 125,000 American “draft dodgers” who fled to Canada between 1966 and 1976 is nothing new and has entered the folklore of both countries.10 But this chapter seeks to understand the impact of the so-called doctor draft on the migration and relocation of American and American-based medical practitioners to Canada, as well as the avoidance of the United States by migrant doctors seeking to relocate to North America. The chapter will demonstrate that the risk of being drafted was a catalyst for the influx of American, and American-based, physicians to Canada, many of whom would begin practice at the very time that universal health insurance was rolled out in Canada. The Doctor Draft The United States Military Selective Service Act of 1967 stated that every male citizen over the age of eighteen years and six months, and under twenty-six years, was liable for training and service in the Armed

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Forces. In the early years of the Vietnam War, draftees were a minority of the total U.S. Armed Forces, yet they accounted for more than half of Army battle deaths. Their higher percentage of placement in the Army meant that they formed the majority of the infantry rifleman – a dangerous trade. These draft protocols faced much criticism, however, as accounts of higher draft rates of people of colour drew public attention. For example, African-American men who constituted only 11 per cent of the male U.S. population were 16 per cent of Army casualties in Vietnam in 1967 and 15 per cent for the entire war.11 Nixon’s new “lottery system” in 1969 sought to end the perception of this inequality as well as alleviate the uncertainty men faced for the seven years between the ages of nineteen and twenty-six. This lottery would ensure that men would be eligible to be drafted only in their nineteenth year, beginning in 1970. Nineteen-year-old students would continue to receive educational deferments, but would be placed in the pool when their deferments ended.12 Regardless of the randomization that such a lottery entailed, there were myriad ways in which people were able to avoid the draft, as spoofed in the epigraph to this chapter. Once called by the draft board, one could become exempt for physical, medical, or mental reasons, for criminal records, or for being a homosexual. Furthermore, draftees could defer if they were university students who carried fourteen credits and maintained higher than a C average13 or if they worked in certain jobs that were deemed necessary for national defence (such as certain agricultural jobs). Students in divinity school or undergoing rabbinical training were also exempt. Some men married earlier and immediately began having children in order to defer the draft. People learned tricks to appear sick or paid off medical inspectors. These ruses and exemptions themselves created socio-economic inequalities. Those who learned the deceptions or had the means to dodge the draft through education tended to be the children of middle-class and bettereducated families.14 While the randomized selection of able-bodied men would provide enough troops to fit the Army’s combat needs, highly skilled occupations – such as medicine – required another form of recruitment. Brigadier General Thomas J. Wheelan Jr, special assistant to the Army surgeon general, warned that if the Army was without a method other than the general lottery, they would not have the means to require the necessary medical specialists during the war.15 As a result, despite changes to the general draft selection, the medical draft of 1950,

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otherwise known as the “doctor draft” (Public Law 779 of the 81st Congress), continued.16 This federal statute inducted members of the medical profession into military service for assignment to the Medical Corps as commissioned officers. Under the Doctor’s Draft Act, doctors were given commissions commensurate with their age, ability, and experience.17 Unlike in the general draft, doctors were eligible to serve until they reached thirty-five years of age (rather than twenty-six for regular draftees). The act required twenty-four months consecutive service unless the doctor, dentist, or allied health specialist was prematurely discharged or released. If the health-care professional was under age twenty-six at the time of appointment, there was a further requirement of forty-eight months of inactive reserve service comprising thirty-six months Ready Reserve and twelve months of Standby Reserve, which could be satisfied before or after active duty service – a combined total obligation of six years.18 The creditable occupations for fulfilling this obligation was service in one of the seven uniformed services consisting of the Army, Navy, Marine Corps, Air Force, Coast Guard, Public Health Service, and working in the Indian Health Services (IHS) or the Environmental Science Services Administration. Others could fulfil their requirements by conducting clinical research at the National Institute of Health in Bethesda, Maryland.19 This substitute service was known informally as the Berry Plan. It was understood that a physician who satisfied the Selective Service obligation, either in an officer or enlisted status prior to becoming a physician, would not again be required to serve. Although it has faded into obscurity, the doctor draft, which continued until 1973, was, unsurprisingly, a topic of great discussion and concern among medical students of the time, prompting many to consider their options. As the testimony of one online repository of interviews about the draft reveals, Canada was on the radar of medical graduates in the late 1960s: I was already in medical school at the time of the draft lottery, having entered in the fall of 1968. There was a special “Doctor Draft” that drafted all doctors after one year of internship into the military as General Medical Officers. Introduction to war training for four weeks then straight to Vietnam. The law expired June 30, 1969, the day my internship ended, so all in my intern year were drafted unless we had made other plans. Under the Berry plan, we could complete residency first, then enter the army as a specialist, or enter the US Public Health Service, in Indian Health, Prison,

170  David Wright, Alex Ketchum, and Gregory Marks or Coast Guard. I entered the Indian Health Service – great experiences that changed my life. My wife and I planned to go to Canada if the IHS had not accepted me.20

Most doctors who served in the military during the Vietnam War, despite the doctor draft, were not technically drafted, despite their having received a notification of their selection. The law provided a clause whereby physicians, after receiving notice, could apply “voluntarily” for a position in the medical corps at a higher pay grade than they would as drafted doctors. As a result, many “drafted” physicians ultimately were “draft-motivated volunteers” who technically enlisted in order to receive the higher pay grade and officer status for doing the same work they would have ultimately been forced to do.21 In this chapter, however, we will refer to both those doctors who were drafted or “draft motivated” as drafted doctors. Needless to say, the need for physicians during the Vietnam War was vast and affected a whole generation of young male doctors.22 According to a commission formed by the Department of Defence, 80 per cent of all male physicians in the United States under thirty-five had served in the Armed Forces or held reserve commissions; only 4 per cent of male physicians under thirty-five who were eligible for service had not yet served as of 1970.23 The commissioners realized that, without the draft, the medical needs of the military could not be met; as a result they recommended both the reduction of the demand for military physicians through civilianization (such as using civilian doctors to treat military personnel and their dependants on military bases), and increasing the remuneration of military physicians. While continuing the draft, they planned for the future by creating subsidies to medical students in order to encourage participation.24 To be clear, a doctor drafted during the Vietnam War years would not necessarily go to Vietnam. In fact, only a small proportion ever did. One alternative available was, ironically, to remain in the United States as medical examiners for those about to be drafted in the regular conscription call. Drafted medical officers who conducted medical examinations on men who had been drafted held an ethically problematic position. For young men whose number had been called and reported for duty at their local draft centres for their pre-induction medical exam, doctors could be one of the most important allies in escaping the draft. Young men would try a variety of techniques to trick doctors into thinking that they were sick in order to be excused from the draft, such as starving

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themselves for weeks before they were due in order to be under the weight required for service, staying up for days straight in order to seem to have psychological issues when they arrived, or pretending to have high blood pressure by running the miles from their homes to the offices. Other men simply begged the doctor to pronounce them as sick. Some men tried to bribe doctors, as did their families. Doctors spoke of how difficult these situations were when they had prominent members of their communities pressuring them to excuse their sons or how hard it was knowing that the men they declared fit for duty might never return home.25 These tensions were discussed within the medical community. In the New England Journal of Medicine, Dr Peter Elias opened his article with the following statement: “One manifestation of the antipathy among much of America’s youth toward the war in Southeast Asia has been widespread unwillingness to be drafted into the armed forces.”26 This claim, as the rest of the article, inspired many letters to the editor in the following issue. Dr Craig B. Leman, of the Corvallis Clinic, Oregon, spoke of how acting as a medical officer presented an ethical dilemma that was in tension with a doctor’s training: “The injustice of letting the burden of the Vietnam slaughter fall on a few young men while the rest of us grew ever fatter and richer was constantly demoralizing every time I saw a draftee.”27 He felt that having doctors decide who was fit to fight compromised their position as physicians. Furthermore, he found the draft inconsistent with American values and hoped that the medical societies at all levels would confront the problem by taking a stand.28 Dr Howard Waitzkin of Stanford University, a self-proclaimed “disillusioned participant” in medical draft resistance, remarked on the race and class of those whom doctors would relieve of military service. In his work trying to resist the draft by letting men not be drafted, he talked about “the more general issue of physicians’ actions as agents of [the government]. This apparently beneficent act on the physicians’ part may result in unintended conservative and perhaps counterrevolutionary consequences for social change.”29 Doctors like him who wanted to support resistance to the Vietnam War faced difficulty in doing so. The government became aware of doctors who granted too many passes and began to ignore those requests. Doctors were in a tenuous position when it came to their ethical responsibilities, especially when some of them had taken these posts as a means to avoid going to Vietnam themselves. Such chose to avoid this situation altogether and head north.

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Draft Doctors in Canada We will never know the precise numbers of American and Americantrained doctors who relocated to Canada during the Vietnam War. However, a detailed manual and digital examination of the 1966 and 1971 editions of the Canadian Medical Directory (CMD) yielded over 200 doctors who had completed their undergraduate training in the United States and were licensed as of 1971.30 The CMD was the national compendium of all licensed medical practitioners in the ten provinces and two territories. Of these American-trained doctors, 108, or just over half, appear as new licensed practitioners in 1971 (compared to the 1966 CMD), suggesting they had arrived in the late 1960s. These ­American-trained physicians received their undergraduate medical education in one of over 60 different medical colleges in the United States. No individual university predominated. There were graduates of the prestigious medical schools of the Northeast, such as Johns Hopkins (14), Harvard (10), Columbia (5), and University of Pennsylvania (5). There were doctors from Midwestern colleges, including Northwestern (7) and the University of Chicago (12). West Coast universities also figured prominently, including University of Washington (9), University of Minnesota (5), and a staggering 34 from Loma Linda University, a private medical college established by Seventh-Day Adventists in California.31 The area of medical practice may be inferred from the qualifications listed with the names of the practitioners in the CMD. Of the two-thirds of American-trained doctors whose area of practice can be ­determined from the directory, the overwhelming majority were specialists. There were fifty surgeons of every stripe – otolaryngology, obstetrics/­ gynaecology, ophthalmology, plastics – and a variety of medical specialities, with notable numbers of radiologists and psychiatrists. By contrast, there were only ten general practitioners. Unremarkably, the cohort included thirty-six women doctors, a proportion (15 per cent) that approximated the proportion of newly graduating women practitioners in contemporary American medical practice.32 Although women could not be drafted, some were married to other doctors (or health-care practitioners) who might be. As map 7.1 demonstrates, the American-trained graduates set up practice throughout Canada. The direction of migration from these medical schools defies easy generalizations, save for the Loma Linda graduates, who migrated disproportionately to Alberta and British Columbia.

Map 7.1.  Physicians Trained in the United States in Canada (ca 1971)

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Three-quarters of the American-trained physicians settled in the principal urban centres and provincial capitals in Canada, from Victoria (British Columbia) to St John’s (Newfoundland). This suggests a rate of setting up urban practices that was scarcely different from newly graduating Canadian-trained medical practitioners. But some physicians relocated to less populous destinations, such as Quesnel, Prince George, South Cariboo, and Lytton (British Columbia), Lacombe, St Albert, and Tofield (Alberta), Whitehorse (Yukon), Viscount (­Saskatchewan), Belleville (Ontario), Port Clyde and Passboro (Nova Scotia), Twillingate (Newfoundland), St Martins (New Brunswick), Birch River (Manitoba), and Weyburn (Saskatchewan). The reasons for settling in smaller communities has been one of historical debate, but one might conjecture that foreign-trained doctors, with few or no community ties, would have had the greatest opportunity building up practices in areas where there was little or no medical competition.33 Oral histories can help flesh out the role of the doctor draft in the migration of American-trained physicians to Canada. J.H.H., a selfdescribed Irish-American, was raised in the United States but began his medical studies in Dublin. He returned to Syracuse to intern, only to migrate to Canada to dodge the draft. “I had American citizenship and was drafted,” he confided matter-of-factly. He found little trouble arranging a job and securing landed immigrant status at the border. He first worked in Montreal, then Newfoundland, before finally settling in Toronto. He was immersed in the anti-war movement in Ireland and became quite involved in the United States as well, which, he admitted, “wasn’t very healthy.” Confronted by the draft, he became aware of the possibility of coming to Canada. If it weren’t for Vietnam he did not think that he would have migrated north. However, he was very happy with his decision, because he found the “the people were kinder and calmer here and in general, it was just a very comfortable place plus I had a couple colleagues who already established in Montreal which was a help.”34 The decision to dodge the doctor draft, however, continued to affect his life after migrating to Canada. After moving to Ontario he “did have some trouble” with the law in the United States. There he was indicted as a felon in absentia for draft evasion and bail-jumping. His outstanding warrants did not pose a problem for medical licensure in Canada. However, when he began work at his new hospital in Toronto, the Ontario College of Physicians and Surgeons requested his presence and told him that he “should be very careful and [he] asked them

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why and they refused to tell [him].” He claimed that when he went to his “first school when [he] was in Montreal, the Mounties [the Royal Canadian Mounted Police (RCMP)] called several times, just to check that [he] was legally in Canada, which [he] was, and [his] ex-father-inlaw and his family [in the United States] were very much hounded by the FBI for about five years.” However, while he described that stage as “uncomfortable,” it was unimportant, as he was hired and already accepted by the University of Toronto for postgraduate studies. He believed that perhaps the RCMP had contacted the people at his hospital, yet his colleagues there remained vague as to where they received their information about his dodging. He continues to feel anxious entering the United States, even though President Carter granted a general amnesty in 1977, which eliminated the draft-dodging felony.35 Not all American physicians who moved to Canada were anti-war. Indeed J.D., who also settled in Ontario, served his time in the U.S. Air Force, received an honourable discharge, and did not risk being drafted at the time of his departure. He moved to Canada partly because his wife was Canadian and wanted to relocate closer to family. While political reasons were not a motivation for J.D.’s move, the Vietnam War pervaded his life. When he moved to Canada many of his former colleagues in the United States joked at reunions that he must have been dodging the draft. So too did immigration officials at the Canadian border, who questioned why he would chose to move to Canada rather than remain in the United States. While he was not a conscientious objector himself, he soon found that many of his staff in his clinic, mostly allied health-care practitioners, were. J.D. claimed that he did not seek these Americans out but rather they began to work for him by chance. They were not eligible for the doctor draft but rather for the general draft, and although they “were allowed to avoid military combat if they did a non combat service, … these guys they wanted to have nothing to do with the military, so they fled the country.”36 Alien Doctors Given the proportionately small number of American-trained physicians in the Canadian health-care system by 1971 (200 American-trained physicians would have represented about 1 per cent of the Canadian physician workforce at the time), it is unlikely that the Americans had an appreciable impact as a national group of diasporic doctors. Our oral interviews of foreign-trained doctors37 indicate, however, that

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scores of non-American nationals were motivated to resettle in Canada, despite their professional preference to remain in the United States. Dr S., an Eastern European postgraduate trainee, remembers clearly, “I had to register [for the draft], it was compulsory and I got a classification, I don’t remember now what it was, a letter and a number, classified as such and such and so I called them cause I said what does this mean?” He at first did not understand how he could have possibly been drafted, because he “thought … I was not a U.S. citizen so how can you be drafted if you are not a U.S. citizen?” He felt that most great medical research was done in cities such as New York, Chicago, and Washington, yet he did not want to sacrifice his family’s quality of life for his own research opportunities. However, while other social, cultural, and economic factors preliminarily motivated his relocated to Canada, he mentioned that that, as a result of Vietnam, “people were leaving.”38 Dr S.’s rhetorical question – How could I be drafted if I am not a U.S. citizen? – raises an important component of this micro-history. According to U.S. law, a person did not need to be a citizen of the United States to be eligible for the doctor draft. The Military Selective Service Act of 1967 also obliged all male non-citizens over the age of eighteen years six months and under twenty-six years who had been resident in the country for a year or more.39 For physicians, dentists, and certain allied specialists, the upper age limit was raised to thirty-five for those who had received an educational deferment.40 The possibility of being drafted if one wished to stay in the United States after postgraduate studies as a doctor was serious. Such issues caused stress in the medical community among non-nationals. As word circulated that foreign-trained doctors could be drafted for Vietnam, defensive articles appeared in contemporary medical journals downplaying the effect of the doctor draft, in the hope that knowledge of this possibility would not dissuade doctors from immigrating to the United States. Dr Anthony Hall of the Department of Medicine, University of Washington, Seattle, for example, wrote to the British Medical Journal that the draft was not actually as bad as it seemed. In response to a critical article of the previous year, he insisted that the author “has reminded us foreign physicians in the U.S.A. (with an immigrant rather than a visitor’s visa) … are liable to be drafted for military service. This should not deter any potential immigrant. By most accounts military service can be a worth-while experience (life is what you make it!).” Hall insisted that foreign physicians were, in practice, rarely drafted. Even if they were technically drafted, it was unlikely that they would

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be posted overseas, and even if they were overseas there were plenty of places other than Vietnam. For good measure, he observed, “The only doctor I know who has served in Vietnam (an American) enjoyed the experience.”41 Nonetheless, Vietnam redirected physicians to Canada and other countries who might have chosen the United States if it were not for the draft. Dr S., born and raised in South Africa of British parents, returned to England for medical training. When faced with the prospect of pursuing postgraduate training in the United States (as was the advice of colleagues in England), he rather chose Canada, primarily because of the Vietnam War. He did not, he readily insisted, “have any anti-­American feelings … but it was the time of Vietnam and I really disapproved strongly about [the] war.”42 “I had no sympathy for it,” he continued, “and as for the domino theory, which was what it would be, I thought it was just silly, it was beyond stupid … And to lose how many men and countless civilians. And I think it is a terrible mistake that the States made, and I didn’t want to be a part of it.”43 One of his good friends and former lab partners at Oxford had established himself in Canada and helped him imagine having a life in a country that he had not yet even visited. Dr S.’s experience was hardly unique. A Hungarian doctor was motivated to move to Canada for similar reasons. He never actually lived in the United States but considered it for a short time: “With the Vietnam War going on I didn’t want to end up in the army,” he admitted. One of his friends who had “graduated earlier, a fellow Hungarian, six months after he arrived in the United States he was drafted and was sent to [Vietnam] as a physician [and] he was serving on a ship in, you know, somewhere in Vietnam, so that wasn’t very attractive.” He knew that he could “get the [American] citizenship because [of] serving in the army, but no … if you are a landed immigrant or whatever, they will call, and you would end up there before the year is over.” U.S. citizenship was not worth the deployment. Ultimately, he decided that Canada would be a much better home for him and his family.44 “Operation Retrieval” It is noteworthy that, amid the debate over the Vietnam War, Canadian medical authorities were looking southward to replenish their own health human resource challenges. The briefs of the Canadian Royal Commission on Health Services in Canada (1961–4) had demonstrated

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the undersupply of physicians, particularly in light of plans to establish at least four new medical schools. The Canadian Medical Association Journal also forecasted severe shortages by the end of the decade.45 The McFarlane Report of 1965 highlighted the challenges in medical personnel and was accompanied by the Health Resources Infrastructure Fund, a $500 million initiative to co-fund new medical training facilities in several provinces. The Association of Colleges of Medicine of Canada (ACMC) also began a recruiting initiative to convince Canadian doctors working in the United States to return, entitled “Operation Retrieval.” This initiative grew out of a vague sense that Canada’s emerging “doctor shortage” was, in part, a reflection of the net loss of physicians to the United States, a flow that could be slowed, or indeed reversed, given appropriate incentives and propaganda. Canadian authorities, using the annual census of the American Medical Association, estimated that there were 702 graduates of Canadian medical schools in residency programs in the United States (in 1968),46 though this figure may have been inflated by American citizens who had received their undergraduate training in Canada and returned to the United States. To this end, a joint recruiting team of representatives from the ACMC, the Royal College of Physicians and Surgeons of Canada, the Department of National Health and Welfare, and the Department of Manpower and Immigration began site visits in 1968 in the United States, including Los Angeles. They identified almost 200 graduates of Canadian medical schools working in Boston and New York alone, which they visited in April 1969.47 The group and individual meetings sought to brief Canadians (and Americans who had attended Canadian medical schools) on the exciting new era of medicine in Canada, including the rolling out of the Medical Care Act (effective 1 July 1968) and the construction and staffing of four new medical schools – Memorial University (St John’s, Newfoundland), University of Sherbrooke (Sherbrooke, Quebec), McMaster University (Hamilton, Ontario), and the University of Calgary (Calgary, Alberta). Opportunities were thus there for the type of university-affiliated training and research support that was an important influence on Canadian doctors migrating south. It is unclear how successful this initiative was. An American health economics paper, published in 1971, studying in-flow and out-flow of doctors to the United States for 1967 and 1968, suggested that the ratio of gains to losses of the United States from Canadian medical graduates was approximately 2:1 (meaning for every doctor migrating north, there were two migrating south).48 Although the flow was asymmetrical, the

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ratio was the least lopsided of any bilateral relationship that the United States had with any other country in the world. Conclusions The United States was often framed by contemporary analysts as the final stop on the “hop, skip, and jump” of migration, which was estimated by the World Health Organization in the order of 60,000 physician emigrations per year by the early 1970s. Indeed, a contemporary study suggested that approximately 60 per cent of all migrant physicians were ending up in the United States and Canada. As a consequence, it is hardly surprising that most contemporary American scholars did not notice such a relatively small outmigration of their own physicians but, rather, engaged in debates on the desirability (or not) of “alien doctors” in their own public hospitals.49 Rashi Fein (1967) and Margulies and Bloch (1969) both wrote about the growing phenomenon of foreigntrained doctors in the American health system, raising questions about the quality of these medical practitioners.50 Despite the doctor draft, the United States was receiving 8,000 to 9,000 foreign medical graduates from developed as well as developing parts of the world each year – a number even greater than that from domestic American medical schools. From time to time, the U.S. Congress and other bodies believed that such a reliance on foreign-trained physicians was not optimal and that the United States should produce more of its own medical practitioners.51 Seen in this context, the outmigration of American-born medical graduates might be considered almost negligible from an American standpoint.52 Indeed, one American researcher referred to Canada as a “parking lot” country, where foreign medical graduates were there only to set up practice temporarily, awaiting entrance to the United States.53 However, this chapter suggests that the directionality of physician migration in the 1960s and 1970s was more complicated, with the Vietnam War acting as a catalyst, encouraging American physicians to migrate north of the border, alien doctors (already in the United States) to cut short their American training for a Canadian settlement, and finally potentially U.S.-bound migrant doctors to forego the United States altogether for another country. In this way, the histories of Canadian and American physician immigration and emigration were entangled, with the Vietnam War acting as an important motivator in the direction and redirection of physicians across borders. One can only speculate on the political impact of these physicians on the landscape

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of Canadian health care, occurring as it did during the rolling out of universal health care between 1966 and 1972.54 Notes 1 Phil Ochs, “Draft Dodger Rag,” recorded 1964. I Ain’t Marching Anymore. Jac Holzman, 1965. 2 Kara Dixon Vuic, Officer, Nurse, Woman: The Army Nurse Corps in the Vietnam War (Baltimore: Johns Hopkins University Press, 2010), 142; Elizabeth Norman, Women at War: The Story of Fifty Military Nurses Who Served in Vietnam (Philadelphia: University of Pennsylvania Press, 1990), 3–4; Elizabeth Scannell-Desch, “The Culture of War: A Study of Women Military Nurses in Vietnam,” Journal of Transcultural Nursing 11, no. 2 (2000): 87; Philip Caputo, A Rumor of War (New York: Henry Holt, 1996), 223–4, quoted in Jan C. Scruggs and Joel L. Swerdlow, To Heal a Nation: The Vietnam Veterans Memorial (New York: Harper and Row, 1985), 40; Mary T. Sarnecky, A History of the U.S. Army Nurse Corps (Philadelphia: University of Pennsylvania Press, 1999), 387–8. 3 Lynn Hampton, The Fighting Strength: Memoirs of a Combat Nurse in Vietnam (Canton, OH: Daring Books, 1990), 48; Doreen Spelts, “Nurses Who Served – And Did Not Return,” American Journal of Nursing 86 (September 1986): 1037–9. Roughly 6 per cent of military nurses were wounded while serving in Vietnam. 4 Natasha Moulton, “‘Serve Yourself and Your Country’: Wartime and Homecoming Experiences of American Female Military Nurses Who Served in the Vietnam War” (PhD diss., McMaster University, 2012). 5 Carol Jean Sundling in William Schroder and Ronald Dawe, Soldier’s Heart: Close-up Today with PTSD in Vietnam Veterans (Westport, CT: Praeger, 2007), 3–40. 6 Allan Young, The Harmony of Illusions: Inventing Post-traumatic Stress Disorder (Princeton: Princeton University Press, 1995). 7 See, inter alia, Eric Dean, Shook over Hell: Post-traumatic Stress, Vietnam, and the Civil War (Cambridge, MA: Harvard University Press, 1997); and J. Douglas Bremmer, Steven M. Southwick, Adam Darnell, and Dennis S. Charney, “Chronic PTSD in Vietnam Combat Veterans: Course of Illness and Substance Abuse,” American Journal of Psychiatry 153, no. 3 (1996): 369–75. 8 Antonia Maioni, “Parting at the Crossroads: The Development of Health Insurance in Canada and the United States, 1940–1965,” Comparative Politics 29 no. 4 (1997): 411.

Draft Doctors  181  9 Jill Quadagno, “Why the United States Has No National Health Insurance: Stakeholder Mobilization against the Welfare State, 1945–1996,” in “Health and Health Care in the United States: Origins and Dynamics,” extra issue, Journal of Health and Social Behavior 45 (2004): 39. 10 Renee Goldsmith-Kasinsky, Refugees from Militarism: Draft-Age Americans in Canada (New Brunswick, NJ: Transaction, 1976); Frank Kusch, All American Boys: Draft Dodgers in Canada from the Vietnam War (Westport, CT: Praeger, 2001); John Hagan, Northern Passage: American Vietnam War Resisters in Canada (Cambridge, MA: Harvard University Press, 2001). 11 “Senate Passes Nixon Draft Lottery Scheme,” Harvard Crimson (Cambridge), 20 November 1969. 12 David Card and Thomas Lemieux, “Going to College to Avoid the Draft: The Unintended Legacy of the Vietnam War,” American Economic Review 91, no. 2, Papers and Proceedings of the Hundred Thirteenth Annual Meeting of the American Economic Association (May 2001): 97–102. 13 Goldsmith-Kasinsky, Refugees from Militarism. 14 Kusch, All American Boys; Valerie Knowles, Strangers at Our Gates: Canadian Immigration and Immigration Policy, 1540–1990 (Toronto: Dundurn, 1992), 214. 15 “Draft Lottery Concerns Army,” Lodi News-Sentinel, 26 November 1969. 16 The 1950 law had amended the Selective Service Act of 1948. This law had authorized a separate draft for physicians for the first time in U.S. history. U.S. Committee on Armed Services, Doctor Draft Substitute: Amending the Universal Military Training and Service Act, as Amended, as Regards Persons in the Medical, Dental, and Allied Specialist Categories. June 6, 1957. Hearing before the Committee on Armed Services, United States Senate, Eighty-Fifth Congress, First Session, on HR 6548. 1957. For responses in the early 1950s, see Reginald Myers, “Doctor-Draft Law,” New England Journal of Medicine 247, no. 19 (1952): 743; James L. Gamble, Charles D. Cook, William C. Wigglesworth, and George E. LaCroix, Letters to the Editor, “Comments on the Doctor Draft,” New England Journal of Medicine 248, no. 16 (1953): 705–6; C.D. Swope, “Doctor Draft Regulations,” JAOA: Journal of the American Osteopathic Association 50, no. 4 (1950): 232–4. 17 Nelson v Peckham, 210 F.2d 574, 577 (1954). 18 United States Senate Committee on Armed Services, Armed Services Security Cases: Hearings before the Committee on Armed Services, United States Senate, Eighty-Third Congress, Second Session, on Report on Progress in Implementing Defense Department Directive on Armed Services Security Cases Having a Loyalty Connotation, as Requested in Hearings on S 3096, Doctor Draft Act Amendments. July 15, 1954 (US Government Printing Office, 1954).

182  David Wright, Alex Ketchum, and Gregory Marks 19 Sandeep Khot, Buhm Soon Park, and W.T. Longstreth Jr, “The Vietnam War and Medical Research: Untold Legacy of the US Doctor Draft and the NIH ‘Yellow Berets,’” Academic Medicine 86, no. 4 (2011): 502. 20 “Draft Lottery: Jay, Wisconsin, 1969. Doctor Draft,” Vietnam War Draft Lottery, 2007. http://www.vietnamwardraftlottery.com/phpnuke/ modules.php?name=News&file=article&sid=341. John T. Greenwood and F. Clifton Berry, Medics at War: Military Medicine from Colonial times to the 21st Century (Annapolis, MD: Naval Institute, 2005). 21 Louis Rousselot, “Doctor Draft,” Archives of Surgery 102, no. 1 (1971): 87; M.J. England, “Doctor Draft,” Journal of the American Medical Women’s Association (1972) 38, no. 5 (1983): 138. 22 Women could not be drafted (either as civilians or as doctors). 23 Bernard Rostker, I Want You! The Evolution of the All-Volunteer Force (Santa Monica, CA: Rand Corporation, 2006), chap. 4. 24 This would involve scholarships to (civilian) medical schools and the creation of the Department of Defense’s own medical school, the Uniformed Services University of the Health Sciences. See M. Klein, “The Legacy of the Yellow Berets: The Vietnam War, the Doctor Draft, and the NIH Associate Training Program” (unpublished, Office of NIH History, 1998). 25 Michael Foley, Confronting the War Machine: Draft Resistance during the Vietnam War (Chapel Hill: University of North Carolina, 2003), 157. 26 Peter Elias, “Medical Draft Resistance: A Washington, D.C., Experience,” New England Journal of Medicine 288, no. 8 (February 1973): 399–402. 27 Craig Leman, letter to the editor, Doctors and the Draft. New England Journal of Medicine 288, no. 24 (June 1973): 1305–6. 28 Ibid. 29 “Medical draft resistance probably protected the military from a source of articulate internal opposition, by preventing conscription of a large number of well educated, white, upper-middle-class youths who opposed the Indochina War.” Charles B. Strozier and Michael Flynn, Genocide, War, and Human Survival, 196. 30 The Canadian Medical Directory for 1966 and 1971, each consisting of approximately 500 pages and over 25,000 individual entries, was searched for individuals who received their undergraduate medical training in the United States. Of course, this does not mean, necessarily, that these practitioners were American citizens. See discussion below. 31 Seventh-Day Adventists espouse pacifism so their predominance in this group may well arise from anti-war views. 32 A determination of whether there were a disproportionate number of incoming women doctors poses interpretive challenges, since women

Draft Doctors  183 

33

3 4 35 36 37

3 8 39 40 41 4 2 43 44 45 46

4 7 48 49 50

began entering medical schools in larger numbers in the 1960s than a generation earlier. Thus, a strict comparison between the proportion of women doctors emigrating to Canada can easily be distorted by a comparison to contemporary proportions of female licensed practitioners in the United States, since such a statistic would include cohorts of older, overwhelmingly male practitioners. See J.R. Barnett, “Foreign Medical Graduates in New Zealand 1973–79: A Test of the ‘Exacerbation Hypothesis,’” Social Science and Medicine 26 (1988): 1049–60. Interview (anonymous). Ibid. Ibid. We have conducted twenty-six interviews of foreign-trained doctors as part of ongoing research that is funded by the Canada Research Chair program of research. Many of the interviews cited in this chapter were part of a pilot project of twenty interviews conducted in 2008–9. Interviewees have been anonymized as per Research Ethics Board regulations of the host research institutions. Interview (anonymous). Rousselot, “Doctor Draft,” 87. Ibid., 88. Anthony Hall, “Brain Drain and the Draft,” British Medical Journal 1, no. 5542 (1967): 764. Interview (anonymous, per REB requirement). Ibid. Ibid. Interview (anonymous, per REB requirement). Sheila Duff and David Fish, “Canadian-Trained Physicians in United States Internships and Residencies: ‘Operation Retrieval’ and Report of Statistics, 1966–1968,” Canadian Medical Association Journal 102 (14 February 1970): table 8. Ibid., 291–5. Irene Butler, “The Migratory Flow of Doctors to and from the United States,” Medical Care 9, no. 1 (1971): table 1, 17–31. Alfonso Mejia, “Migration of Physicians and Nurses: A World Wide Picture,” International journal of Epidemiology 7, no. 3 (1978): 209–13. R. Fein, The Doctor Shortage: An Economic Diagnosis (Washington, DC: Brookings Institution, 1967); H. Margulies and L.S. Bloch, Foreign Medical Graduates in the United States (Cambridge, MA: Harvard University Press, 1969); Rosemary Stevens, Louis Wolf Goodman, and Stephen S. Mick, The

184  David Wright, Alex Ketchum, and Gregory Marks

51 52

5 3 54

Alien Doctors: Foreign Medical Graduates in American Hospitals (New York: Wiley, 1978). Fein, Doctor Shortage; Margulies and Bloch, Foreign Medical Graduates in the United States. Oscar Gish, Doctor Migration and World Health: The Impact of the International Demand for Doctors on Health Services in Developing Countries (London: G. Bell, 1971), 12. Butler, “Migratory Flow of Doctors,” 30. The advent of medicare is sometimes simplistically dated from 1966. However, it should be remembered that the legislation did not take effect until July 1968, and even then required provincial legislation to be passed that conformed to the four principles of the Medical Care Act. This was not complete until 1972.

8 “Without racism there would be no geriatrics”: South Asian Overseas-Trained Doctors and the Development of Geriatric Medicine in the United Kingdom, 1950–2000 joanna bornat, parvati raghuram, and leroi henry There has been a long history of migration of doctors from the colonies to the United Kingdom. Records of medical migration show that the practice of moving in order to study in the United Kingdom began at least in the 1840s and kept pace throughout the nineteenth and twentieth centuries, and South Asians1 accounted for a significant part of this migration.2 Those who taught medicine in India, Pakistan, Bangladesh, and Sri Lanka had often trained in the United Kingdom for some time. As a result, many doctors in South Asia felt that they were part of a community of medical practitioners for whom some markers of participation in the U.K. labour market were central to career progression. They had often been advised by their teachers to get training in the United Kingdom.3 Upgrading and validating skills through training at one of the U.K. royal colleges was therefore seen as crucial to being recognized as a good doctor and was embedded in South Asian doctors’ professional cultures. Organizations like the royal colleges implicitly shaped migration (and indeed directly benefit financially from it) through their ability to award internationally accredited professional qualifications that were prestigious across the Commonwealth. As a result, many doctors in South Asia were already in some way part of a professional community where migration to the United Kingdom was seen as part of career progression. The South Asian doctors were not alone, of course. The history of colonialism and postcolonialism meant that doctors from other parts of the British Empire and Commonwealth were similarly leaving home to gain qualifications in the

186  Joanna Bornat, Parvati Raghuram, and Leroi Henry

United K ­ ingdom’s medical system, though with different experiences and outcomes, as Armstrong’s research shows.4 This long history of medical migration to the United Kingdom is relatively well known. However, until recently the story of the contribution of South Asian doctors to specific fields has been less discussed. In this chapter we address this gap by focusing on the contributions of migrant doctors to the geriatric specialty. We begin with a history of geriatrics in the United Kingdom and go on to outline our methodology before describing the process by which South Asian doctors came to be working in geriatric medicine, what barriers they encountered, and how networks worked both for and against them, before concluding with a consideration of how certain regional centres of excellence played a part in their professional development and careers as consultants in the specialty. The History of Geriatrics in the United Kingdom Since its inception, geriatric medicine had been a “Cinderella specialty,” its image affected by ageist attitudes towards a patient group of older people, and its appeal limited among medical practitioners by lack of access to acute beds and thus to private practice.5 These are general characteristics, shared by the specialty internationally. However, developments in the United Kingdom, which proved to be pioneering, owed much to the historical coincidence of two factors: early recognition of the possibility that some conditions in old age were recuperable and the inception of a socialized medical service in 1948. The emergence of a clinical medicine of old age had begun in France with Charcot in the nineteenth century and the recognition that, despite their age, many people presumed incurable could be treated and that, in late life, illnesses may have symptoms specific to the aged body.6 These ideas were quickly taken up by medical researchers, rather than in therapeutic contexts. It was their application in the latter by Dr Marjory Warren, working in a Poor Law infirmary, the West Middlesex Hospital, in the mid-1930s that would lead to the creation of the specialty. As Grimley Evans argues, “Ignatz Nascher invented the word, Marjory Warren created the specialty; directly and indirectly, her work inspired the development of geriatrics in many countries of the world.”7 Typically, the chronic sick and older people were not considered capable of rehabilitation or treatment and were housed together in inaccessible buildings and wards. Older people’s care was relegated to back spaces,

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the backs of buildings, small cottage hospitals, tuberculosis and isolation hospitals, former Poor Law infirmaries and workhouses, and the “back wards” of municipal hospitals. Doctors were rare visitors, and nurses, though caring, rarely fully qualified. Lord Amulree, an early proponent of improved medical care and treatment of older people, wrote in 1951: A large number of patients were in bed for social and not for medical reasons. Some had been admitted for some forgotten acute or semi-acute condition and had remained … long after this was cured. Some had been admitted because their relatives, in many cases at work themselves, had found the care of an elderly relative burdensome, and for others there seemed no valid reason why they should be occupying a hospital bed. Many were kept in bed for no better reason than that it was easier for the nursing staff and administration to keep them in bed. Sometimes there was a suspicion that patients were kept in bed because the wards looked tidier that way. Because of this outlook, there was an atmosphere of apathy in the wards that was almost frightening; the patients lay almost like so many animals, with nothing to amuse or interest them.8

Marjory Warren devised a system of classification, which depended on the recognition that certain conditions, if not curable, could at least be treated, and in some cases rehabilitation followed. Her aim was to “make a case for their treatment in a special block in a general hospital” so that geriatric medicine might become part of the curriculum of medical students and nurses, improving the care and treatment of chronically sick older people and encouraging research into “the diseases of old age.”9 Applying these principles to the 714 chronically ill patients, not all old, in the wards for which she was responsible, she was able to reduce the number of beds occupied by people with chronic conditions to 240, at the same time increasing bed turnover to three times the previous rate. Her approach depended on the treatment of older people being recognized as a part of medicine, with teams of trained staff working with professionals in the community, including general practitioners, nurses, and other services.10 Once published, her results were quickly recognized and taken up by others working in hospitals that, during the Second World War, had come under national direction. However, it was to be the arrival of the National Health Service (NHS) in 1948 and the consequent absorption of so many chronic wards and their patients into a system struggling to manage resources economically and fairly that

188  Joanna Bornat, Parvati Raghuram, and Leroi Henry

would secure recognition of the geriatric specialty.11 Pioneering work, following Warren’s example, proved successful in other centres around the United Kingdom. Among geriatricians there were to be divisions over the emphasis given to cure and to long-term care; however, results that freed up beds and created shorter waiting lists meant that the specialty had support in the highest places, with the result that over sixty geriatric units, often in poorly resourced accommodation, were set up from the late 1950s, led by a new cadre of consultants with s­ pecialist knowledge in the illnesses of old age.12 Organization and leadership for geriatricians came with the founding of the Medical Society for the Care of the Elderly in 1947, instigated by Marjory Warren and with the support of early geriatricians, including Lord Amulree. This became the British Geriatrics Society in 1959.13 Development in the United Kingdom was very much in contrast with elsewhere in anglophone and other European countries. Though the science of the medicine of old age took off in mid-twentieth century, the development of new care arrangements would be much slower and patchy. In the United States, centres of excellence such as Mount Sinai Medical School and the Jewish Home and Hospital for the Aged, though set up in the context of increased governmental awareness of the need for greater medical research into the illnesses of late life and appropriate clinical interventions, depended on private funding. The Department of Veterans Affairs, with a remit to provide effective care to a more general population,14 would lead in training and awareness of geriatric medicine that approached the more comprehensive model emerging in the United Kingdom from the mid-­twentieth century. In Canada the picture was very similar, with research centres emerging in the 1950s in most provinces, and the Department of Veterans Affairs providing leadership for assessment and rehabilitation, together with comprehensive assessments for older patients. Though the federal Liberal government at the time was committed to health-care programs that would provide financial support, older people would take their place in the queue. A spur to development of trained physicians in geriatric medicine was, Hogan argues, the fact that “about a quarter of its [Canada’s] physicians [had] trained outside the country … in locales where geriatrics was an acceptable specialty.” He suggested that in the role of “the stranger,” with the accompanying “mobility, objectivity and freedom from convention … the outside expert can play an important role in the establishment of a specialty.” And so it was, for example, in Canada where, during the 1970s,

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British geriatricians were recruited to develop health services for older people and in return Canadian physicians travelled to the United Kingdom to train in geriatrics.15 One element missing from this account is how the geriatric specialty in the United Kingdom was enabled to grow. As we have seen, care and treatment of older people was not highly regarded within the medical profession, and although funding of consultancies would provide leadership and a degree of acknowledgment among peers, growth would be needed in the lower ranks if movement of patients was to be achieved. Histories of the development of the specialty tell us very little about how it was peopled, though there were clues. During 1991, Professor Margot Jefferys and colleagues embarked on an oral history of those she describes as “survivors of the earliest cohort of geriatric consultants.”16 While carrying out final checks for a chapter she was writing,17 it became evident that recurring references in the transcript summaries suggested another presence among the first generation of geriatric specialists. Reading through the transcripts, these pioneers talked about their junior doctors: “Some of my Indians were very good indeed.”18 “When I came we had an establishment of three house officers … They were always Asian.”19 “I had an Indian registrar and an Indian houseman. And actually, some of these chaps were quite good.”20 “There weren’t all that number of British people about but there were some very good Indians.”21 Jefferys interviewed only one South Asian doctor who was quite clear about the development of the specialty: “The local boys wouldn’t touch it with a barge pole. So, in effect, geriatrics owes its origin and its beginning to the pioneers who had the vision and the junior doctors from the Indian subcontinent – as simple as that.”22 Of course geriatric medicine was not the only area of the U.K. NHS to benefit from the contribution of migrant doctors from the subcontinent, as Simpson, Snow, and Esmail in this volume show. What interested us was the combination of two minoritized populations: overseastrained South Asian doctors and older patients. How and why had the two been brought together appeared to be an interesting question for research. Given that the presence and contribution of this group of doctors was not documented in the history of the specialty, gathering accounts directly from them offered a possible approach. This would have the added advantage of following Jefferys’s example. In the following section we outline the research design that followed when a bid for funding proved successful.23

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Methodology The seventy-two interviews that Jefferys and colleagues carried out in 1991 with the founders of the geriatric specialty would be followed by a second set of oral history interviews with sixty South Asian overseastrained doctors (SAG interviewees). The two sets of interviews would cover the history of developments in the health care of older people from the late 1930s. This second set of data was recruited through networks of overseas doctors (the British Association of Physicians of Indian Origin, for example), the British Geriatrics Society, and snowballing. Interviews cover the period from 1950 to 2000. The two data sets thus reflect slightly different, albeit overlapping, periods in the history of geriatrics, the emergence of the discipline in some centres, and the adoption and adaptation of practices as they radiated from these centres across the country. Hence, the South Asians operated in a framework where there was some national infrastructure for advancing geriatrics but faced issues similar to those interviewed by Jefferys, as up to the mid-1980s both were operating in areas that had very little local infrastructure and accorded geriatrics with little status.24 Both sets of interviewees use a life history approach, asking participants to talk about their life from childhood to the present. Areas of interest included the development of services and the progression of careers during fluctuations in the supply of and demand for doctors. The SAG interviewees included doctors trained in India, Bangladesh, Sri Lanka, Pakistan, and Burma, ranging in age between forty and ninety-one and arriving in the United Kingdom from the early 1950s onwards. Almost all of these interviewees work(ed) as consultants, and some also held academic posts. We focused primarily on the period between the late 1960s and late 1980s, when the issues of the time often resonate with many today: anxieties about an aging population;25 a highly politicized environment around issues of migration and race, as evidenced by the Commonwealth Immigrants Acts (1962, 1968) and the Immigration Act (1971).26 Debates and legislation led to change in the meaning of race. Together with concerns over the management and future of the NHS,27 this meant that the habitus within which social networks, recruitment practices, and career progression operated was altered. The choice of oral history as a method is well-attested. It offers the possibility of locating the migration experience within the longer trajectory of a life history, contextualizing migration as one of many events

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that shapes individual lives. It is produced in a dialogue that encourages narration and reflection and thus provides evidence of subjective lived experiences.28 Comparing two different data sets has produced its own richness, revealing hidden links in the experiences of both groups29 and providing evidence on the ways in which opportunity may be fashioned and created under conditions of adversity and perversity.30 The oral history interviews have been supplemented by archival research. The archives of the Department of Health, the British Geriatric Society (BGS), British Medical Association, Royal College of Physicians, Royal Society of Medicine, and the papers of organizations such as the Overseas Doctors Association have all been consulted to understand the issues facing doctors working in the specialty in the second half of the twentieth century. South Asian Doctors and the Geriatric Specialty As we have seen, from its inception the NHS has depended on recruiting staff from overseas. This migration was part of a long-standing tradition of movement between South Asia and the United Kingdom. Development of a medical career often involved experience of overseas work so that movement across the Commonwealth countries, and especially to and from the United Kingdom and the colonies, was part of colonial history. Moreover, the reach of Western medicine was made possible only by this mobility, as its spatial claims rested on movement, learning medicine from these Western centres and reproduction of its practices in centres around the world.31 Hence, U.K.-trained doctors moved to countries like India, while Indian doctors moved to the United Kingdom to learn and to be trained.32 Migrant doctors were necessary for the operation of the health service, as they provided a mobile army of labour in the lower rungs of the medical hierarchy. However, once in the United Kingdom, they were systematically disadvantaged in access to jobs, career mobility, the places where they found employment and the specialties they could occupy.33 These doctors were ethnically marked through their race and their countries of qualification.34 The fact that in 2003 only 17 per cent of South Asian doctors were consultants compared with 42 per cent of white doctors35 provides some evidence that migrant doctors from South Asia found their careers limited by the institutionally racist and hierarchical nature of the NHS.36 For instance, migrant doctors found that, despite the internationalization of the education they had received in South Asia and the

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dependence of the United Kingdom’s NHS on migrant doctors, this international professional community had a preference for local graduates built into it that would direct their careers in ways that they had not expected. Barriers based in traditions of assumed superiority or straightforward prejudice might present substantial impediments to mobility inside the United Kingdom. Letters of reference written by doctors who had trained in the United Kingdom but had returned to South Asia were not considered adequate for a substantive post, as one interviewee found: “No. I always had a job. I’ve never … only when I first came, for the first two weeks I didn’t have a job. The first two weeks I was getting acclimatised, wondering what to do, then my brother found this. And I sent job applications with my reference from consultant and so on and didn’t work at all, you know, when I first came. I sent lots of applications with copies of my glowing reference from my consultant in Sri Lanka. Didn’t help at all.”37 They also found themselves channelled into the less popular specialties like geriatrics, as another interviewee recalled: And he said, “I’ll show you something then.” So there was a job in Newcastle coming up, applying for cardiology consultant job, you see. And he showed me the applicants, you see, because he was on the interview panel for that consultancy. So guy from Edinburgh, a guy from Cambridge, a guy from Oxford, one guy coming from Canada, one coming from New Zealand, one coming from London, from Brompton. And he said, “Have a look at their names as well. They are all local graduates.” So he said, “Where do you fit in there? Do you think you have any chance there?” [Laughs] So I said, “Probably not,” so he said, “Well my advice to you, forget about it, because you could be wasting for time by doing cardiology.”38

As Simpson, Snow, and Esmail show in this volume, doctors who became general practitioners encountered similar prejudice and obstacles, deflecting them from their original and preferred area of medical work.39 The quotation included in the title of our chapter succinctly describes the outcome for the geriatric specialty. A lack of interest among U.K.born graduates in working with older patients40 led to opportunity for South Asian graduates. In geriatrics from the 1960s, as the early geriatricians sought to build departments, a crisis of staffing from the 1960s meant that it was difficult to fill posts using a U.K.-trained cohort. As a result the new specialty depended on overseas-trained doctors for its existence and growth. By 1974, 31 per cent of consultant geriatric

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posts and 60 per cent of registrar posts were filled by overseas-trained graduates, the figures having risen from 15 and 33 per cent respectively in 1967.41 A survey found that 40 per cent of geriatricians who were appointed as consultants in England in 1981–2 were overseas graduates.42 These doctors built up a specialty at a crucial time in the history of the discipline. Migrant doctors were encouraged, with commitment that varied from whole-hearted support to a distance bordering on discrimination by senior staff, as the quotations from the Jefferys interviews illustrate, keen to build the specialty and change to practices that offered rehabilitation rather than incarceration. Interestingly, geriatrics had offered similar opportunities to some founders of the specialty. Among those interviewed by Jefferys were several who, for a variety of reasons – including disruption to their training due to wartime service, refugee status, or wrong choices – rose to prominence in the early years of geriatric medicine.43 The phrase “falling off the ladder” tends to recur in the Jefferys interviews as they describe their careers. Dr Marion Hildick-Smith recalls that when she wanted to return to work after a childcare break, going down a few rungs could be advantageous to someone hoping to progress: There was the beginning of a plan to attract married women back, because I think they felt they were perhaps wasting a lot of potentially helpful people. And so I said, “What about the possibility of coming back and training in geriatrics?” The comment from the regional officer at that time was, “What on earth would you want to do that for?” So it was not really immediately taken up with enthusiasm … I applied for and got a registrar post in geriatric medicine, part time, with the possibility that it might become a senior registrar post. There was no guarantee and it was a bit of a gamble, because really it was going down a couple of grades, but I felt it was worth doing that in order to try and get restarted on the medical ladder.44

Gaining Access to a U.K. Medical Specialty Though the specialty offered opportunity to those prepared to take it up, and who were also prepared to work hard to prove their worth, progress was not automatic. Networks still mattered, and the geography of access was also a determinant. In what follows we consider two aspects of medical networks – their international and professional limits – before going on to look at where South Asian doctors found opportunity in the NHS.

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Networks and Their Limits As we saw earlier, migrant doctors who had expected that recommendations from teaching staff in their medical colleges would ease their entry into the U.K. medical profession and its most desirable specialties were, with few exceptions, disappointed. Geriatrics was considered to be the “crumbs” that people went into, not out of choice but because of the compulsions of exclusion from more desirable specialties, as one interviewee stated: “Initially I think people went in not out of choice. It was almost out of compulsion because you were here, you didn’t have a job, etc. So we were given the crumbs basically. Whatever was left at the … you know.”45 Rejection of job opportunities in geriatrics by white, U.K.-trained medical trainees meant that South Asians, who found few other opportunities, came to dominate geriatrics. It therefore came to be known as the “curry” department and to be held in disdain, especially by those who worked in teaching hospitals. One interviewee talked about how Sunderland, a general hospital that became a centre for geriatric development, was viewed by doctors visiting from the teaching hospital in neighbouring Newcastle-upon-Tyne in the northeast of England: Yes, Newcastle University. Because we always had senior registrar from here. We used to have medical students coming from there all the time. So we never had any problem. It was different matter if we find the oddball registrar coming over here and talk to the university: “Oh it’s a curry department at Sunderland. Why do you want to send me there?” [laughs] Is that what they call it? Well one of them did. He went to professor, he said, “Oh it’s a curry department” [laughs].46

The interviewee speaks about how visits to Sunderland were related back at Newcastle, where white doctors were more dominant. So how did South Asian doctors come to be over-represented in geriatrics? And what forms did this participation in the speciality take? There were a number of ways in which their paths tended to be directed, and throughout the interviews the selective usefulness of networks was iterated.

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Gaining access was determined in part by using migrants’ own networks of support and communication and the transnational social capital of family members (as we saw earlier), but, more commonly, members of college alumni. These networks were adequate for shortterm locum posts (covering for absent doctors) and clinical attachments. But it was the structure of the medical labour market – abundant availability of short-term, temporary posts – that allowed these networks to be effective.47 As one doctor said, the hospital authorities would not advertise for such locum posts but would use references from staff: “‘My God we want a locum doctor. Do you say that’s a nice Sri Lankan doctor and he says he’s good? We can take his word for it.’ And they appointed.” However, there were limits to these introductions, as non-migrants’ own networks took precedence over those of the migrants. And CV, none of that helped then? No, no. I suppose I didn’t really try hard enough, I think because I thought the thing is to get a job and get some money. Close to a place where I could still come to my brother’s place. Yeah. So I think once you get a good reference, then it’s good. But patronage definitely helps, because I’ve certainly seen British people doing it too. They know somebody who knows somebody and they are … it’s more difficult now, it’s more fair actually now. Patronage doesn’t help that.48

Patronage was clearly an important route into the career of nonmigrants. Limited access to the social networks of non-migrants meant that those networks often worked against migrants.49 In order to be successful, migrant doctors had to learn to utilize and benefit from selective incorporation into these non-migrant networks. Forms of patronage selectively opened up job opportunities for migrant doctors’ entry into paths offering career progression. As was frequently the case, for one interviewee the first locum was arranged through contacts with other South Asians, while the more substantive post depended on contacts with, and entry into, non-migrant networks. “So he said ‘No, no. There is a locum post has come up for you in Glasgow. You take it.’ He said it is for me, but you will not get any job otherwise. [laughs] So I took the job. Locum for six weeks. Once I got the job, that’s it. They want me all the time there. You won’t believe it, because that is the job, senior house officer in respiratory medicine, a bit of elderly care.”

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Finding Opportunities in the NHS Once in post, access might be achieved and maintained by working long hours and displaying high levels of commitment to patients and the specialty: In that post I spent most of the time in the ward looking after the patients. Being totally committed to the patients and teaching … And so one day one of the consultants turned up at about six thirty, seven in the evening, and he saw me still doing the round, and said, “What are you doing there?” “I’m finishing my patients. Still there are two more left.” He said, “You are too dedicated,” … and the next year recommended me for a senior registrarship post to the professor.50

However, the places in which South Asian geriatricians found jobs also reflected exclusion – not merely from desirable specialities but also from many of the infrastructures of modern medicine, such as new buildings: One thing was disappointing that care of … geriatric medicine and care of the elderly was not given enough, you know, importance. We were not part of the district general hospital. We were about a mile away in a workhouse. And I think we were very well organized. From day one I liked the speciality, because you could see teamwork and, you know, multidisciplinary team-working. It changed my whole way of thinking what medicine’s about. But definitely we were not given the right, you know. We were seen as second-class citizens within the NHS. In what ways were you seen as second class? Like I said, we were not part of the district general hospital, separate hospital. That was brand new hospital. We were in a workhouse. Here we went for clinical meetings, you know, we just felt as if we were not at the same level as the others. Generally you would find that these jobs were all for people from my part of the world, while all the other local graduates were getting jobs in those sort of general medical posts, etc.51

South Asian doctors largely found their opportunities in hospitals with fewer facilities and areas that U.K.-qualified graduates avoided: “First of all, in the initial days they filled the jobs when nobody else would take it. And they tried to copy the best leaders, and implement

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changes in their own patch like the best leaders had done. So there were geriatricians in hospitals where facilities were so poor I probably wouldn’t work in those even today. And so that’s one of the things that they went to the areas where local doctors didn’t go. And they filled those jobs where local doctors weren’t interested. It wasn’t that the local doctors didn’t get those jobs. They weren’t interested in those jobs.”52 Overseas qualified doctors also found it easier to get posts in provincial district general hospitals, rather than in major metropolises or teaching hospitals. Why do you think there’s so many South Asian doctors went into geriatrics? … One should recognise it actually, that that was a specialty where the local graduates were not attracted to at that time because it was not very attractive to go to. So it was easier to get, probably to become a consultant actually, yes. But then places like King’s College or Greenwich – not easy. It was not easy there, ok. So in provincial hospitals it was probably easier.53

However, these “provincial hospitals” were less likely to offer training, and most doctors found themselves on short-term contracts, moving around the non-metropolitan areas, until they found a sympathetic consultant who would take them on in a post where they could expect to be able to study for their membership in the Royal College of Physicians. Even in geriatrics where the pressure was on to build departments, access could be difficult, as some found: “He liked people from overseas very much. There were people … how I should put it? They may not … couldn’t care less. For example, I met one professor, I described earlier on, in Liverpool [he mentions an example of direct discrimination]. There’s another one, he was in Birmingham … I went to see him while I was in Birmingham. He gave me ten minutes of his time and said, ‘Could you see my secretary after that?’ And that was the end of it. Not everybody likes foreign doctors.”54 Opportunities to progress thus depended on a combination of structural constraints that worked both against and for the migrant doctors. Barriers rooted in racist attitudes and discriminatory practice foreclosed career development and satisfaction for overseas doctors, who were clearly not “local.” A frequent comment was that in the mid-1970s the consultants would say “I have shortlisted. This is my shortlist. I have included all those that I could … the names I could pronounce and spell.”55 Stories of these barriers to entry in more desirable specialties

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were echoed by almost all our interviewees. Perversely, as we have shown, the marginalization of geriatric medicine meant that promotion up the ladder became possible, even if it meant that hopes for success in other specialties such as cardiology or surgery had to be given up. Importantly, it also gave doctors opportunities to contribute to developing a growing discipline to shape it through rearranging the spaces of care, learning and disseminating how to care better, and thus institutionalizing a set of care practices across the United Kingdom. Creating spaces where learning could happen meant taking chances for migrant doctors seeking their way in the specialty. This could be future-oriented risk-taking but it offered personal and professional opportunities for change, which could also provide something new to local populations. From such centres, whether or not they were attached to teaching hospitals, teaching and learning – for junior doctors, nurses, and general practitioners – could be developed, and substantive evidence for the efficacy of the specialty’s approach became evident, as we explore in the next section. Establishing Geriatrics / Becoming Established in Geriatrics The South Asian doctors we interviewed embedded themselves within geriatric medicine and the NHS often by becoming attached to senior doctors at centres where there was innovative and successful practice. Then, as we show, they began to set up their own centres.

Establishing Geriatrics and the Role of Centres of Learning As we saw earlier, geriatrics came to be established in centres away from teaching hospitals in the big cities where services were so poor that these disregarded spaces required and offered the most opportunities for innovation. Thus Sunderland, rather than the teaching hospital in Newcastle, became the centre of excellence in geriatric practice, for several reasons. In Sunderland, the snooty hospital was the old voluntary hospital, so the Royal Infirmary was where all the nice people were doctors and the nice people were patients. The less nice doctors were in the old municipal hospital and the less nice patients were there too. But as so often happened – it happened in Southampton as well – the municipal hospitals were endowed with much bigger grounds, so that when

“Without racism there would be no geriatrics”  199  massive expansion came, it largely couldn’t be in the old ­voluntary hospitals, because they outstripped the envelope size and quickly o ­ utstripped the site size too. So that eventually, when the major rebuild of hospitals took place in Sunderland, it was on the general hospital site rather than on the restricted Royal Infirmary site. Anyhow, Oscar Olbrich – this is in the 1940s–1950s, soon post-war – developed a research unit there. He developed an acute admissions unit. He had recruited good remedial therapy staff and social work staff and that sort of thing and had persuaded the hospital management committee – probably Jack Cohen was the chairman of that – and the Newcastle Regional Hospital Board – they still had a board in those days – to fund lots of medical posts, so it was a relatively well-staffed unit.56

Their physical location, the backing of individuals such as Jack Cohen and the Labour town council, and most importantly the leadership of individuals who innovated their practices and established new ways and norms for the care of older people was paramount in establishing these centres of excellence. As we see in the extract above, the practice in Sunderland was led initially by Oscar Olbrich, a refugee from Vienna who had wanted to do nephrology in Edinburgh but, being a refugee and not an Edinburgh graduate, he realized that he had little chance of being appointed as a consultant there and therefore moved to Sunderland. Olbrich, along with his assistant, Dr Eluned Woodford Williams, developed geriatrics through the 1950s, and Sunderland was then ably led by Williams for a number of years, providing opportunities for several of our SAG interviewees.57 Sunderland was one of the first places to use age-related admissions policy – admitting all patients over a particular age, in this case sixty-five – into a ward, irrespective of their ailments. This practice was based on the recognition of, and the desire to, care for the special needs of an age cohort. Dr Brown, while talking about the work of Dr Olbrich, argued that this care was underlain by “elementary principles which is ‘Just give the same standard of care to old people as you give to others.’”58 This practice was subsequently adopted and adapted in centres by many who passed through Sunderland. These centres of good practice were not only claiming excellence in care but were also significant in the development of geriatrics in the United Kingdom. But in the words of Philip Hutton, “How much these ‘pockets’ were just pockets of development and how long it took for other places to catch up is a question.”59 Hence, the spread of practices depended on people passing through these centres, which soon became reified as centres of learning, through which those in the learning stages

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of the medical career hierarchy (especially as registrars and senior registrars) had to pass to claim knowledge. As one SAG interviewee recalled, having been through a centre of learning clearly gave him an edge and shaped his career decisions: If I were to make a career in U.K., geriatric medicine was perhaps a better career for me, especially being trained in Sunderland. But again, as I said, the career progression was so rapid in Sunderland that, you know, I just rode with it … And how did you feel about going into geriatric medicine then? No problem, because what I was seeing the geriatric medicine there was very appealing branch, because we had … funnily enough we also had a first special dedicated six-bed ward for MI [myocardial infarction] care in Sunderland.60

Passing through these centres gave geriatric trainees pride in their field and a form of capital that they could use to develop their careers elsewhere. Association with such centres of learning thus shaped career trajectories. However, the success of centres such as Sunderland was also related to the ways in which those who passed through them extended its reach by following practices they had learned there. They were not about individual learning but about embedding good practice as a model for policy development. “Models, in this sense, do not simply designate placespecific processes of innovation or sites of creative invention, as the diffusionist paradigm might have it; they connote networks of policymaking sites, linked by overlapping ideological orientations, shared aspirations, and at least partly congruent political projects.”61 In effect this bundling of good practice laid the basis for solving a set of policy problems that were extant throughout the United Kingdom during that period.

Becoming Established in Geriatrics and Building Their Own Centres Geriatricians who passed through Sunderland also made choices about where they might have the most impact and where they might have the most chance to adopt and adapt these innovations when making decisions about their career. As one SAG interviewee remembered, I found out that the unit is very well developed, nothing I can do. Then I had other interview I didn’t go, then I came to Rotherham one, in between

“Without racism there would be no geriatrics”  201  I’d got, Harrogate, which I refused because I came to know that it’s not I, my consultant Pengelly wants Harrogate, because he like Harrogate, posh area you see. I don’t want to go posh area. Then I came to Rotherham and looked at the unit. Nothing was here. Blank sheet, in Rotherham, nothing, no junior staff, lots of beds, no geriatric, nothing, no services, lot of patient here long stay.62

He recognized the potential that the “blank sheet” gave him to practise the learning he had acquired in Sunderland. It would allow him to set his own mark. As such, professional growth, it appears, was intimately tied to practising innovation in new territories and spaces, thus extending the reach of these forms of innovation. It offered a way of forwarding their field. Finally, as the speciality became more established, these stories of entering geriatrics for lack of choice become tempered by stories of how people chose geriatrics as a discipline: And what was it that you particularly liked about geriatrics? Because it was still general medicine, a lot of … and you could do a lot of specialities within the speciality itself, but also the multidisciplinary working, because I’d never seen it before and I thought it was wonderful it worked. And was there anything particularly distinctive about the ways in which geriatric medicine was practised in that hospital? Yeah, in the hospital where I worked, where I worked as an SHO [senior house officer] the geriatrics was very high profile. And we had some really great geriatricians in it who were both academically brilliant but had a lot of national standing and ... made geriatrics look a very attractive speciality.63

Migrant doctors thus became not only the workhorses of the new specialty as it developed, away from the main teaching hospitals and centres, in the district hospitals in north and south Wales, the Northwest, Midlands, and Northeast of England but the leaders also set out an agenda on how new departments should expand and teach. Conclusion In this chapter we have focused on the development of a specialty in one of the less desirable specialties, geriatrics, within the United

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Kingdom’s National Health Service. This in many ways echoed the status of migrant doctors who too were marginalized within the NHS. From the 1960s through to the 1980s this migration was dominated by South Asians who came to the United Kingdom to obtain training, as working there had been considered part of the natural career progression for many doctors in the Commonwealth. Shortages of home-grown doctors and the historical relationship between the United Kingdom and its former colonies meant that the NHS attracted and depended on the skills and commitment of overseas-trained staff. “Without racism there would be no geriatrics” tells the story from the perspective of those doctors. Once in the United Kingdom they found that, although South Asians considered themselves a part of the same medical fraternity, the references the migrant doctors obtained from their home countries rarely carried weight. Instead they initially found access to jobs through their compatriots who were already working in the NHS. Access to more substantive posts, however, depended on being able to access patronage networks of non-migrant doctors. This was more easily done in some specialities where there were few non-migrant doctors, either because of the nature of the speciality or because of the places where they were practised. One such area in which migrant doctors found opportunities to progress in their career and where they benefited from the push to expand and develop services was in the care of older people. In doing so they also played a central role in its development. Interviews by Margot Jefferys with those who originally set up the geriatric specialty in the early years of the NHS, followed up by our interviews with South Asian overseas-trained doctors demonstrate how, to grow and become established, the geriatric specialty depended on migrant doctors. Thus a marginalized group of doctors were brought into contact with marginalized patients. Individual interviews enabled us to go beyond counting heads to establish a spoken presence, over time, which we argue has had a direct impact on health debates. A recurring theme is the extent to which the South Asian doctors we interviewed were not only providing a service but were innovating and taking the practices they had learnt in the centres of excellence beyond the selected pockets of development. The doctors were in part able to overcome the history of racism in the NHS that had led them to be in the speciality of geriatrics by adopting and adapting a career in this speciality. They thus helped to advance the discipline, although this is a story that is not widely recounted in the history of the discipline. Specifically, our study of migrant doctors and

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their role in the emergence and establishing of the geriatric specialty demonstrates an aspect of health policy that is still of great concern today. In an era where concern over the future health needs of older members of society is pressing, recognition for what may be learned from the experiences and commitments of migrant doctors is crucial. Notes 1 Throughout we use the term South Asian to refer to people from countries in the southernmost tip of the Asian continent, from Afghanistan to Sri Lanka and including Burma, Nepal, Bhutan, and the islands of the Indian Ocean. In so doing we are following the practice of the World Bank and common usage in the United Kingdom. 2 M.H. Fisher, Counterflows to Colonialism: Indian Travellers and Settlers in Britain 1600–1857 (New Delhi: Permanent Black, 2004); R. Visram, Asians in Britain: 400 Years of History (London: Pluto, 2002); A. Martin Wainwright, “The Better Class” of Indians: Social Rank, Imperial Identity and South Asians in Britain, 1858–1914 (Manchester: Manchester University Press, 2008). 3 P. Raghuram, L. Henry, and J. Bornat, “Ethnic Clustering among South Asian Geriatricians in the UK: An Oral History Study,” Diversity in Health and Care 6 (2009): 287–96. 4 J. Armstrong, “Doctors from ‘the End of the World’: Oral History and New Zealand Medical Migrants, 1945–1975,” Oral History 42, no. 2 (2014): 41–9. 5 D.J. Smith, Overseas Doctors in the National Health Service (London: Policy Studies Institute, 1980); M. Jefferys, “Recollections of the Pioneers of the Geriatric Medicine Specialty,” in Oral History, Health and Welfare, ed. J. Bornat, R. Perks, P. Thompson, and J. Walmsley, 75–96 (London: Routledge, 2000); P. Thane, Old Age in English History: Past Experiences, Present Issues (Oxford: Oxford University Press, 2002); J. Evans, “Geriatrics in the United Kingdom: What Happened Next,” Journals of Gerontology, ser. A, 59, no. 11 (2004): 1160–1. 6 Stephen Katz, Disciplining Old Age: the Formation of Gerontological Knowledge (Charlottesville: University Press of Virginia, 1996). 7 Evans, “Geriatrics in the United Kingdom,” 1160. 8 L. Amulree, Adding Life to Years (London: National Council of Social Services, 1951), 39. 9 M. Warren, “Care of Chronic Sick: A Case for Treating Chronic Sick in Blocks in a General Hospital,” British Medical Journal 2, no. 4329 (25 December 1943): 822–3.

204  Joanna Bornat, Parvati Raghuram, and Leroi Henry 10 A. Barton and G. Mulley, “History of the Development of Geriatric Medicine in the UK,” Postgraduate Medical Journal 79, no. 930 (2003): 229–34; G.C. Rivett, National Health Service History, chap. 1, http://www. nhshistory.net/cvrivett.htm. 11 R. Means and R. Smith, The Development of Welfare Services for Elderly People (London: Croom Helm, 1985); M.J. Denham, “The History of Geriatric Medicine and Hospital Care of the Elderly in England between 1929 and the 1970s” (PhD diss., University College, London, 2004); Paul Bridgen, “Hospitals, Geriatric Medicine, and the Long-term Care of Elderly People 1946–1976,” Social History of Medicine 14, no. 3 (2001): 507–23. 12 Susan Pickard, “The Role of Governmentality in the Establishment, Maintenance and Demise of Professional Jurisdictions: The Case of Geriatric Medicine,” Sociology of Health and Illness 32, no. 7 (2010): 1072–86; Denham, “History of Geriatric Medicine.” 13 G.F. Adams, “Eld Health: Origins and Destiny of British Geriatrics,” Age and Ageing 4, no. 2 (May 1975): 65–8. 14 John E. Morley, “A Brief History of Geriatrics,” Journals of Gerontology, ser. A, 59, no. 11 (2004): 1132–52; Lissy Jarvik, “Commentary: A Brief History of Geriatrics,” Journals of Gerontology, ser. A, 59, no. 11 (2004): 1162–3. 15 David B. Hogan, “History of Geriatrics in Canada,” Canadian Bulletin of Medical History / Bulletin canadien d’histoire de la médecine 24, no. 1 (2007): 131–50. 16 The seventy-three Jefferys interviews are catalogued in the British Library (hereafter BL) Sound Archive with the collection title “Oral History of Geriatrics as a Medical Specialty” (hereafter OHGMS) cat. no. C512, http://cadensa.bl.uk/uhtbin/cgisirsi/x/0/0/5?searchdata1=CKEY504060 1&library=ALL. 17 Margot Jefferys. 18 Dr Morag Insley (born United Kingdom 1924, WHO consultant in geriatric medicine), interviewed by Margot Jefferys, OHGMS, BL cat. no. C512/36/01–02. 19 Dr Eric Morton (born United Kingdom 1919, consultant physician in geriatric medicine), interviewed by Margot Jefferys, OHGMS, BL cat. no. C512/4/01–02. 20 Dr Richard Benians (born United Kingdom 1906, consultant physician in geriatric medicine), interviewed by Margot Jefferys, OHGMS, BL cat. no. C512/55/01–02. 21 Dr Thomas Rudd (born United Kingdom 1906, consultant physician in geriatric medicine), interviewed by Margot Jefferys, OHGMS, BL cat. no. C512/21/01.

“Without racism there would be no geriatrics”  205  22 Dr Mohan Kataria Singh (born India 1917, arrived United Kingdom 1947, consultant physician in geriatric medicine), interviewed by Margot Jefferys, OHGMS, BL cat no. C512/50/01. 23 ESRC funded project, “Overseas-Trained South Asian Doctors and the Development of Geriatric Medicine,” grant reference number RES-06223-0514, 2007–09. All the interviews have been transcribed and have been deposited at the BL under “Overseas Trained South Asian G – Interviews,” cat. no. C1356, http://cadensa.bl.uk/uhtbin/cgisirsi/x/0/0/5?searchdata 1=CKEY7308185&library=ALL. 24 See, for example, Martin Gorsky, “‘To Regulate and Confirm Inequality’? A Regional History of Geriatric Hospitals under the English National Health Service, c. 1948–c. 1975,” Ageing and Society 33, no. 4 (2013): 598–625. 25 Royal College of Physicians, High Quality Long Term Care for Elderly People: A Report of the RCP and BGS (London: Royal College of Physicians, 1972). 26 The Commonwealth Immigrants Act (1962) ended the rights of British Commonwealth citizens to migrate to the United Kingdom without government vouchers. This was followed by the 1968 act, which gave rights only to those born in the United Kingdom or with a parent or grandparent born in the United Kingdom. The 1971 Immigration Act introduced the concept of partiality or right of abode, which is tied to citizenship. 27 HMSO, Royal Commission on the National Health Service, Cmnd 1615 (London: HMSO, 1979). 28 P. Thompson, The Voice of the Past: Oral History, 3rd ed. (Oxford: Oxford University Press, 2000); R. Perks and A. Thomson, eds., The Oral History Reader, 2nd ed. (London: Routledge, 2006); L. Abrams, Oral History Theory (London: Routledge, 2010). 29 J. Bornat, P. Raghuram, and L. Henry, “Revisiting the Archives: A Case Study from the History of Geriatric Medicine,” Sociological Research Online 17, no. 2 (2012): http://www.socresonline.org.uk/17/2/11.html. 30 J. Bornat, L. Henry, and P. Raghuram, “The Making of Careers, the Making of a Discipline: Luck and Chance in Migrant Careers in Geriatric Medicine,” Journal of Vocational Behavior 78, no. 3 (2011): 342–50. 31 Raghuram, Henry, and Bornat, “Ethnic Clustering among South Asian Geriatricians in the UK,” 287–96. 32 G. Forbes, “Medical Careers and Health Care for Indian Women: Patterns of Control,” Women’s History Review 3, no. 4 (1994): 515–30; M.H. Fisher, Counterflows to Colonialism: Indian Travellers and Settlers in Britain 1600–1857 (New Delhi: Permanent Black, 2004); Bornat, Raghuram, and Henry, “Revisiting the Archives.”

206  Joanna Bornat, Parvati Raghuram, and Leroi Henry 33 C. Kyriakides and S. Virdee, “Migrant Labour, Racism and the British National Health Service,” Ethnicity and Health 8, no. 4 (2003): 283–305. 34 M. Anwar and A. Ali, Overseas Doctors: Experience and Expectations (London: Commission for Racial Equality, 1987), 72; N. Coker, ed., Racism in Medicine: An Agenda for Change (London: King’s Fund Publishing, 2001), 107, 111. 35 K. Decker, “Overseas Doctors: Past and Present,” in Coker, Racism in Medicine, 25–47; M. Goldacre, J. Davidson, and T. Lambert, “Country of Training and Ethnic Origin of UK Doctors: Database and Survey Studies,” British Medical Journal 329, no. 7466 (2004): 597. 36 A. Esmail and D. Carnall, “Tackling Racism in the NHS,” British Medical Journal 314, no. 7081 (1997): 618. 37 Dr MG, who preferred to be anonymized, born Sri Lanka 1944; arrived United Kingdom 1964, consultant physician, interviewed, 2009; SAG Collection, BL cat. no. C1356/28. 38 Dr Suchel Bansal (born India 1947, arrived United Kingdom 1973, consultant geriatrician in geriatric medicine), interviewed by Leroi Henry, 4 April 2008, SAG Collection, BL cat. no. C1356/04. 39 Simpson, Snow, and Esmail, “Providing ‘Special’ Types of Labour.” 40 J. Maisonneuve, C. Pulford, T. Lambert, and M. Goldacre, “Career Choices for Geriatric Medicine: National Surveys of Graduates of 1974–2009 from All UK Medical Schools,” Age and Ageing 43, no. 4 (2014): 535–41. 41 BGS Minutes of the Meeting of the Working Party on Geriatric Medicine, Aspects of Recruitment and Relationship to General Medicine, St Pancras Hospital, 14 November 1975. 42 Health Consultants and Specialists Association, “The Less Popular Specialties,” working paper of the Council of the HCSA (1984), BGS Archives, 12/246. 43 See Bornat, Henry, and Raghuram, “Making of Careers.” 44 Dr Marion Hildick-Smith (born 1928, consultant physician in geriatric medicine), interviewed by Margot Jefferys, OHGMS, BL cat. no. C512/51/01–02. 45 Dr Pradip Khanna (born 1952, arrived United Kingdom 1978, consultant in geriatric medicine), SAG Collection, BL C1356/14. 46 Bansal, BL C1356/04. 47 P. Raghuram, J. Bornat and L. Henry, “Difference and Distinction? NonMigrant and Migrant Networks,” Sociology 44, no. 4 (2010): 623–41. 48 Dr PO21, interviewed by Parvati Raghuram, 15 January 2009, SAG Collection, BL cat no. C1356/28. 49 See Raghuram, Bornat, and Henry, “Difference and Distinction?”

“Without racism there would be no geriatrics”  207  50 Dr Anant Narayan (born India 1946, arrived United Kingdom 1976, consultant physician interested in general medicine and geriatric medicine), interviewed by Parvati Raghuram, 1 April 2008, SAG Collection, BL cat. no. C1356/22. 51 Khanna, BL C1356/14. 52 Dr Dwarak Sastry (born India 1945, arrived in United Kingdom 1973, consultant physician in general medicine), interviewed by Leroi Henry, 21 January 2008, SAG Collection, BL cat. no. C12356/12. 53 Dr Mohamed Shaukat Ali (born Bangladesh 1939, arrived United Kingdom 1965, consultant physician), interviewed by Leroi Henry, 24 June 2008, SAG Collection, BL cat. no. C1356/03. 54 Dr Ragru Ban Shukla (born India 1936, arrived United Kingdom 1969, consultant physician), interviewed by Leroi Henry, 30 October 2008, SAG Collection, BL cat. no. C1356/20. 55 Sastry, BL cat no. C12356/12. 56 Dr William Davison (born 1925, consultant physician in geriatric medicine), interviewed by Margot Jefferys, OHGMS, BL cat. no. C521/56/01–03. 57 Barton and Mulley, “History of the Development of Geriatric Medicine in the UK,” 229–34; Rivett, National Health Service History, chap. 1. 58 Dr Ian MacDiarmid Brown (born 1919, consultant physician in geriatric medicine), interviewed by Margot Jefferys, OHGMS, BL cat. no. C521/53/01–02. 59 Dr Philip Hutton (no DOB given, consultant physician in geriatric medicine), interviewed by Margot Jefferys, OHGMS, BL cat. no. C512/11/01. 60 Dr Virasal Prajal Hajela (born India 1933, arrived United Kingdom 1956, consultant physician in geriatric medicine), interviewed by Leroi Henry, 12 June 2008, SAG Collection, BL cat. no. C1356/18. 61 J. Peck and N. Theodore, “Mobilizing Policy: Models, Methods, and Mutations,” Geoforum 41 (2010): 171. 62 Dr Bijoy Krishna Mondal (born India 1949, arrived United Kingdom 1965, consultant physician geriatrician), interviewed by Leroi Henry, 30 April 2009, SAG Collection, BL cat. no. C1356/56. 63 Dr LO21 (preferred to be anonymized) (born India 1940, arrived in the United Kingdom 1976, consultant), interviewed by Leroi Henry, 2009, SAG Collection, BL cat no. C1356/24.

9 Providing “Special” Types of Labour and Exerting Agency: How Migrant Doctors Have Shaped the United Kingdom’s National Health Service julian m. simpson, stephanie j. snow, and aneez esmail Introduction Since the establishment of the National Health Service (NHS) in 1948 as a state-run system providing universal access to health care, nonU.K.-born doctors have constituted a significant proportion of its workforce.1 Yet it is only recently that their contribution, beyond the simple provision of labour, has become the focus of historical enquiry. This chapter builds on an emerging body of research by historians who have explored the roles of migrant doctors. It draws on a broader social science literature that provides evidence of their presence and describes the roles they played. It shows that, to borrow the terminology used by Castles and Miller, as well as being a source of “additional labour,” they have provided “special types of labour”2 throughout the history of the NHS. They have also been able to exert agency on the British health-care system. They therefore played a central role in its development. Their work can be described as “special” in terms of the nature of their employment. Overseas doctors have traditionally been concentrated in unpopular fields of medicine. A study of (white and nonwhite) overseas-trained NHS consultants appointed between 1964 and 2001 found that they were over-represented in geriatric medicine, psychiatry, learning disability, and genitourinary medicine.3 In 2001, over 50 per cent of NHS consultants in learning disability who had been appointed between 1964 and 1991 were non-white and overseastrained.4 The same was true of only 3 per cent of consultants working in general medicine.5 General practice in deprived areas also offered

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opportunities to a substantial number of migrant doctors who decided to build careers outside the hospital system.6 This pattern can be connected to the status of different types of medical work and the social aspirations of doctors as middle-class professionals. A study published in the British Journal of General Practice found that general practitioners were particularly attracted to rural and coastal locations and areas with good social and cultural amenities.7 There is, in addition, a well-established hierarchy of work among medical professionals, influenced by perceptions of the difficulty involved in acquiring the necessary skills, the nature of complaints being treated (treating chronic conditions is associated with low status), and the age of patients (work with the elderly is unpopular).8 The labour of a significant proportion of migrant doctors can thus be defined as “dirty work,”9 involving as it did the performance of tasks that were constructed by the medical profession in the United Kingdom as somehow undesirable or not meeting their aspirations. The clustering of medical professionals in such areas, allied to the social status and professional autonomy that they had as doctors, brings to the fore the question of the extent of their influence on the development of the NHS. Understanding the specific nature of the impact that these doctors had on the health-care system in which they worked is therefore of historiographical relevance. It can also reframe our contemporary understanding of the nature of the NHS, how it has functioned in the past, and how it continues to operate. Echoing the argument made by Marie-Claude Thifault10 about the role of a “caste” of women in shaping health services in Quebec and Canada, we argue that it is necessary to conceive of successive generations and different groups of migrant doctors as fulfilling specific roles and as being actors in the development of health care in the United Kingdom. Like women in the Canadian health-care system, they tended to find themselves grouped in undervalued roles (thus in a sense they were members of a “caste” confined to particular types of work) and were able at times to shape their professional environment. As Bornat, Raghuram, and Henry show in this volume, migrant doctors have played a “constitutive role” in the development of the NHS by, for instance, shaping specialties such as geriatrics. Appreciating and recognizing the extent of the importance of the function of these doctors can lead to a reappraisal of the factors that contributed to the making of the U.K.’s health-care system and an appreciation for their complexity and multidirectionality. Greater understanding of the impact of

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generations of migrant doctors is therefore central to detailed understanding of the history of the National Health Service and can provide an important historiographical challenge to accounts of the development of the organization. The implications of this argument for the “making” of the NHS are explored in more detail here with specific reference to two recent oral history research projects carried out by the authors at the University of Manchester. They focused on one geographical location where migrant doctors were concentrated and a professional niche where they clustered. The roles played by black and ethnic minority migrant doctors in Manchester between 1948 and 2009 and by overseas-born South Asian general practitioners (GPs) across Great Britain between 1948 and 1983 show that the “special” nature of the work done by migrant doctors can also be connected to the locations in which medicine was practised – underscoring the importance of developing a spatial analysis of medical migration, as Bornat, Raghuram, and Henry argue. These doctors were employed in working-class areas as a consequence of the racist and “heterophobic”11 environment that they encountered in the NHS. These studies provide additional evidence that discriminatory employment practices and the disregard of U.K.-trained doctors for certain types of medical work are key aspects of the history of the U.K. health-care system. They also show that the individual and collective agency of migrant doctors was a significant factor in the shaping of the NHS in particular parts of the United Kingdom and in certain medical fields. The history of health care in locations such as Manchester and in specialties such as general practice was to a degree the product of the individual and collective agency of migrant doctors. Exploring and analysing the ways in which they built careers in the face of discrimination, established relationships with patients, developed health services, and formed professional and social networks leads us to a more nuanced and layered sense of the actors and forces that “made” the NHS. The approach we adopt here is therefore grounded in a conception of history as a social science12 that, as well as adding to our understanding of the past, can enhance our understanding of the present.13 In this context, we draw on social theory to provide a framework within which historical evidence and the significance of the narratives of participants is discussed. Our aim is to draw out themes from the emerging historiography on migrant doctors in the NHS, discuss them in relation to further evidence we have gathered on South Asian migrant doctors, relate these findings to social theory, and point to further lines

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of enquiry that may prove fruitful when understanding the past and present nature of the NHS. Defining “Migrant” Doctors Referring collectively to “migrant” doctors is of course problematic in this context. First, the term covers a wide range of groups across a period of over sixty years since the inception of the National Health Service. Many of the overseas-trained doctors who worked in the NHS in the years immediately following its establishment were refugees from Central Europe.14 From the late 1950s, migration from the Indian subcontinent played an increasingly important part in the staffing of the organization.15 Later, migratory flows from the European Union helped to limit the effects of staff shortages.16 Other groups, such as Irish, African, Canadian, or Australian doctors have been a constant presence in the NHS workforce.17 While the literature does not provide detailed information on the historical roles of all of these doctors, it does indicate that they tended to be concentrated in certain types of work – even if this tendency was greater or lesser, depending on the ethnicity of the doctor concerned. David Smith found, for instance, that doctors who qualified in what he termed “white anglophone” countries were much more likely to be able to access training opportunities in more prestigious teaching districts than doctors who qualified in the Indian subcontinent or in Arab countries and Iran.18 Moreover, given the imperial and post-imperial hinterland to some of these movements and the particular nature of the relationship between the United Kingdom and the Republic of Ireland, describing doctors as migrants is in some cases arguably anachronistic. It certainly does not necessarily reflect the language used at the time. An Indian doctor migrating in 1946 and who subsequently had a career in the NHS would have, for instance, moved initially within the British Empire rather than between distinct national political entities. Even when the formal British Empire was dismantled, the “socio-cognitive community”19 that linked medicine in the United Kingdom and South Asia continued to draw to the former metropole South Asian doctors who aspired to gain British qualifications.20 South Asian GPs interviewed about their initial movement to the United Kingdom thus generally do not describe the moment of migration as a hiatus, but rather as a natural continuation of a medical education received in the Indian subcontinent.21 The presence of white overseas-trained doctors in the United Kingdom was driven

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by similar forces, as Armstrong has noted in the case of New Zealand.22 This notion of shared socio-cognitive space is equally relevant in the Republic of Ireland (another important provider of medical labour to the United Kingdom) to the extent that Irish doctors were sometimes counted alongside U.K. doctors in studies of overseas doctors, as they were considered to be part of the same medical system.23 The category of migrant doctors in the NHS therefore covers a wide range of groups, across a period of more than sixty years, during which the nature of migratory flows evolved considerably. Some doctors who, from a twenty-first-century perspective, can be described as migrants are in fact British citizens. Some are white anglophones and some are nonwhite in a context where ethnic background was an important factor in determining the trajectory of careers. Refugees from Central Europe migrated in very different circumstances and faced challenges different from those of graduates from the Indian subcontinent educated in English in a post-imperial context. It is important therefore to recognize the extreme diversity of experience behind the label of “migrant doctors.” Another complicating factor is the temporary migration of doctors to obtain training – a movement seldom conceived of as permanent but that can lead to permanent settlement.24 Occupying junior posts in hospitals forms part of the postgraduate education that doctors gain when specializing in a branch of medicine. It was therefore possible for the United Kingdom to employ doctors from other countries in junior posts in the 1960s and 1970s while presenting them as an educational opportunity. This explains the development of an official discourse that claimed that the reliance of the NHS on migrant labour was in fact a form of aid to the Commonwealth. As late as 1981, Doyal, Hunt, and Mellor described this argument as being “the traditional justification” for the presence of large numbers of migrants in the NHS.25 While this sort of official claim that recourse to migrant labour was in fact a noble gesture made for the benefit of former colonies might be met with wry amusement by a contemporary reader, it is again important to acknowledge when writing history that those we might characterize as migrant doctors today were not necessarily seen as migrant doctors when they came to the United Kingdom. Nor would they necessarily have described themselves as such. In the late 1980s, a report by the U.K. Commission for Racial Equality still felt it necessary to underline the fact that “the relationship between overseas doctors and the NHS is complex. It is no longer temporary, as some overseas doctors themselves and many of the administration of

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the NHS thought originally.”26 It was still possible to argue, for much of the period under consideration, that South Asian doctors and doctors from other Commonwealth countries working in United Kingdom hospitals were not in fact migrants. A striking example is provided by the fact that Enoch Powell, in his 1968 “Rivers of Blood” speech, which has come to symbolize postwar British anti-immigrant sentiment, unequivocally excluded doctors from his apocalyptic warnings about the impact of immigration on the United Kingdom’s social fabric: “This has nothing to do with the entry of Commonwealth citizens, any more than of aliens, into this country, for the purposes of study or of improving their qualifications, like (for instance) the Commonwealth doctors who, to the advantage of their own countries, have enabled our hospital service to be expanded faster than would have otherwise have been possible. They are not, and have never been, immigrants.”27 Of course, Powell’s views may simply constitute an instance of political expediency. As a former minister of health, he would have known that he was open to the accusation of hypocrisy, having facilitated the arrival of medical migrants in the early 1960s. This would certainly help to explain the somewhat unlikely reference to the centrality of an overseas workforce to the functioning of the NHS in such a speech. It remains that this was seen as a credible position to adopt in the late 1960s. Discussing the roles of “migrant doctors” in the NHS therefore involves the creation of a category that would not necessarily have been perceived as appropriate at the time by the doctors themselves or by those who had recourse to their labour. Many of the migrant doctors who worked in the NHS were temporary migrants28 who collectively played a vital role in maintaining the NHS workforce. In the overall structure of the NHS, the fact that some doctors returned was of little significance, as they were replaced by others. There are therefore no simple answers to the question of how to define a migrant doctor. The term has been used here in preference to international medical graduates, as it indicates that migrants were working as doctors, as opposed to being medically qualified and resident in the United Kingdom – a key distinction when attempting to gauge the impact that the migration of doctors had on the delivery of health care. While it could be argued that discussing the experiences of Central European doctors, Australian doctors, Irish doctors, South Asian doctors, and those of temporary migrants separately would provide greater historical coherence,29 constructing these doctors collectively as

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migrants in the U.K. National Health Service is essential to facilitate our understanding of a key dimension of the development of the NHS. It is, in this context, a label designed to facilitate an analytical reflection that highlights common points between the experiences of doctors who moved across national borders as currently defined and worked in the NHS. The development of such an analysis naturally involves making comparisons between different groups but also drawing on evidence taken from different times to support our theoretical reflection. We accept that from a purely historical point of view, it would be more satisfying to focus on a specific group at a specific time. We believe that conducting this exercise is nevertheless worthwhile, as it enables us to gain an appreciation of why the roles played by different groups of migrant doctors at different times should be seen as a central aspect of the development of the British health-care system. The Marginalization of Migrant Doctors in NHS Histories The U.K. National Health Service has always depended on the labour of consecutive and overlapping waves of medical migration. Substantial numbers of doctors from a range of nationalities have over the years contributed to maintaining the staffing levels of the British health-care system. The main migratory movements have been from the former British Empire and more recently from the European Union.30 Less than ten years after the NHS was created, the Willink Committee on medical manpower found that 12 per cent of doctors in a random sample taken from the medical directories of 1953 and 1955 were mainly overseas-trained.31 The committee noted that a majority of these doctors had entered Britain during or after the Second World War, and it is therefore likely that a substantial proportion of the sample of doctors was of ­Central European origin. Paul Weindling32 has estimated that just over 5,000 medical refugees came to the United Kingdom between 1933 and 1950 – the majority from Germany, Poland, Austria, and Czechoslovakia. In 1960, 40 per cent of junior posts in hospitals were filled by overseas doctors.33 By then, the principal influx of doctors was from the Indian subcontinent: around 10,000 doctors from India or Pakistan were working in the United Kingdom in the late 1970s.34 Other movements were extremely significant. Ireland has traditionally been a key supplier of medical labour to the United Kingdom.35 In the 1950s, an estimated 120 physicians a year left Eire for the United Kingdom, and in 1965, over 3,500 Irish-born physicians were working in the

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United Kingdom.36 This U.K. dependency on doctors trained outside of its own medical schools continues to the present day. In 2007, almost a third of doctors practising in the NHS were from overseas, and they accounted for nearly 60 per cent of new registrations with the U.K. General Medical Council.37 In the same year, over 4,000 German doctors were practising in the United Kingdom.38 The contrast between the significant numbers of doctors who work in the NHS and their marginalization in historical accounts of the development of the organization is stark. As outlined by Gorsky’s39 review of the historiography of the National Health Service, the main focus of academic research into the history of the NHS has been on official policy and its development. General histories of the NHS contain very little on the impact of immigration.40 The migration of doctors and other health-care professionals is dealt with in a cursory fashion and in quantitative terms. Charles Webster, having noted that by the 1960s around 40 per cent of junior hospital posts were filled by overseas doctors, concludes that there was an “undesirable degree” of reliance on migrants.41 Geoffrey Rivett42 similarly limits his engagement with immigration to staffing concerns, even though he recognizes that “doctors from overseas have often kept the NHS running.” In spite of this implicit acknowledgment that immigration is central to the history of health-care services in Britain, Rivett’s account does not build on this insight and includes only passing references to overseas doctors and nurses. Charles Webster similarly stops short of establishing a connection between the numerical significance of immigration and the way in which the NHS developed, in spite of the fact that his exploration of the history of the NHS points towards the importance of immigration, in particular from the Indian subcontinent, as one driver of the development of health services in Britain. Webster notes, for instance, that “recruitment into general practice improved between 1964 and 1979” and draws attention to the dramatic increase in the number of health centres in the United Kingdom.43 He also mentions that by 1979 about 20 per cent of GPs were migrants, that this figure had increased to 25 per cent by the 1990s, and that most overseas GPs came from the Indian subcontinent.44 There is therefore, in the historiography of the NHS, an implicit assumption that the roles of migrant doctors are confined to the provision of labour in a context of workforce shortages. Such approaches overlook the historical importance of the specific nature of the roles played by migrant doctors since the inception of the NHS. Their contribution to the organization should be seen as

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providing “special types of labour” as well as “additional labour.” The nature of their labour differed from that of U.K.-trained doctors in at least three respects: it was concentrated in specific fields of medicine, in junior roles, and in particular geographical areas. Specialties such as psychiatry, general practice, and geriatrics have historically depended on migrants and offered them professional opportunities.45 Migrant doctors were also concentrated in junior roles. By the late 1970s, over 50 per cent of senior house officer posts and 60 per cent of registrar posts46 were filled by doctors from outside the United Kingdom, as opposed to 16 per cent of consultant posts.47 Finally, they were disproportionately located in less affluent parts of the United Kingdom. In the early 1990s, a third of general practitioners in the northern postindustrial cities of Manchester and Sunderland and over 50 per cent in some deprived parts of Greater London had been trained as doctors in the Indian subcontinent.48 The figures for the more affluent c­ ounties of Somerset and Dorset were of 0.87 per cent and 1.47 per cent respectively.49 Irish and Central European general practitioners have also historically played an important role in provision in working-class areas.50 As indicated by these figures for general practice, the patterns of deployment of migrants in more junior positions, in less popular fields of medicine, and in less affluent areas intersected. In 1974, 31 per cent of consultant posts and 60 per cent of registrar posts in geriatrics were filled by ­overseas-trained graduates.51 In this respect, the deployment of migrant doctors in the NHS is comparable to the roles frequently assigned to other migrant workers in Western economies who are deployed in professional occupations that the local population see as unrewarding.52 It is in this sense that migrants can historically be seen to have done the “dirty work”53 of British medicine: they performed roles that did not meet the professional or social aspirations of locally trained doctors. This is one of the two key dimensions of the role of migrant doctors in the NHS. In addition, as doctors, their professional status placed them in positions where they were able to shape the nature of the system they worked in. The importance of understanding the agency of migrant doctors and its effect on the development of the NHS has been highlighted by recent work that engages with the history of migrant doctors.54 Yet there are many significant gaps. We know little, for instance, about the impact on the development of British psychiatry of psychiatrists from Central Europe or the Indian subcontinent. Other work has illustrated the potential that focusing on the actions of migrants

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within the NHS system has to contribute to our understanding of the history of the organization. Bornat, Raghuram, and Henry, in this volume, show the importance of the professional clustering of South Asian doctors in geriatrics, which became a professional niche for migrant doctors facing discrimination. In the words of one of their research participants, “Without racism, there would be no discipline of geriatrics.”55 The development of care for the elderly can therefore usefully be seen as the product of the marginalization and stigmatization of both aging and migrant bodies.56 Paul Weindling’s work on the Central European medical refugees who came to Britain mentions the difficulties they encountered, including anti-Semitism, but also indicates that they were disproportionately represented in work that involved providing care to other European migrants and that a number of individuals were able to reach positions of influence.57 Weindling also argues that Central European refugees should be seen as actors of a struggle between modernizers and traditionalists in British medicine, with refugees being natural allies of scientific modernizers and thus contributing to driving changes in British medicine.58 He describes some specialities such as psychiatry and pharmacology as being “accommodating” to refugees59 and points out that doctors were in some cases directed towards what he terms “remote” locations in the British colonies and dominions such as Newfoundland, Hong Kong, or Burma where there was an undersupply of medical labour.60 Winkelmann-Gleed and Eversley61 provide further evidence of the impact of refugee doctors from Central Europe on health care in the United Kingdom, noting, for instance, that many of them entered psychiatry where some played prominent roles: Max Glatt was thus a pioneer of the rehabilitation of people with alcohol dependency. The questions raised here about the “making” of the NHS can be further explored through a focus on geographical concentrations and professional niches. Research into the roles played by black and minority ethnic migrant doctors in Manchester between 1948 and 2009 and by overseas-born South Asian general practitioners across the United Kingdom between 1948 and 1983 further illustrates the extent to which the geographical and professional marginalization of migrant doctors was central to the history of the National Health Service. The archival research and oral history interviews carried out for these projects also underscore the importance to the historiography of the NHS of engaging with the impact of the individual and collective agency of migrant doctors.

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Geographical and Professional Marginalization as Central Aspects of the History of the NHS: The Role of Racism and “Heterophobia” Institutional discrimination is key to understanding how doctors came to be concentrated in particular roles in particular parts of the United Kingdom. That discrimination was taking place within the NHS on grounds of ethnicity was demonstrated in the 1990s when researchers applied for NHS jobs using fictitious CVs purporting to be from doctors that featured both “traditional British” names and “Asian-sounding”62 names.63 The response rates for the candidates presumed to be South Asian were significantly lower. Difference in a wider sense has also been identified as a factor in obtaining desirable posts as a result, for instance, of the role of patronage networks in medicine.64 Albert Memmi’s distinction between racism, grounded in the perceived biological distinctions between “races,”65 and the broader concept of “heterophobia”66 provides a useful framework for an analysis of these processes. The history of the NHS in particular parts of the United Kingdom, in junior roles and in specific types of medicine is closely intertwined with racism and heterophobia, which directed migrant doctors towards certain parts of the health-care system.67 This does not mean that all migrant doctors were confined to particular roles but rather that they ended up being significantly over-represented in less popular specialties. It was not impossible for them to build careers in prestigious specialties, but being marked as different made it harder for them to do so. Conversely, if discrimination in the NHS is understood as the product of racism and more broadly racism and heterophobia, the enhanced ability of certain doctors to negotiate discrimination because of their ethnicity, social background, or gender helps to explain how some of them were able to find work in the more popular specialties.68 As John Armstrong puts in it his contribution this volume, understanding the progress of migrant doctors in professional contexts involves paying attention to factors such as gender and ethnicity as well as the interactions among cultural norms, individual attitudes, professional structures, and employment opportunities.69 Racism is therefore an important part of the picture; drawing on the notion of heterophobia emphasizes the importance of other forms of exclusion and allows for the fact that some doctors successfully negotiated discriminatory processes. Urban, (post-) industrial towns and cities in the north of England such as Manchester have been particularly reliant on migrant doctors.70 In 1972, over 80 per cent of senior house officers in the Manchester

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Regional Hospital Board’s area were from overseas.71 The dependency on migrant doctors was particularly acute in general hospitals, as opposed to teaching hospitals, which were seen as offering better career prospects: a report published in 1960 stated that a number of hospitals outside the teaching centre in Manchester were quasi-exclusively dependent on being able to employ overseas doctors.72 Medical migrants took these jobs in deprived areas in a professional environment that limited their opportunities to obtain different posts. Either through direct discrimination or because they were more subtly excluded from professional networks, migrant doctors found themselves limited to opportunities that were not perceived as desirable by local graduates. As one overseas-trained doctor interviewed for the research on black and ethnic minority clinicians in Manchester put it, “The NHS generally favours local graduates and stops overseas doctors climbing on the seniority ladder.”73 Another described the process of applying for jobs in the NHS after qualification: I passed my exam and got junior jobs, not so easily, but with difficulty. Was there a lot of competition for these jobs? Tremendous competition and tremendous indirect discrimination … They looked at your face and that was all they needed to do about your employment and there was nothing you could do about it.74

In this context, doctors went to work where posts were available and where competition with local graduates was limited. In one respect they were palliating well-documented workforce shortages in the NHS.75 The movement of doctors to the United Kingdom is, however, paralleled by the movement of U.K.-trained doctors to other countries.76 The decisions of these doctors to leave the NHS can be linked to their inability to obtain senior posts in hospitals and their unwillingness to enter general practice.77 This, in turn, helps to explain why such large numbers of overseas-born doctors have always worked in the NHS. The higher concentrations of migrants in industrial, working-class cities and away from prestigious teaching hospitals can be seen as an indication not just of labour shortages but of the unwillingness of local graduates to keep working in junior roles or to enter general practice in deprived areas, and conversely, the willingness of migrant doctors to exploit the resulting gaps in the medical workforce to build careers. As a South Asian doctor in Manchester put it, jobs were a­ vailable for migrants in fields

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such as psychiatry and geriatrics that were “less popular, less romantic and less sought after by Caucasians.”78 The geographical location of Manchester, allied to the nature of work done in fields that involved low-status work caring for socially marginalized and stigmatized populations, made these roles undesirable. The experiences of South Asian doctors in general practice further illustrate the overlap between geographical and professional marginalization in British medicine. As Michael Gavin has noted, general practice continues to be regarded in the United Kingdom as “‘dirty work,’ an inferior branch of medicine … imbued with connotations of misfortune and failure.”79 As a result, GPs are still seen by some of their colleagues as “lesser doctors.”80 These “lesser” roles were frequently left to migrant practitioners, particularly in areas where the stigma of general practice overlapped with the lack of desirability of the practice location. This context helps to explain why, by 1988, just over 16 per cent of unrestricted GPs81 practising in the United Kingdom were born in India, Pakistan, Sri Lanka, or Bangladesh.82 In addition, as has been noted, these doctors were overwhelmingly concentrated in less affluent areas. Racism and heterophobia were driving geographical and professional clustering. One description of the recruitment of a GP to a practice, included in the memoirs of a white British GP, provides an illustration of how medical migrants could be denied the chance to work in more affluent parts of the United Kingdom without even having had the opportunity to apply for a job: “Baffer had had a letter from a Dr Robert Forbes … to say that his son, James, would like to practice in or near Winchester.83 I thought there was no harm in us seeing him … and he duly arrived for interview. He had been trained at St Mary’s (he was an excellent rugger84 player) but had done his house jobs at Bart’s.85 He also wore an old school tie86 with which I was familiar … By mutual consent Jimmy Forbes joined the practice.”87 This shows how heterophobia could affect the opportunities of graduates who had not trained in the “right” hospital, had the advantage of having been to a particular school, or gained access to white male networks forged on the rugby field (and in postmatch drinking sessions). In addition, discrimination against overseas graduates was openly practised and a recognized part of medical culture. Some posts were advertised as being open only to British graduates.88 One GP interviewed regarding the role of South Asian doctors in the development of British general practice recalled hearing a lecturer at a postgraduate course run by the Royal College of General Practitioners boast about favouring white male candidates ahead of female and

Providing “Special” Types of Labour and Exerting Agency  221 

South Asian candidates when recruiting. This doctor took up a post as a GP in south Wales, at the time a coal-mining area where a substantial proportion of general practitioners were migrants. According to him, “The ideal practices … didn’t even have a look at you.”89 The Individual and Collective Agency of Medical Migrants and the Development of Health Care As well as providing the “special” labour that was not forthcoming from local graduates, migrant doctors were in a position to shape the health-care system that they found themselves working in. The history of the NHS in geographical locations such as Manchester and in fields such as general practice was thus to a great extent the product of the individual and collective agency of migrant doctors. Their social status and in the case, for instance, of general practice in the first thirty-five years of the NHS, the professional autonomy afforded to GPs in the United Kingdom,90 combined to enable them to exert their agency. In some instances, interviewees made clear references to their personal and professional backgrounds as factors that informed the way they practised medicine and worked as GPs in the United Kingdom: “To have to wait for a week or two weeks for … results to come back from somewhere and the consultant won’t probably be able to see a patient for weeks on end is something that was difficult to get used to. Because, looking back at where I came from, Dhaka … you could go and see … a doctor, you could get immediate … treatment and … investigations done – if you had money … So I had then realized that this is something GPs need to do themselves to improve their lot.”91 Initiatives to improve care were not the sole preserve of general practitioners – Satya Chatterjee, was thus responsible for the development of a new chest clinic at the Manchester Baguley Hospital in 1952.92 If agency is evident at the level of practices and hospitals, it could also be apparent in a wider social context. One South Asian general practitioner spoke of launching a television program aimed at providing advice on health and social issues to the South Asian population in the northwest of England.93 Others were politically active, being elected as local councillors,94 becoming prominent members of the British Medical Association,95 or influential trades-unionists.96 In light of the clustering of non-white doctors in working-class areas, some of them overwhelmingly white, the ability of doctors to forge relationships with patients should not be taken for granted. Even if

222  Julian M. Simpson, Stephanie J. Snow, and Aneez Esmail

some participants reported serious incidents, including assaults and death threats,97 most stated that they had very good relationships with patients and local communities.98 An element of reluctance, followed by acceptance, once the doctor had been evaluated as a professional, is a recurring feature of the descriptions that migrant doctors give of their early careers.99 The initial observation period could be lengthy but was not indefinite, as Ralph Lawrence, a South Asian doctor born and trained in South Africa, found when he started to work as a general practitioner in Derbyshire in the 1950s: “The local community was based largely around the mining community and was very much a matriarchal society, with mothers making the important decisions. I was assessed by the older women of the village and, having received their approval, they encouraged the younger women and their families to register with me. It took the best part of three years for the practice to become established and after that progress was uninterrupted.”100 The decisions of migrant doctors to stay in the United Kingdom and build careers in the face of discrimination should equally not be taken for granted. As one Manchester clinician observed, “Disheartened fellows either go back or try their luck outside the NHS. I decided to fight on.”101 The fact that migrant doctors took on the posts that were available to them was a choice, albeit a constrained choice – many U.K.-trained doctors chose to migrate rather than seek to exploit the same opportunities. Migrant doctors also formed professional and social networks. The Overseas Doctors’ Association (ODA), established in 1975, campaigned on racism in medicine, provided advice and training to its members, and obtained representation on the United Kingdom’s medical regulatory body, the General Medical Council, after selecting candidates and encouraging its members to vote for them.102 Individual doctors report drawing support from groups such as the ODA and the British Association of Physicians of Indian Origin.103 In 2008, the latter organization successfully mounted a legal challenge to a government attempt to restrict the access of overseas-trained doctors to training posts.104 Other associations bringing together former graduates of particular South Asian medical schools or doctors originating from a specific country performed important educational, social, and networking functions.105 Being aware of the ways in which migrant doctors developed health services, built career trajectories in the face of discrimination, established relationships with patients, and formed professional and social networks thus leads us to better understand how their presence in the United Kingdom contributed to the making of the NHS. This is

Providing “Special” Types of Labour and Exerting Agency  223 

particularly the case when it comes to the history of the provision of services to some of the most vulnerable sections of the British population and in areas where the demand for health care has historically been the highest. Conclusion Research on medical migrants in the United Kingdom is slowly revealing their impact on the development of the NHS. This impact was structural: they were over-represented in less popular roles. It is also the result of the agency that they were able to exert within the British health-care system. The historiography of medical migration in the United Kingdom remains, however, in its infancy, and we have only an imperfect understanding of the extent to which overseas-trained doctors contributed to the development of the National Health Service. Although recent work has enhanced our understanding of the contribution that migrant doctors have made over the years, its focus has been on particular groups and at times on specific groups within particular fields of medicine. It therefore leaves significant gaps. We still know very little, for instance, about the history of Irish or African doctors in the United Kingdom. A study of the impact of international medical graduates on the specialty of psychiatry would undoubtedly yield illuminating insights. The range of experiences of particular groups of doctors (e.g., Muslim practitioners) and the gendered dimensions of the professional trajectories of migrant doctors remain underexplored, as do the roles of migrant doctors occupying junior posts and those of temporary migrants. Writing these histories and integrating them into the overarching history of the NHS has the potential not just to increase our understanding of the past but also to inform our understanding of the present. The history of the United Kingdom’s National Health Service is, to a great extent, the history of racism, discrimination, and the agency of migrant doctors within a health-care system that is also the product of the long history of medicine and professionalism. Understanding why and how migrant doctors’ career choices were limited can support reflections on the nature of the NHS and its current use of migrant labour. It can provide a starting point for a debate on systemic issues such as recurring staff shortages and the ongoing dependency of the United Kingdom on migrant labour.106 Finally, it can bring into focus the specific nature of

224  Julian M. Simpson, Stephanie J. Snow, and Aneez Esmail

the pressures that migrant doctors face, deployed as they are in often demanding roles that are shunned by local graduates.107 Notes 1 J.M. Simpson, A. Esmail, V.S. Kalra, and S.J. Snow, “Writing Migrants Back into NHS History: Addressing a ‘Collective Amnesia’ and Its Policy Implications,” Journal of the Royal Society of Medicine 103, no. 10 (2010): 392–6. 2 S. Castles and M.J. Miller, The Age of Migration: International Population Movements in the Modern World, 4th ed. (Basingstoke: Palgrave Macmillan, 2009), 242. 3 M. Goldacre, J. Davidson, and T. Lambert, “Country of Training and Ethnic Origin of UK Doctors: Database and Survey Studies,” British Medical Journal 329, no. 7466 (2004): 597. 4 Ibid., 598. 5 Ibid. 6 D.H. Taylor Jr and A. Esmail, “Retrospective Analysis of Census Data on General Practitioners Who Qualified in South Asia: Who Will Replace Them as They Retire?” British Medical Journal 318, no. 7179 (1999): 307–8. 7 J.R. Butler and R. Knight, “The Choice of Practice Location,” Journal of the Royal College of General Practitioners 25, no. 156 (1975): 496–504. 8 M. Norredam and D. Album, “Prestige and Its Significance for Medical Specialties and Diseases,” Scandinavian Journal of Public Health 35, no. 6 (2007): 655–61. 9 E.C. Hughes, Men and Their Work (Westport, CT: Greenwood, 1958), 48–53; R. Simpson, N. Slutskaya, P. Lewis, and H. Höpfl, eds., Dirty Work: Concepts and Identities (Palgrave Macmillan, 2012 [e-book]). We are grateful to Dr Ivy Lynn Bourgeault for pointing out the relevance of this concept to our findings. 10 Marie-Claude Thifault, “Introduction,” in L’incontournable caste des femmes: histoire des services de santé au Québec et au Canada, ed. M.C. Thifault, 7–11 (Ottawa: Les presses de l’Université d’Ottawa, 2012). 11 A. Memmi, Le racisme: description, définitions, traitement, rev. ed. (Paris: Gallimard, 1994), 229–34. Memmi uses the French term hétérophobie, which the authors have translated as “heterophobia.” The term heterophobic is derived from this translation. 12 V. Berridge and J. Stewart, “History: A Social Science Neglected by Other Social Sciences (and Why It Should Not Be),” Contemporary Social Science: Journal of the Academy of Social Science 7, no. 1 (2010): 39–54.

Providing “Special” Types of Labour and Exerting Agency  225  13 J. Tosh, Why History Matters (Basingstoke: Palgrave Macmillan, 2008); P. Cox, “Future Uses of History,” History Workshop Journal 75, no. 1 (2013): 125–45. 14 P. Weindling, “Medical Refugees and the Modernisation of British Medicine, 1930–1960,” Social History of Medicine 22, no. 3 (2009): 489–51. 15 Simpson et al., “Writing Migrants.” 16 K.D. Ballard, S.I. Robinson, and P.B. Laurence, “Why Do General Practitioners from France Choose to Work in London Practices? A Qualitative Study,” British Journal of General Practice 54 (2004): 747–52; T. Kopetsch, “The Migration of Doctors to and from Germany,” Journal of Public Health 17 (2009): 34; A. Esmail, “Asian Doctors in the NHS: Service and Betrayal,” British Journal of General Practice 57 (2007): 827. 17 David J. Smith, Overseas Doctors in the National Health Service (London: Policy Studies Institute, 1980), 8–10; O. Gish, “Emigration and the Supply and Demand for Medical Manpower: The Irish Case,” Minerva 7, no. 4 (1969): 668–79; M. Mackintosh, P. Raghuram, and L. Henry, “‘A Perverse Subsidy’: African-Trained Doctors and Nurses in the NHS,” Soundings 34 (Autumn 2006): 103–13. 18 Smith, Overseas Doctors, 14–15. Smith considered Australia, New Zealand, South Africa, Rhodesia, the United States, and Canada to be “white anglophone” countries. This is clearly a problematic categorization, but it does suggest that the experiences of white doctors from these countries were in some respects different from those of non-white migrant doctors. 19 Bornat, Raghuram, and Henry, “Without racism there would be no geriatrics,” in this volume. 20 Esmail, “Asian Doctors,” 830. 21 J.M. Simpson, “The Socio-Cognitive UK / South Asian Medical Community and the Staffing of the NHS (c. 1948–1983)” (paper given at the 24th International Congress of History of Science, Technology and Medicine, July 2013, Manchester). 22 J. Armstrong, “‘A System of Exclusion’: New Zealand Women Medical Specialists in International Medical Networks, 1945–1975,” in this volume. 23 O. Gish, “British Doctor Migration 1962–67,” British Journal of Medical Education 4, no. 4 (1970): 279; Smith, Overseas Doctors, 8. 24 Smith, Overseas Doctors, 50. 25 L. Doyal, G. Hunt, and J. Mellor, “Your Life in Their Hands: Migrant Workers in the National Health Service,” Critical Social Policy 1, no. 2 (1981): 54. 26 M. Anwar and A. Ali, Overseas Doctors: Experience and Expectations (London: Commission for Racial Equality, 1987), 72.

226  Julian M. Simpson, Stephanie J. Snow, and Aneez Esmail 27 E. Powell, speech to the Conservative Association, Birmingham, 20 April 1968, http://telegraph.co.uk/comment/3643826/Enoch-Powells-Riversof-Blood-speech.html. 28 Smith, Overseas Doctors, 50; O. Gish, “Overseas-Born Doctor Migration 1962–66,” British Journal of Medical Education 5, no. 2 (1971): 101–3. 29 Although differences within such groups in gender, country of origin, religion, social background, and familiarity with British culture could equally justify further subdivisions. 30 O. Gish, “Assessing Commonwealth Trained Doctors for the NHS,” Social Policy and Administration 3, no. 4 (1969): 264–72; Mackintosh, Raghuram, and Henry, “Perverse Subsidy”; Ballard, Robinson, and Laurence, “General Practitioners”; Esmail, “Asian Doctors,” 827. 31 Simpson et al., “Writing Migrants,” 392. 32 Weindling, “Modernisation,” 499. 33 C. Webster, The Health Services since the War (London: HMSO, 1996), 2:283. 34 Simpson et al., “Writing Migrants,” 392. 35 G. Jones, “‘A Mysterious Discrimination’: Irish Medical Emigration to the United States in the 1950s,” in this volume. 36 Gish, “Emigration,” 675–6, 669. 37 Esmail, “Asian Doctors,” 827. 38 Kopetsch, “Migration of Doctors,” 34. 39 M. Gorsky, “The British National Health Service 1948–2008: A Review of the Historiography,” Social History of Medicine 21, no. 3 (2008): 437–60. 40 Webster, Health Services, vols 1 and 2; R. Klein, The New Politics of the National Health Service, 6th ed. (Oxford: Radcliffe Publishing, 2010); G. Rivett, National Health Service History [online] (2012), http://www. nhshistory.net/. 41 Webster, Health Services, 1:283. 42 Rivett, National Health Service. 43 C. Webster, The National Health Service: A Political History (Oxford: Oxford University Press, 1998), 130–1. GPs were essential to the running of health centres. 44 Ibid. 45 Esmail, “Asian Doctors,” 830–1; J. Bornat, L. Henry, and P. Raghuram, “‘Don’t Mix Race with the Specialty’: Interviewing South Asian OverseasTrained Geriatricians,” Oral History 37, no. 1 (2009): 74–84; Weindling, “Modernisation,” 505. 46 These are both junior positions in British hospitals. 47 Doyal, Hunt, and Mellor, “Your Life,” 57. 48 Taylor Jr and Esmail, “Retrospective Analysis,” 307–8.

Providing “Special” Types of Labour and Exerting Agency  227  4 9 Ibid. 50 Esmail, “Asian Doctors,” 834. 51 Bornat, Raghuram, and Henry, “Without racism there would be no geriatrics,” 192–3. 52 S.S. Thandi, “Migrating to the ‘Mother Country,’ 1947–1980,” in A South Asian History of Britain, ed. M.H. Fisher, S. Lahiri, and S.S. Thandi (Oxford: Greenwood World Publishing, 2007), 165. 53 Hughes, Men and Their Work, 50–1. 54 Esmail, “Asian Doctors”; Simpson et al., “Writing Migrants.” 55 P. Raghuram, L. Henry, and J. Bornat, “Ethnic Clustering among South Asian Geriatricians in the UK: An Oral History Study,” Diversity in Health and Care 6, no. 4 (2009): 295. 56 P. Raghuram, J. Bornat, and L. Henry, “The Co-Marking of Aged Bodies and Migrant Bodies: Migrant Workers’ Contribution to Geriatric Medicine in the UK,” Sociology of Health and Illness 33, no. 2 (2011): 321–35. 57 P. Weindling, “The Contribution of Central European Jews to Medical Science and Practice in Britain, the 1930s–1950s,” in Second Chance: Two Centuries of German-Speaking Jews in the United Kingdom, ed. W.E. Mosse (co-ord.), J. Carlebach, G. Hirschfeld, A. Newman, A. Paucker, and P. Pulzer (Tübingen: J.C.B Mohr [Paul Siebeck], 1991), 253; Weindling, “Modernisation,” 500, 505–6. 58 Weindling, “Modernisation.” 59 Ibid., 505. 60 P. Weindling, “Medical Refugees in Britain and the Wider World 1930–1960: Introduction,” Social History of Medicine 22, no. 3 (2009): 455–6. 61 A. Winklemann-Gleed and J. Eversley, “Salt and Stairs: A History of Refugee Doctors in the UK,” in Refugee Doctors: Support, Development and Integration in the NHS, ed. N. Jackson and Y. Carter (Oxford: Radcliffe Publishing, 2004), 15–17. 62 The term Asian was used in this study in the usual British sense of the word, designating people who were born in present-day India, Pakistan, Bangladesh, or Sri Lanka, or people of South Asian descent who were born elsewhere. 63 A. Esmail and S. Everington, “Racial Discrimination against Doctors from Ethnic Minorities,” British Medical Journal 306 (1993): 691–2. 64 Smith, Overseas Doctors, 154–6. 65 Memmi, Le racisme, 229–30. 66 Ibid., 234. 67 On racism in the NHS, see also N. Coker, ed., Racism in Medicine: An Agenda for Change (London: King’s Fund Publishing, 2001); and

228  Julian M. Simpson, Stephanie J. Snow, and Aneez Esmail

68

9 6 70 71 2 7 73 74 75 76

7 7 78 79

8 0 81

82 83 8 4 85 86 87 88

C. Kyriakides and S. Virdee, “Migrant Labour, Racism and the British National Health Service,” Ethnicity and Health 8, no. 4 (2003): 283–305. J.M. Simpson and J. Ramsay, “Manifestations and Negotiations of Racism and ‘Heterophobia’ in Overseas-Born South Asian GPs’ Accounts of Careers in the UK,” Diversity and Equality in Health and Care 11, nos 3–4 (2014): 177–85. Armstrong, “‘System of Exclusion,’” passim. Webster, Health Services, 1:309. E.L. Jones and S.J. Snow, Against the Odds: Black and Minority Ethnic Clinicians and Manchester, 1948 to 2009 (Lancaster: Carnegie, 2010), 36. Ibid., 84. Ibid. Ibid., 80. Ibid., 6–12. D. Wright, S. Mullally, and M.C. Cordukes, ‘“Worse Than Being Married’: The Exodus of British Doctors from the National Health Service to Canada, c. 1955–75,” Journal of the History of Medicine and Allied Sciences 65, no. 4 (2010): 546–75; Gish, “British Doctor Migration.” Gish, “British Doctor Migration,” 285. Jones and Snow, Against the Odds, 83. M.J. Gavin, “A Crisis of Legitimacy? The Clinical Role, Intellectual Status and Career Motivations of General Medical Practitioners” (PhD diss., University of Manchester, 2004), 52. Ibid. This expression refers to doctors who provide a full range of general medical services and whose list is not limited to a particular type of person. It excludes some GPs, such as GP assistants, salaried GPs, and non-permanent staff. P.S. Gill, “General Practitioners, Ethnic Diversity and Racism,” in Coker, Racism in Medicine, 107, 111. Winchester is a small picturesque city located in the prosperous county of Hampshire in the south of England. English slang for rugby. St Bartholomew’s (Bart’s) and St Mary’s are prestigious London teaching hospitals. The “old school tie” is traditionally worn by alumni of British “public” (in fact private) schools. R. Gibson, The Family Doctor: His Life and History (London: George Allen & Unwin, 1981), 83. Esmail, “Asian Doctors,” 832.

Providing “Special” Types of Labour and Exerting Agency  229  89 H. Joshi interview with by J.M. Simpson, 27 April 2010. 90 J. Lewis, “The Medical Profession and the State: GPs and the GP Contract in the 1960s and the 1990s,” Social Policy and Administration 32, no. 2 (1998): 132. 91 L.R.M. Kamal interview with J.M. Simpson, 8 March 2010. 92 Jones and Snow, Against the Odds, 94. 93 S. Pande interview with J.M. Simpson, 23 November 2009. 94 Kamal interview with Simpson; R. Chandran interview with J.M. Simpson, 7 March 2011. 95 R.A.A.R. Lawrence, A Fire in His Hand (London: Athena, 2006), 60–6. 96 D. Ray interviews with J.M. Simpson, 5 December 2008, 19 March 2010. 97 Anonymous participant interview with J.M. Simpson, 10 January 2011; K. Korlipara interview with J.M. Simpson, 24 September 2009. 98 Jones and Snow, Against the Odds, 86. 99 Anonymous participant interview with J.M. Simpson, 17 September 2009; M.A. Khaled interview with J.M. Simpson, 2 April 2010. 100 Lawrence, Fire in His Hand, 50. 101 Jones and Snow, Against the Odds, 87. 102 M.N.I Talukdar interview with J.M. Simpson, 1 December 2009; S. Venugopal interview with J.M. Simpson, 5 November 2009; Korlipara interview with Simpson; Overseas Doctors’ Association letter to members August 1984, private papers of K. Korlipara. 103 Jones and Snow, Against the Odds, 102. 104 Ibid., 108. 105 A. Chaudhuri interview with J.M. Simpson, 30 March 2010; S.A.A Gilani interviews with J.M. Simpson 30 June, 10 November 2010. 106 S.J. Snow and E.L. Jones, “Immigration and the National Health Service: Putting History to the Forefront,” History and Policy, 8 March 2011, http://www.historyandpolicy.org/policy-papers/papers/immigrationand-the-national-health-service-putting-history-to-the-forefron. 107 J.M. Simpson and A. Esmail, “The UK’s Dysfunctional Relationship with Medical Migrants: The Daniel Ubani Case and Reform of Out-of-Hours Services,” British Journal of General Practice 61 (2011): 208–11.

10 Connecting to Canada: Experiences of the South Asian Medical Diaspora during the 1960s and 1970s1 sasha mullally and david wright

Late in 2013, Dr Mohan Virick surprised the community of North Sydney when he announced he was giving 140 hectares of property to the local Mi’kmaq First Nation at Eskasoni. This, he said, was given as part of their “inheritance.” North Sydney, a large town in the eastern reaches of Cape Breton Island, Nova Scotia, Canada, is a small ­workingclass city built around coal mining. The nearby Eskasoni reserve is the largest in the Atlantic region, comprising a community of about 4,000 individuals. Virick had lived and worked in the North Sydney area for over fifty years, and the announcement of this land transfer, which included valuable commercial property in the downtown core, came on the cusp of the physician’s retirement. Although he and his wife had four children and nine grandchildren of their own, Virick says he also considered the Eskasoni Mi’kmaq part of his family. They were so close, in fact, they seemed collectively like a sort of “fifth child” to the doctor and his wife. Since the community needed support in the here-andnow, he saw little merit in waiting for a posthumous bequest. As he told a reporter from the Halifax Chronicle-Herald, “I love them like my kids. When you get older, you pass on things to your children.”2 Originally from Burma, Virick immigrated to Canada in 1963 after graduating from the Christian Medical College in eastern India. This fulfilled a long-held dream for the young physician, who had decided in elementary school that he wanted to move to Canada after seeing a documentary on log-rolling in British Columbia. He wrote to the Canadian embassy in Burma to get more information, and they advised him to apply after he grew up, which is exactly what he did. As Virick’s story goes, he did indeed arrive in Canada several years later, a medical diploma in his hand but with only five dollars in his pocket. He also

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had little geographic knowledge of Nova Scotia, having arranged no means to get from the airport in the capital city of Halifax to his first Canadian job, 600 kilometres away, in Sydney. It was at this juncture that an aboriginal man, Michael Sappier, helped the newly arrived physician by driving him to Cape Breton so he could arrive on time for his first scheduled day of work. This began a relationship that would last for decades. Sappier became Mohan Virick’s first patient, but also his friend. One year later, Sappier would loan Virick a suit so the doctor could get married to Mabel Ann, a woman from the area with whom he had also become acquainted soon after his arrival. His connection to Mabel Ann provided him with a domestic base in the town, and, eventually, family life. His connection to Sappier provided Virick with a lifelong friend, as well as entry into the lives of the Eskasoni. This would be the community who, over the years, would comprise the bulk of patients coming through his walk-in clinic in North Sydney. Still practising three days a week after a half-century in medicine, he is the epitome of a persistent and successful transplant, surrounded by patients whom he considers “family.”3 Virick’s emigration to Canada, the story of his move, the life he builds, and the key connections he makes are part of a larger diaspora of trained health personnel from the Indian subcontinent to Canada and other wealthy nations of the world in the mid- to late twentieth century. His journey in the 1960s was an early ripple in advance of a large-scale migratory wave of tens of thousands of health practitioners relocating across national boundaries over the 1970s. This phenomenon did not go unnoticed, and indeed, beginning in this decade, it elicited much concern internationally.4 Alfonso Mejía, chief medical officer of Manpower Systems for the World Health Organization, wrote extensively on the phenomenon, noting by 1978 how “anxiety evoked by migration was reach[ing] a peak in both major donor and recipient countries.”5 This “brain drain,”6 according to Mejía, was inextricably linked to economic inequality, and it presaged an uncontrollable loss of medical practitioners from the “developing” world to the “industrialized” world for the rest of the twentieth century and perhaps beyond. While countries like Britain, the United States, and Canada largely profited from this mass migration,7 physicians were mobile in this era, drawn to North America at a time of health-care service expansion.8 Canada was a country that pulled from the brain drain but also lost many physicians to the United States.9 As we can see from Virick’s narrative, the “industrialized” nations who received such migrants struggled with significant economic and

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social inequalities themselves. Physicians who fled poverty and want did not always escape them, even by coming to relatively stable and prosperous nations like Canada. Virick’s story suggests that individual physicians could profit from participating in the mass out-migration. This doctor seemed to enjoy material satisfaction; the narrative he offers is a rags-to-riches story that culminates in a spectacular act of generosity. But how representative is Mohan Virick? On the one hand, Virick’s material success as a Canadian doctor is evident by his role as a First Nations benefactor, but his rendition of his life gives equal emphasis and value to the personal connections fostered over years in practice, and the communitarian values that first connected him to Canada and that underpinned the rest of his life and career. Is the search for connection a central experience of the South Asian diaspora? Does the experience of mass emigration leave South Asian physicians feeling a loss of community and adrift as a group, or does it foster a tendency to gather in expatriate enclaves in their new home countries? Where and how do they first, and then lastingly, connect to Canada? This chapter will explore themes in the social history of the immigration of foreign-trained doctors to “developed” countries in the mid- to late twentieth century, by taking a collective snapshot of the careers and sampling the experiences of South Asian doctors who came to Canada in the late 1960s and early 1970s, during the early decades of the late twentieth-century Indian diaspora. Throughout we ask questions that explore this theme of “connection.” We also try to make sense of the singular narrative in the context of group experience, as well as social demography. Is there a “representative” Canadian experience for those caught up in this diaspora? Where did individuals from the larger wave of South Asian doctors land when they came to Canada, and where did they ultimately put down roots? What are the outlier experiences, and what can they tell us about the possibilities for such physicians in Canada? How do themes of margin and centre, global and local, separation and connection emerge in their narrative accounts of diaspora? Interrogating Virick’s migration narrative in light of a broader demographic analysis and against the backdrop of other physicians’ oral histories provides a way to understand the social and cultural experiences of those caught up in the mass migrations of this period. A “typical” experience is elusive, although we can confirm most South Asian medical registrants in 1971 did tend, as one might expect, to gravitate to large urban areas, and most of these in central Canada. Nonetheless, the demographic analysis reveals one significant minority trend, one that

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is captured in the qualitative narrative accounts: a surprisingly sizeable number, approximately one-third, seem to have made their homes in small and medium population centres across Canada. In this chapter, and within the larger project, we are calling this the “small town and city” phenomenon. Whether these were short-term or longer-term practices remains the subject for another paper, but here we explore the experiences and transitions inherent in moving from South Asia, to Britain for advanced training, and then to a variety of smaller urban centres and larger regional towns in Canada. In such communities, it seems, the fortunes for many South Asian practitioners would lie. Understanding this phenomenon helps us understand career patterns and resilience within the South Asian diaspora community and places the stories of immigrant doctors in Canada in a global perspective. Global Trends, National Goals, and Local Needs The Indian diaspora is sometimes described as the second-largest diaspora in the world today.10 Canada has been a long-standing destination for South Asian émigrés, beginning with a large-scale late nineteenthcentury Sikh migration.11 These were mostly male labourers who came to work, first on the transnational Canadian Pacific Railroad, and later in the agricultural and forestry sectors of western Canada.12 By the first decade of the twentieth century, Indian immigrants were numerous enough to be subjected to exclusionary immigration policies, despite their status as British citizens.13 Until the First World War, the need for Indian-born British subjects of non-Anglo-Saxon parentage to have a “continuous voyage” ticket14 through Canada radically curtailed the number of immigrants from this part of the world.15 Post-war immigration remained limited until 1957, when numbers slowly began to increase. A majority of these migrants were pulled almost exclusively from the Punjab.16 By the 1970s, however, many regions of India were represented in the Canadian population, including the Canadian medical profession.17 Canada was a destination in large part because it was a part of the British Empire, and this facilitated the movement of South Asian migrants with British medical credentials, as they were in high demand at the time. Nonetheless, for the South Asian physicians who ended up in Canada in the mid- to late twentieth century, their outlooks were first shaped by experiences in the British health-care system. Their migration must also be understood in a British imperial context and legacy, just as the

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opportunities and challenges that presented during welfare state expansion in Canada’s late industrial capitalist economy opened up options for members of the medical profession. To capture these contexts, this chapter moves between individual and collective accounts and records, to help explain how the years of universal health-care implementation diversified the face of Canadian medicine, even as it placed Canada in a competitive position with other “Western” nations in international medical recruitment. This is a new trajectory in the history of universal health insurance. In Canada, policy histories have dominated the historical record on the implementation of medicare,18 the term used to describe the nation’s publicly funded, universal health-care system.19 Yet recent work applies a nuanced social history lens to both the linear and positivist public histories20 of how Canadians implemented this keystone element of the larger national welfare state.21 Historians, for instance, are moving away from broad-stroke national accounts of medicare founders, accounts that celebrate their political acumen and statesmanlike foresight, to explore the challenges posed by implementation, especially for smaller communities and select Canadian provinces. These, increasingly, include the role played by foreign-trained medical personnel in implementation.22 Others deal with the historical antecedents to medicare in different provinces that shaped each province’s policy culture,23 and ongoing problems associated with both funding and administering the new system by poorer provinces in Canada.24 Over this decade, Canadian jurisdictions had a seemingly insatiable thirst for new doctors. In the late 1960s and 1970s, the Canadian economy enjoyed the last few years of a lengthy post-war period of economic prosperity and diversification. As Canadians became more urban and suburban, it quickly became clear that the growth of the professional classes was not keeping pace.25 Especially, growth in the number of health-care providers fell far short of what was required to staff the burgeoning hospital system and supply health services in the early years following the adoption of medicare. As above, medicare was a culmination of the efforts by several federal governments to implement a wide-reaching welfare state, and until the mid-1970s, when new and expanded Canadian medical schools could produce enough physicians domestically to staff the system, the concomitant “medical manpower” shortage could be solved by allowing applications from immigrant physicians extra “points.”26 Importantly, the new health-care system, though financed by the central federal government, was nonetheless

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administered through individual provinces. Within each province, physician-run medical boards managed the supply of new doctors through licensing legislation. Thus, the discussion of medical diasporas must also consider each province’s local need for physician services. This reality has directed our larger project about physician immigration towards an approach that marries quantitative and qualitative primary sources. This, we believe, helps make sense of a diversity of demographic, political, economic, and social contexts for medical practices across a vast continental nation state. To understand how the local becomes a key site for global analysis of international physician immigration patterns, this chapter draws specifically on demography and narrative. Demography and Narrative To get a sense of the scale of South Asian medical immigration to Canada, we took a snapshot of physician registration statistics in the 1971 edition of the Canadian Medical Directory (CMD).27 This source, published since the 1930s by the Canadian Medical Association, enables analytical profiles of physicians registered in cities, towns, and other registered municipalities across the country.28 By the 1970s, each annual edition includes listings for approximately 25,000 physicians. Over the year we investigated, all CMD physicians we identified as “South Asian” were those who received their undergraduate medical degree in pre-Partition British India, post-Partition India and Pakistan, as well as Bangladesh, Sri Lanka (Ceylon), and Burma. These individuals could be ethnic Indians living as expatriates in Africa or elsewhere – the location of their first medical degrees is what earned them the identifier. These names, the location of any advanced training, their specialist credentials (if such training was indicated), and their geographic placement within the country were all captured on a relational database. After drawing up a statistical picture and profile for this group, we then added additional insights from a qualitative analysis of oral interviews. We drew from details about the careers of eight South Asian physicians captured as part of a larger oral history investigation underway since 2008. Most of these were detailed interviews, each between one and two hours long, which provide individual reflections on the process of professional and social acculturation, as well as details about career trends and decisions made at each step of the respective physician’s immigration journey. We recruited through a sample taken from the most recent version of Scott’s Medical Database (the digital successor

236  Sasha Mullally and David Wright

to the CMD). Almost all South Asian physicians experienced work in larger metropolitan centres, as well as regions with rural, small, and medium-sized populations. In fact, most of the narrative material speaks specifically to how doctors ended up in small and mediumsized population centres of Canada in the period. Combined with the demographic picture, above, these offer key insights into how people caught up in the South Asian medical diaspora eventually connected to Canada. Parsing the Immigration Patterns of South Asian Physicians As opportunities for new physicians to Canada expanded in the late 1960s and early 1970s, the trickle of immigrant physicians in the 1950s turned into a flood ten years later.29 The 1971 Canadian Medical Directory listed 508 physicians trained in South Asian jurisdictions.30 This surge in the late 1960s was facilitated by changes to the way in which Canada processed and vetted immigrant applications to attract candidates of “merit.”31 By 1967, changes established the aforementioned new “points” system that erased country of origin as a weighted criterion, substituting a supposedly race- and ethnicity-blind system that prioritized English- and French-speaking candidates with professional training, including engineers, university professors, and doctors.32 Unsurprisingly, we find that the South Asian physicians coming to Canada, like other foreign-trained physicians, were overwhelmingly drawn from those practitioners who had received postgraduate or fellowship training in the United Kingdom.33 Ironically, the demand for their employment was in part a reflection of the out-migration of British-born physicians who were leaving the NHS for Canada,34 the United States, and Australia.35 Fortunately for them, having been registered in their specialty by the General Medical Council (GMC) of Britain was considered an acceptable minimum standard by most provincial medical boards on the Canadian side of the Atlantic; in some provinces like Manitoba and Nova Scotia, it gained them immediate licensing to practice.36 In others, the formality of passing the Licentiate of the Medical College of Canada (LMCC) exam was a requirement. But impediments were few and, as a result, South Asians comprised a significant number of new foreign-trained doctors in Canada by the late 1960s and early 1970s. The South Asian physicians registered to practise medicine in Canada by 1971 were a diverse group, and, if their documented credentials

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and training are any indication, they brought a high level of skills with them to Canada. Of the South-Asian trained physicians listed in the CMD that year, 10 declared specializations in family medicine and/or general practice. A further 94 did not state or had an “unknown” level of postgraduate and specialist training, though many of them had large hospital appointments, suggesting a specialty. The approximately 400 remaining doctors trained in South Asian medical schools had training across the spectrum of specialties, as grouped in table 10.1. Among the specialties listed, surgeons dominated the field, numbering about 157 across the several specialist categories (see note 36). After surgery, the most common declared specialty was internal medicine. As seen from map 10.1, South Asian physicians were distributed quite widely across the Canadian landscape. Many did find their way to the larger urban centres of the country, although they were not limited to the very large and diverse cities of Vancouver, Toronto, and Montreal. We note equally significant urban clusters in smaller but growing cities such as Calgary, Edmonton, and Winnipeg. Furthermore, a significant Table 10.1.  South Asian Medical Graduates in Canada, Specialist Training, 1971 Specialty

Number of physicians

Surgery* Internal medicine Paediatrics Psychiatry Pathology Anaesthesiology Radiology Neurology Cardiology Rehabilitation medicine Pharmacology Dermatology Microbiology Other credential37 TOTAL

157 83 44 35 31 17 12 7 3 3 2 1 1 8 404

* Of the 157 surgeons listed in the 1971 CMD with medical diplomas from South Asian medical schools, 65 were listed as general surgeons, 31 as obstetrical and gynaecological surgeons, and the rest had surgical training for the following specialties: urology (15), orthopaedic surgery (13), otolaryngology (12), ophthalmology (8), neurosurgery (6), cardio surgery (5), and plastic surgery (2). Source: Canadian Medical Directory (Ottawa: Canadian Medical Association, 1971).

Map 10.1.  National Distribution of South Asian Physicians in Canada, 1971

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clustering emerged in St John’s, Newfoundland, and in the greater Halifax area of Nova Scotia. Their distribution throughout the small population centres and rural areas of Canada is noteworthy. Indeed no fewer than eighty small towns across the country had only one or two practising Indian-trained physicians in 1971. Some of these far-flung communities had populations of only a few thousand. Perhaps unsurprisingly, these destinations attracted many “generalists” in the specialty categories listed above, either general practitioners or general surgeons, but also a large number of those who specialized in the relatively flexible specialty of internal medicine as well. A more specific demographic distribution is revealed in a breakdown by region and type of population area. Cities and towns of central Canada (Ontario and Quebec) attracted the lion’s share, just over half, of South Asian physicians registered to practise in 1971. Another third of physicians found themselves located in either northern or western Canada, and a little less than one-fifth ended up in the Atlantic region. The proportion in Atlantic Canada is nonetheless noteworthy as well, as this cluster represents a larger proportion of foreign-trained physicians relative to the population of the region at the time. This gives further indication of what we have noted from map 10.1: while there is a strong trend for South Asian physicians to locate in larger cities, a significant number end up in small and medium-sized population centres, and some in rural and remote locations. Investigating this trend further, we examine the distribution in four provinces’ 1971 registrations by type of population centre. We find that, within each provincial jurisdiction, the distribution of these physicians could vary considerably. Charting the number of South Asian physicians who practised in a variety of large, medium, and small population centres, as well as isolated rural areas38 reveals significant inter-­provincial variation in career patterns and geographic distribution. Tables 10.2 and 10.3 give the 1971 location of South Asian physicians in four representative provinces from the regions in British Columbia for the west and north, Ontario and Quebec for Central Canada, and Nova Scotia for Atlantic Canada. This sample comprises approximately half the total population of South Asian physicians registered in Canada at the time. From the breakdown, we see how the large centre urban distribution of the South Asian physicians is strongest in south central Canada. However, once one moves outside the gravitational pull of the large metropolitan centres of Toronto and Montreal, they become more evenly divided among large and small towns, urban areas and rural zones.

240  Sasha Mullally and David Wright Table 10.2.  South Asian Physicians in Large (LPC), Medium (MPC), and Small Population Centres (SPC) and Rural/Unincorporated Areas (R/Un), by Select Province, 1971 Province

LPC

MPC

SPC

R/Un

Total

British Columbia Ontario Quebec Nova Scotia

 10 120  43  27

12 28  4 14

10 14  0 23

5 4 0 4

 37 162  47  68

Source: Canadian Medical Directory (Ottawa: Canadian Medical Association, 1971). Table 10.3.  South Asian Physicians in Large (LPC), Medium (MPC), and Small Population Centres (SPC) and Rural/Unincorporated Areas (R/Un), Expressed as a Percentage of South Asian Physicians in Select Provinces, 1971 Province

LPC

MPC

SPC

R/Un

British Columbia Ontario Quebec Nova Scotia

27 74 91 38

32 17  9 22

27  9  – 34

14  3  –  6

Source: Canadian Medical Directory (Ottawa: Canadian Medical Association, 1971).

These findings confound the common assumption that South Asian physicians, like most South Asian professionals, congregated in larger urban areas, clustering in ethnically diverse communities where their race and religion would not stand out. As the above tables and maps suggest, some certainly did. They were particularly urban in the province of Quebec, where an overwhelming majority of the forty-seven South Asian physicians registered in that province had practices in either Montreal or Quebec City, and most of them were in Montreal. Just under 10 per cent of those physicians located elsewhere in ­Quebec – a total of three individual doctors – found themselves in smaller cities of the Eastern Townships, though even these were still in satellite to the two main urban centres of the province. It is unsurprising that they would settle in the English-speaking pockets of the province, English being the dominant second language of this South Asian cohort. Where language is not a limiting factor, the dispersal changes. The large population centre clustering weakens when we examine the rest of English-speaking Canada. In the larger, neighbouring province of Ontario, the population of South Asian doctors does likewise

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cluster within the greater Toronto area, and we discovered that almost three-quarters of the physicians registered in Ontario had either Toronto addresses, including the growing suburban communities of Don Mills, Weston, and Scarborough, or were located in the prosperous steel and auto-manufacturing city of Hamilton. But another 17 per cent were distributed in the smaller towns of Southwestern Ontario, and a few found themselves serving the resource mining sectors in the northern reaches of the province, including Moose Factory and Thunder Bay. Numerically, those South Asian physicians who find themselves practising outside the reach of the Canadian metropolises are comparable to the number of South Asian doctors one finds in medium and small population centres of the less wealthy and less generously populated provinces of British Columbia and Nova Scotia. Although British Columbia, with its vast timber stands and mineral resources, was a rising economic star in the early 1970s, there were proportionally fewer physicians from South Asia situated in the largest city of Vancouver, when compared to the other two large provincial jurisdictions of Ontario and Quebec. Instead, we find the South Asian physicians of this western province almost equally divided among large, medium, and small population centres, and the highest proportion ended up in the medium-sized cities, not Vancouver itself, as one might otherwise expect. Moreover, 14 per cent of South Asian physicians on the Pacific end of Canada are situated in remote locations such as Alert Bay, or the district of Sechelt. Finally, in the smallest and poorest jurisdiction in this sample, Nova Scotia, we find a relatively large number of South Asian physicians relative to the province’s modest population. Otherwise, the distribution of South Asian physicians is similar to that of British Columbia. The capital city of Halifax39 certainly commanded the largest proportion of South Asian physicians, but its resident population of South Asian medical professionals was rivalled by the mining towns of Cape Breton, particularly Sydney and Sydney Mines, where a significant and strong cluster of South-Asian trained doctors persists to the present day. The first South Asian physician to migrate to this region was, in fact, Mohan Virick. What emerges from these explorations of demographic distribution in Canada is a richly varied South Asian medical diaspora. These physicians, as a group, found practices across the vast continental landscape of Canada, serving resource towns, Inuit villages, fishing outports, and agricultural communities in numbers that rival those who sought out and settled in the major metropolises of the growing country.

242  Sasha Mullally and David Wright

These data raise several questions. First, they suggest that the South Asian cohort of new physicians to Canada were quite varied in their career choices and career experiences in Canada. But upon closer qualitative investigation, do other patterns emerge to link the diaspora experiences together? Was the decision to locate in a particular area of Canada a matter of choice or chance, or something more like institutionalized coercion (as with specialist training in British health system of the day)? What set of circumstances might have allowed them to connect, like Mohan Virick, to a community for the duration of a half-century? When they did move on, what would prompt them to do so? Why did they end up in the small cities and towns where many of them did in 1971? Storied Migrations, Storied Lives We rely on the narrative accounts from physicians themselves to help answer these questions about location, relocation, and the important question of connection within the small town and city phenomenon identified above. The ethnic variation of the South Asian diaspora complicates our attempt to analyse these physicians as one single cohesive group. Among the eight narratives used in this chapter, we find rich stories that are distinguished from each other by ethnicity, geography, and generation.40 Two of the physicians interviewed are ethnically Pakistani (though they left before Partition), two others are from expatriate communities and grew up in Africa, and one is from the former Portuguese colony of Goa. Religion divides the oral interview cohort under investigation. One identifies as Muslim, four are Hindu, while the Goan physician is a professed Roman Catholic. Three of the doctors are quite elderly and, like Mohan Virick, left India in the late 1950s and early 1960s, in the years immediately following independence. The rest are slightly younger, having left in the early 1970s. These later migrants are less inclined to remember India in positive terms, leaving during years of relative strife, marked by ethnic and sectarian conflict. Two grew up in rural villages, while the rest are urban in their background and outlook. Two are women and six are men. To speak of a single “South Asian medical diaspora” experience in Canada would be to obscure these essential differences among the physicians interviewed. Like the wide-ranging geographic distribution of South Asian phy­sicians across the continental span of Canada, these respondents espouse a wide-ranging set of beliefs and have divergent backgrounds, despite sharing a common region of origin. Still, as we discover, there

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are common threads that bind their stories together into a collection of linked narrative accounts. While we did not ask specific questions about social class, it is clear they had a shared ability to access post-­ secondary education and thrive in schools built around British curricula. This provides an entry point into their narratives: how education facilitated immigration. The first theme to emerge quite strongly is that, unlike Virick, few of our respondents initially considered Canada a first destination. In fact, the rest all emigrated seeking advanced medical training in the United Kingdom, or, in one case, the United States. Most then intended to return to India to practise and live out their lives. Going to Britain held considerable cachet and would cement career advancement, so many opted to go abroad for this reason, and the trend was established by the 1960s. For these early-wave respondents, the trip to the United Kingdom was rendered in epic terms. One Bengali physician who trained in Kolkata remembered the trip by boat from Mumbai to Naples in 1961 quite vividly, a significant first step of a longer voyage that would end with him taking on a position as house surgeon in a northern British hospital. Over the voyage, he remembered the onset of cold as a metaphor for acclimatization; he stuffed his jacket with newspapers to protect himself as he gradually adjusted to the chilly temperatures of a northern European spring. And he remembered being far from alone. “All these Indian doctors,” he remembered on the boat with him, “they were studying all over.”41 The atmosphere on the boat he recalled being charged with both ambition and anxiety. “I mean, here we are going to the Suez Canal and so much to see … but everybody is busy reading. Every corner of the boat the boys and the girls are studying. Grey’s Anatomy and Cecil’s medical textbook. Harrison’s textbook. It was a stressful time.”42 A majority of these migrants were men, but, as referenced in the testimony above, many young women were also a part of this diaspora. For those married physicians who immigrated as a couple, often the husband’s career dictated the course of their combined lives and careers. One respondent from northwestern India explained how her husband wanted to study internal medicine and just thought it was a better idea to do it outside of India. And so to satisfy this ambition, they made a move to northern England. She was a later émigré of the late 1960s, and such younger respondents placed less emphasis on family obligation and expectation and greater emphasis on their peer group experience and word of mouth as key factors in their decision-making. So even

244  Sasha Mullally and David Wright

those respondents who did not mention family pressure or involvement in their decision-making still found themselves caught up in a wave of professional out-migration that fascinated and compelled their peer group. But for these later migrants, the pull of opportunities sometimes combined with the push of increasing levels of political strife in the home region. The single Goan physician we interviewed noted how there was no postgraduate training in his home region at that time. As a practising Roman Catholic and a member of a religious minority group, he “felt compelled” to leave India altogether in order to avoid sectarian violence that seemed to be escalating in the late 1960s. And so he arranged to do his residency at a Catholic hospital in the northeastern United States.43 Most, however, went to the United Kingdom and easily found work. The Bengali physician mentioned above remembered that it was easy to get a job as a house surgeon in many British hospitals. His destination was a northern town near Leeds. Starting his new position in September 1961, he found the credentialing process straightforward: “We did our first six months as a house surgeon, and another six months as medical resident … [this] was called pre-registration, so you had to work a year before you got full registration in England.”44 After receiving his general medical certificate (GMC), he stayed in England, moving from one hospital to the next to advance his career through the ranks of junior officer to senior officer, and then to registrar. Eventually, he sat the British licensing exam and earned his MRCP.45 He looked back on this decade of his life with equanimity: “It was a good experience for me, learned the language, you learn the culture,” and earning what he considered a good and comfortable salary.46 Therefore, it may be said that the institutional impediments faced in the United Kingdom worked to Canada’s advantage, but only after some time. While the move to Britain from India was a well-beaten path, facilitated by imperial connections, integrated educational systems, and a widespread understanding of where professional opportunities lay for an educated generation of ambitious South Asians and their families,47 Canada was not as obvious a choice. By contrast, once the British system proved untenable, the next move for these doctors was to go back to their home region. Almost to a person, at the point when they disembarked for the United Kingdom, our respondents remembered expecting to return to South Asia after their training in Britain concluded. Out of the eight stories captured in this chapter, most sought advancement for their families in India through a sojourner

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immigration pattern. Many found, however, their own personal truth in the adage “You can never go home again.” One elderly physician remembered being recruited immediately to a medical school in Nigeria. “I had many options at this point, because once you get the FRCS the world is at your feet, you can go where you want.”48 After six years in Africa, he and his wife tried to practise medicine in India but could not get established. Even the Goan physician who eschewed the United Kingdom for an internship in the United States could not find professional satisfaction back home. He returned to practise in Pakistan briefly after an internship in the northeastern United States, but then left again to seek specialist training in Canada. “I was against the U.K.,” he explained, “[and] just being in a British colonized country before, I didn’t want to go [there].”49 And so he married an American woman he had met during his internship and relocated to Canada to train and to practise instead.50 Even after gaining a specialty, respondents wanted to practise medicine a certain way, attached to hospitals with adequate staff, funding, and technology, and enjoy a lifestyle at the same time. Commenting for themselves and for the communities of Indian medical students and residents of which they were a part, most respondents observed the ways in which the pull of “the West” – by which they meant “Western” medicine as well as “Western” lifestyles – seemed increasingly difficult to leave behind the longer they stayed. The Bengali respondent gave up his Muslim religion, remembering this as a part of a “deep change in my way of thinking” about returning to India. Another doctor who ended up in a small community hospital in Kingston, Ontario, recalled how he had plans “only to do training and get some British experience and go back to India, but as it happened I just spent a lot of time in England.” He, too, explained, “The longer you stay in the Western world, the harder it becomes to go back to your native country, because you are beginning to like this way of life, the style, and I think that is the one big thing. The working environment, you begin to like it, you know.”51 Often, a decision to remain yielded significant material benefits that helped ease the transition. The Bengali-born physician decided to come to Canada because he married a Canadian nurse, but the deal was considerably sweetened by the prospect of a lucrative private practice. He earned less than 200 pounds a month as a registrar in internal medicine in Britain, but his recruitment to a lucrative group practice in a northern Canadian mining town promised him $2,000 per month.52 Such offers

246  Sasha Mullally and David Wright

proved difficult to resist. But even so, the pair only lasted three years in the remote town where they initially landed. He found working in a resource town in the high prairies of Manitoba interesting at first, but the young transient population made for a professionally enriching but socially dislocating experience, managing acute cases, alcoholism, and high rates of sexually transmitted disease. He served some northern fly-in communities as well: “I used to go on a small plane to reservations,” he explained, “and I would … deliver babies, pulled tooth out, lots of dysentery, nephritis, meningitis, children’s disease, dehydration. So actually it was interesting work.” But he recalled being troubled by First Nations poverty: “The native Indians, [their] standard of living was so poor, no running water, not enough heat, and cold and by the lake. Constant misery, that’s what I used to think.”53 Though he bought into the group practice that hired him, the good salary simply could not trump the need for deeper social and family connection. Eventually, he and his wife would relocate to British Columbia, closer to the mountains, but also closer to his wife’s family.54 For most respondents, an international network of South Asian physicians and family connections convinced many to given Canada a try, and consider living in cities and regions they might not even have heard about, let alone considered, without such ties. With too many career blocks in Britain, it seems from the oral histories that the decision to pursue Canadian opportunities was always facilitated and enabled by a relatively open medical marketplace. While all the respondents interviewed got a licence to practise medicine in Canada and passed the LMCC requirements, there were occasional stories of those who did not. One interviewee knew a South Asian woman physician from Madras who struggled too long with the LMCC requirements and eventually moved to the United States and became a nurse. He was perplexed by the exam requirement, saying, “I don’t know why she would have to take this, but I guess discrimination.”55 He blamed her weaker knowledge of English on her inability to pass the oral portion. Such stories raise questions about why some South Asian medical professionals might fail in their attempts to gain licence to practise in Canada, and what might become of them. The experiences of diaspora are not limited to the successful licence to practise, of course, and other researchers may fruitfully explore the more disappointed members of the South Asian diaspora to round out the picture presented here, painted by those we would consider, like Mohan Virick, to be successful transplants.

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But for those who passed the LMCC, opportunities were many, and these were advertised in every issue of the Lancet, the British Medical Journal, and other professional circulars back in the United Kingdom. Faced with such choices, what almost always went hand-in-hand with advertised opportunities was some kind of pre-existing personal connection. This might help explain why and how physicians from the Indian subcontinent might find themselves “off the beaten path” in Canada. Such social connections could take many forms. One woman physician and her husband set their sights overseas after lengthy discussions with her brother-in-law, an internist in the United States.56 They moved to a medium-sized city on the Prairies because it was geographically close to the American Midwest, where he was located. So professional connections, but also the presence of family or other friendly immigrant physicians played a decisive role to come to Canada, and then where to go once the national destination was decided on. While it did not seem from the interviews that any physicians felt blocked by some systemic barrier or the “funnelling” of personnel to less desirable locations, northern, rural communities may be where the first opportunity presented. An examination of wider family connections leads to a consideration of how immediate family needs might figure into the immigration decisions. This common career trajectory, taking time to secure postgraduate training and perhaps some years in practice in Britain, places South Asian medical migrants at a particular point in their career and their life cycle upon arriving in Canada. All but one of the nine South Asian physicians arrived already married, with young children in tow. The Bengali physician we interviewed came to Canada because, as mentioned, he married a Canadian nurse working overseas in the Warwick area. After moving about and changing hospitals every two years or so, he had fallen into a residency in his specialty of choice, internal medicine. He was the only respondent to have such luck, and, chances are he would have stayed were it not for the pull of his wife’s family that brought them to Canada in the late 1960s, with one small child in hand and a second on the way.57 Another couple of married physicians made two international stops before moving to Canada. They were recruited out of Bizza Medical School in what is now Pakistan to practise as house surgeons in Scotland. They then worked for just over a year in Wales before deciding that their careers might benefit from a move to North America.58 They, too, arrived with two small children, both of whom had been born in the United Kingdom. The wife remembers

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trying for many years to make a go of it in Britain, but finally, “We thought there was more opportunity … so [my husband] applied for a job in [a large Western Canadian town] and he got the job from England as a chief resident. He said that was a good opportunity and that’s how we moved.”59 Small and medium-sized population centres did pose challenges with their lack of social diversity. Most respondents felt their social lives and community attachments suffered because of their “foreignness.”60 And while the physicians interviewed reported almost universal good relations with their patients – they were, after all, serving populations that would have had little access to physician services otherwise – this is not so say that there were not difficulties in acclimating to Canadian professional life as physicians. The African-born physician found life in a small rural community completely untenable because of the perceived competition he posed to the local general surgeons in his regional hospital. While they welcomed other new physicians into their midst, he felt there was some bias from his foreign credentials and/or his brown skin that drew their ire and made him a special target.61 He eventually relocated to a small city in eastern Ontario, but stayed for several years longer than he wanted in the first location so his children could have a stable home life. He and his wife left only when the youngest went off to university.62 Conclusions The summation at the end of the interviews, where physicians were asked to reflect on their lives and practices, invariably drew comments typical of the successful migrant. Few indicated they would make any changes to their life courses. Even one of the small-town physicians, one of the most vocal about the challenges he faced immigrating from urban India and Britain to rural Canada, who noted on several occasions that, had he no family in Canada and the freedom to do so, he would have left without a backward glance, summed up his career with satisfaction. “I am happy that I came to Canada and I have achieved more by coming to Canada than I would have achieved in England, or even perhaps in India.”63 What this chapter has shown are the ways in which achievement and satisfaction, in the Canadian context, derived from the “small and medium city phenomenon” that marked South Asian medical practices. This chapter has thus shed light on one common experience of diaspora

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for South Asian doctors. This has, in turn, deepened our understanding of a critical period in Canadian medical history. What emerges is a story where Canadian communities were rather inadvertent beneficiaries of the South Asian medical diaspora. Ultimately, these physicians made immigration decisions based on their experiences of colonialism and what happened to them in other host countries, especially Britain. They trusted the personal connections that drew them to a place over the professional or monetary opportunities. Throughout, a consideration of the needs of their families featured prominently, and all connected to Canada by connecting through them. For some especially fortunate physicians, like Mohan Virick, the family bonds would be long-standing and far-reaching, cementing his position as a caregiver, patron, and fatherly friend to people with whom he shares much history, but no blood ties. Further research is required to determine whether familial, personal, and non-professional factors were determinants for groups of doctors from other parts of the world in this period, as medical professionals of all stripes moved within their respective professional domains. But the story emergent from this study of the South Asian physician migrants is one that places this Canadian health marketplace within in a global web of opportunities that presented to ambitious immigrant doctors of the 1960s and 1970s. These were doctors with “the world at their feet,” to paraphrase one doctor cited on previous pages. Still, at a historical moment when opportunity was everywhere for all different kinds of physicians in Canada, offering a personal connection in diaspora is a deciding factor in any community’s ability to “draw and hold” medical personnel, suggesting that, in an ideal world, doctors and communities simultaneously connect to and care for each other and do it in ways similar to that adopted by Mohan Virick and the Eskasoni First Nation. Notes 1 We are grateful for the research assistance of Renée Saucier, Farwa Malik, Alexandra Ketchum, and Abby Mahon at the Institute for Health and Social Policy, McGill University in 2013, and Cody Hamilton at the Department of History, University of New Brunswick, 2013 and 2014. Johanna Bleecker, formerly a graduate student in geography at McGill University, produced the map. A Research Development Grant from Associated Medical Services, Toronto, and a Canada Research Chair grant supported this research, in part.

250  Sasha Mullally and David Wright 2 “MD’s Gift to Eskasoni: 140 Hectares,” Halifax Chronicle Herald, 24 April 2014. 3 Ibid. 4 This literature is voluminous, but, in addition to the work produced by Alfonso Mejía and colleagues, influential titles that drew attention to the problem include Committee on the International Migration of Talent, The International Migration of High-Level Manpower: Its Impact on the Development Process, Praeger Special Studies in International Economics and Development (New York: Praeger Publishing, 1970); and F.J. Van Hoek, The Migration of High Level Manpower from Developing to Developed Countries (The Hague: Mouton, 1971). 5 Alfonso Mejía, “Migration of Physicians and Nurses: A World-wide Picture,” International Journal of Epidemiology 7 (1978): 207. Mejía himself helped raise these concerns in the early 1970s with the publication of an earlier study of this brain drain, in World Health Organization: Multinational Study of the International Migration of Doctors and Nurses (Geneva: World Health Organization [WHO], 1973). For additional works on this theme, see also Alfonso Mejía, Helena Pizurki and Erica Royston, Physician and Nurse Migration: Analysis and Policy Implications (Geneva: WHO, 1979); Mejía, “Health Manpower Migration in the Americas,” Health Policy Education 2 (1981): 1–31; and Alfonso Mejía, Helena Pizurki, and Erica Royston, World Health Organization Multinational Study of the International Migration of Physicians and Nurses (Geneva: WHO, 1981). 6 According to policy studies expert Joel Spring, the term brain drain, in fact, first gained widespread circulation describing this very phenomenon. Joel Spring, Globalization of Education (London: Routledge, 2009), 128. 7 We have examined the broad strokes of this phenomenon in the Canadian context in Sasha Mullally and David Wright, “La Grande Séduction?: The Immigration of Foreign-Trained Physicians to Canada, c. 1954–76,” Journal of Canadian Studies 41, no. 3 (2007): 67–89. 8 Health Insurance became tied to employment in the United States, but Canada adopted a universal health-care system. For background information, consider Ronald L. Numbers, Almost Persuaded: American Physicians and Compulsory Health Insurance (Baltimore: Johns Hopkins University Press, 1978); and Antonia Maioni, Parting at the Crossroads: The Emergence of Health Insurance in the United States and Canada (Princeton, NJ: Princeton University Press, 1998). 9 Britain was losing hundreds of medical practitioners to both Canada and the United States, while, within North America, the stronger American economy exerted considerable pull. Van Hoek, Migration of High Level

Connecting to Canada  251  Manpower, 54. The United States was the first wealthy nation in the 1970s to become concerned with the problem of over-supply. See, for instance, an opening salvo by Paul J. Feldstein and Irene Butter, “The Foreign Medical Graduate and Public Policy: A Discussion of the Issues and Options,” International Journal of Health Services 8, no. 3 (1978): 541–58. 10 This claim is advanced by the Ministry of Overseas Indian Affairs, in “India and Its Diaspora,” MOIA, 2009, http://moia.gov.in/accessories. aspx?aid=10. 11 See D.S. Tatla, The Sikh Diaspora: The Search for Statehood (London: University College London Press, 1999). 12 Such experiences are described in H. Johnson, The East Indians in Canada (Toronto: Canadian Historical Association, 1984). 13 These included the denial of voting rights, restrictions on running for office, and immigration restrictions on families joining the male workers who had come to Canada. J.J. Mangalam, “The Komagata Maru Affair, 1917,” in From India to Canada: A Brief History of Immigration, Problems of Discrimination, Admission and Assimilation, ed. Sankurathri Chandrasekhar (La Jolla, CA: Population Review Books, 1986), 48–9. 14 Sankurathri Chandrasekhar, “Introduction,” in Chandrasekhar, From India to Canada, 20. 15 During this period, immigrants totalled only 100, and only one man from the region came to Canada over the duration of First World War. See J.G. Chadney, The Sikhs of Vancouver (New York: AMS, 1984). 16 R. Sheel, “Marriage, Money and Gender: A Case Study of the Migrant Indian Community in Canada,” Indian Journal of Gender Studies 12, nos 2 and 3 (2005): 335–56. The post-1957 bump in overall numbers of Indian and South Asian immigrants increased the Sikh population in particular, as it facilitated immigration through sponsorship. K.E. Nayar, The Sikh Diaspora in Vancouver: Three Generations Amid Tradition, Modernity and Multiculturalism (Toronto: University of Toronto Press, 2004), 17; H. Johnson, “The Development of the Punjabi Community in Vancouver since 1961,” Canadian Ethnic Studies 10, no. 2 (1988): 1–19. 17 According to Arti Nanavati, the Indian diasporic community was dominated by Sikhs until the early 1960s. “The relaxation in immigration rules between 1961–1967 with the introduction of skilled class and family class led to influx of immigrants from Gujarat, Kerala, Delhi and Parsis. However till early nineties seventy percent of total Indo-Canadians in Canada were from Punjab.” Arti Nanavati, “Indian Diaspora in Canada,” Diplomacy and Foreign Affairs, accessed 3 September 2014, http:// diplomacyandforeignaffairs.com/indian-diaspora-in-canada/. See also

252  Sasha Mullally and David Wright

18

19

20

21

Arti Nanavati and Sarah Ahmed, eds., Indian-Canada Trade and FDI Bilateral Flows (New Delhi: Allied Publishers, 2013), 21–3. In Canada, policy historians are led by C. David Naylor, Private Practice, Public Payment: Canadian Medicine and the Politics of Health Insurance, 1911–1966 (Montreal and Kingston: McGill-Queen’s University Press, 1986). See also Naylor, ed., Canadian Health Care and the State: A Century of Evolution (Montreal and Kingston: McGill-Queen’s University Press, 1992); and C. Stuart Houston, Steps on the Road to Medicare: Why Saskatchewan Led the Way (Montreal and Kingston: McGill-Queen’s University Press, 2003). Medicare is the common appellation for universal health insurance in Canada. It should not be confused with American program of Medicare, which refers to the program of free health care available to the poor who receive social assistance. These tend to focus on the cult of personality surrounding T.C. (Tommy) Douglas, leader of the first socialist party to be elected to provincial public office in Canadian history, and widely recognized as the “father” of the Canadian medicare system, which he and his government implemented in Saskatchewan over 1962–3. For recent examples of such hagiographic accounts, see Prairie Giant: The Tommy Douglas Story, television miniseries starring Les Vandor, Style Dayne, Dan Savoie, Michael Therriault (Canadian Broadcasting Corporation [CBC], 2006); and Vincent Lam, Extraordinary Canadians: Tommy Douglas (Toronto: Penguin, 2011). The medicare system in Canada is fee-for-service and offers a version of universal health care that falls well within what Ian Mackay has called the “liberal order framework.” MacKay, “Liberal Order Framework: A Prospectus for a Reconnaissance of Canadian History,” Canadian Historical Review 81, no. 4 (2000): 616–78. More radical left initiatives, such as the union-run community health-care clinic in the resource town of Sault Ste Marie in 1960s Ontario, see short shrift in the literature, except for Jonathan Lomas, First and Foremost in Community Health Centres: The Centre in Sault Ste Marie and the CHC Alternative (Toronto: University of Toronto Press, 1985). New work by Esyllt Jones, for instance, highlights the challenges of socialist physicians who rallied behind what was perceived as radical policies from the left to implement community-run health-care programs. Preliminary work includes Esyllt Jones, “Soviet Medicine and Interwar Medical Advocacy for Socialized Medicine in Canada” (paper presented to the Annual Meeting of the Social Science History Association, Chicago, 22 November 2013). See also Gregory P. Marchildon, ed., Making Medicare: New Perspectives on the History of Medicare in Canada (Toronto: University of Toronto Press, 2012).

Connecting to Canada  253  22 From an oral interview with Allan Blakeney, a member of the Saskatchewan government who recruited British NHS physicians as strikebreakers against a province-wide anti-medicare physician strike in 1962, we learn that reciprocal licensing for British doctors made them the safest recruitment pool. His government, expecting “a near complete walkout,” of local physicians, also went over the border and “lined up doctors from the Auto Workers medical plan in Detroit and the Steel Workers plan in Pittsburg.” Alan Blakeney, “The Struggle to Implement Medicare,” in Marchildon, Making Medicare, 278–9. 23 For Nova Scotia, see C. McAlister and P. Twohig, “The Check Off? A Precursor to Medicare in Canada?” Canadian Medical Association Journal 173, no. 12 (December 2005): 1504–6; and for British Columbia, see Gregory P. Marchildon and Nicole O’Byrne, “From Bennett Care to Medicare: The Morphing of Medical Care Insurance in British Columbia,” Canadian Bulletin of Medical History 26, no. 2 (2012): 453–75. 24 Gregory P. Marchildon and Nicole O’Byrne, “Last Province Aboard: New Brunswick and National Medicare,” Acadiensis 47, no. 1 (Winter/Spring 2013): 150–67. 25 J. Wood, “East Indians and Canada’s New Immigration Policy,” Canadian Public Policy 4, no. 4 (1978): 547–67. 26 These points were readjusted in 1976, mainly after pressure from the wealthier provinces, who had recruited enough physicians that they no longer felt a shortage. For a sample of this change in policy culture, see R.G. Evans, “Does Canada Have ‘Too Many Doctors?’: Why Nobody Loves an Immigrant Physician,” Canadian Public Policy / Analyse de politiques 2 (1976): 147–60. And for more details about the larger wave of immigrant physicians in the period, see Mullally and Wright, “La Grande Séduction?” 27 A census was held in 1971, in the middle of the 1970s medical migration wave, and it is a good vantage point from which to take a snapshot. It does not mark the end of the South Asian diaspora, however. In 1979, the Indian Ministry of External Affairs estimated the number of persons of Indian extraction living abroad was 10.7 million, about 1.5 per cent of the population of the country at that time. See Myron Weiner, “International Migration and Development: Indians in the Persian Gulf,” Population and Development Review 8, no. 1 (March 1982): 1–36. However, as we have argued elsewhere, the wave of physician migration in Canada came to a precipitous end in the mid-1970s, with changes to Canadian immigration regulations and a shift in licensing practices in most provinces. Mullally and Wright, “La Grande Séduction?” This makes 1971 a vantage point of special significance for Canadian health history.

254  Sasha Mullally and David Wright 28 It should be noted that the CMD does contain occasional errors of geography, and occasionally we note a physician listing will disappear one year only to reappear in the following edition. However, because we are also engaged in online multi-year analyses, we feel confident that the 1971 sample used in this chapter is complete to a minimal margin of error. 29 See David Wright, Sasha Mullally, and Colleen Cordukes, “‘Worse Than Being Married’: The Exodus of British Doctors from the National Health Service to Canada, c. 1955–1975,” Journal of the History of Medicine and Allied Sciences 65, no. 4 (2010): 546–75. 30 The presence of South Asian physicians in the ranks of medical immigrants to Canada was relatively new in the 1960s. Physicians from South Asia did not come to Canada in any real numbers before the implementation of the points system that removed country of origin from the immigrant selection process. For instance, the CMAJ reported only seventy physicians of “East Indian” nationality immigrated to Canada between 1953 and 1961. “Future Requirements for Physicians in Canada,” CMAJ 85, no. 11 (1961): 1164. 31 This would have a significant and immediate impact on the Canadian health-care system, not only for physician access but also for the supply of other health-care personnel. As Agnes Calliste has pointed out, it immediately facilitated immigration of Afro-Caribbean nurses. See Agnes Calliste, “Women of Exceptional Merit: Immigration of Caribbean Nurses to Canada,” Canadian Journal of Women and the Law 6 (1992): 85. See also Calliste, “Proletarianization, Professionalization, and Caribbean Immigrant Nurses,” Canadian Journal of Women’s Studies 18 (1998): 57. 32 Freda Hawkins, Canada and Immigration: Public Policy and Public Concern (Montreal and Kingston: McGill-Queen’s University Press, 2003), 4–18. 33 Wright, Mullally, and Cordukes, “‘Worse Than Being Married,’” 45–51. For a treatment of more recent and important phenomenon of South African physicians immigrating to the Canadian Prairie Provinces, see Hugh Grant, “From the Transvaal to the Prairies: The Migration of South African Physicians to Canada,” Journal of Ethnic and Migration Studies 32, no. 4 (2006): 681–95. 34 Even in the early post-war period, between 1946 and 1961 approximately 5,000 new international medical graduates (IMGs) immigrated to Canada, and, of these, over 2,000 had British training credentials. See Stanislaw Judek, Medical Manpower in Canada (Ottawa: Queen’s Printer, 1964), 38–44. 35 Ireland has had, for instance, a long history of training physicians for emigration. See Greta Jones, “‘Strike Out Boldly for the Prizes That Are

Connecting to Canada  255 

36

37

38

39

40

Available to You’: Medical Emigration from Ireland 1860–1905,” Medical History 54, no. 1 (2010): 55–74. A common refrain among all respondents was the bureaucratic ease with which they largely sailed through licensing. A number considered options in Nova Scotia, for instance, and, as one respondent explained, “Nova Scotia was [a place] where there was a shortage of doctors. So within two weeks we got the visa and permission to practice.” Oral interview, respondent 4114, 15 January 2014, Kingston, Ontario. Only one respondent expressed disappointment with having to write an LMCC exam to get a medical licence after getting the credential in Britain. But while this formality could be an irritant to otherwise well-educated foreign-trained physicians, it did not appear to pose a systemic impediment to practice. These refer to those who had credentials and training as medical officers of health (three), public health administration (one), other institutional training not categorized as a formal specialty, such as rehabilitation medicine (three) and other non-specialist designations, such as “research” (one). See CMD, 1971. We use the definitions of rural and urban as defined by Statistics Canada. Since 1971, Statistics Canada has used the same criteria and methodology, wherein an urban area was defined as having a population of at least 1,000 and a density of 400 or more people per square kilometre. All territory outside an urban area was defined as rural area. To make the breakdown of urban areas more meaningful, we also adopt the three subcategories for urban as outlined since 2011, wherein a “small-population centre” is a centre with a population between 1,000 and 29,000, a “medium population centre” has a population between 30,000 and 99,000, and a “large population centre” has a population above 100,000. See Statistics Canada, “From Urban Areas to Population Centres,” 7 February 2011, http://www.statcan.gc.ca/eng/subjects/standard/sgc/notice/sgc-06. Data on incorporated towns’ historic populations can be derived from many sources. We used Dominion Bureau of Statistics, Canada Year Book, 1967 (Ottawa: Queen’s Printer, 1967), 188–93. For this analysis, we designated Halifax a large population centre, because its population was by far the largest among municipalities in the province, and it came close to the 100,000 threshold, though not meeting it in the strict sense; in most ways this city functions and occupies the position of being a provincial, and perhaps even regional metropolis. Some researchers believe scholars should recognize three “waves” of South Asian (particularly Indian) brain drain in the twentieth century, one relatively minor out-migration occurring after Independence and

256  Sasha Mullally and David Wright

41 4 2 43 44 45

46 47

4 8 49 50

5 1 52 53 54 55 56 57 58 59 60 61 62 63

into the 1960s, another more significant out-migration surge in the 1970s and early 1980s, and a final wave that began in the 1990s and continues to the present. See V.V. Krishna and Binod Khadria, “Phasing the Scientific Migration in the Context of Brain Gain and Brain Drain in India,” Science, Technology and Society 2, no. 2 (September 1997): 347–85. Oral interview (telephone), respondent 6113, 26 September 2013, Trail, British Columbia. Respondent 6113. Oral interview, respondent 2108, 7 July 2008, Halifax. Respondent 6113. This acronym stands for member of the Royal College of Physicians, and designates a full British licence to practise medicine. The equivalent in Canada is the designation of fellow of the Royal College of Physicians, or FRCP. He remembered earning 150 pounds per month, after expenses. Respondent 6113. The colonial heritage that created institutionalized medical dependency during the interwar period is outlined in Roger Jeffery, “Recognizing India’s Doctors: The Institutionalization of Medical Dependency, 1918–39,” Modern Asian Studies 13, no. 2 (1979): 301–26. Respondent 4114. Respondent 2108. See David Wright, Alex Ketchum, and Gregory Marks, Draft Doctors: The Impact of the Vietnam War on the Migration of Foreign Doctors to Canada, chapter 7 in this volume. Respondent 2108. Respondent 6113. Ibid. Ibid. Respondent 6113. Respondent 1208. Respondent 6113. Respondent 1208. Ibid. Respondents 1108, 1208, 2108, and 5214 stated this most strongly. Respondent 5214. Respondent 4114. Ibid.

Contributors

John Armstrong is a historian at the Office for Treaty Settlements in Wellington, New Zealand. His doctoral thesis, completed in 2013, ­examined the international migration of New Zealand doctors in the twentieth century using a mixed methodology of quantitative analysis and oral history. Juanita De Barros is professor of history, McMaster University, and former president of the Canadian Association of Latin American and Caribbean Studies. Her research concentrates on the nineteenthand twentieth-century Caribbean, with a focus on the social history of health and urban history. Her most recent publication is Reproducing the British Caribbean: Sex, Gender, and Population Politics after Slavery (2014). Annika Berg is a historian of science and ideas at Stockholm University. Her PhD thesis (“Den gränslösa hälsan: Signe och Axel Höjer, folkhälsan och expertisen,” Uppsala University, 2009) analysed gender, expertise, and public health ideologies in twentieth-century Sweden. She has recently finished two research projects focusing on psychiatric patients and negotiations on “troublesomeness” in Sweden in the interwar period, and is currently involved in two other research projects: one on the history of Swedish development aid, and one on scientific personae and travel in the twentieth century. Joanna Bornat is emeritus professor of oral history at the Open University, United Kingdom. She has a long-standing involvement in oral history, nationally and internationally. She has researched and published on aspects of remembering in late life as well as topics relating to social policy and aging. She is an editor of the journal Oral History.

258 Contributors

Aneez Esmail is professor of general practice at the University of Manchester and has carried out extensive research on racism in the medical profession in the United Kingdom. He is recognized nationally for his research on discrimination in the medical profession. Much of the work that he has carried out in this area has resulted in significant changes in recruitment, selection, and monitoring of the medical profession in the United Kingdom. Margret Frenz is lecturer in global and imperial history at the University of Oxford. Her previous publications include Community, Memory, and Migration in a Globalizing World: The Goan Experience, c. 1890–1980 (2014); From Contact to Conquest: Transition to British Rule in Malabar, 1790–1805 (2003); and (edited with Georg Berkemer) Sharing Sovereignty: The Little Kingdom in South Asia (2003; revised edition, 2015). She has also published articles in leading journals such as Past & Present and Immigrants and Minorities. Leroi Henry is senior lecturer in research methodology at Northampton University. He was previously a research fellow at the London Metropolitan University. He has published widely on migration and diaspora. Greta Jones is professor emerita of history at the University of Ulster, Northern Ireland. She has published widely on the history of ideas, with a particular interest in the history of Social Darwinism and t­ uberculosis in Britain and Ireland. Her publications include Captain of All These Men of Death: The History of Tuberculosis in Nineteenth- and ­Twentieth-Century Ireland (2011). Alex Ketchum is a doctoral candidate in the Department of History, McGill University. She has her MA in History and Gender and Women’s Studies also from McGill, and her BA from Wesleyan University in Feminist, Gender, and Sexuality Studies. As the editor of The Historical Cooking Project, Alex works on the intersections of food, environmental, and feminist history. Her research is on North American feminist restaurants and cafés in the 1970s and 1980s. Gregory Marks is a Leverhulme Doctoral Scholar in Global Health under the supervision of Dr Devi Sridhar at the University of Edinburgh. He completed his MSc in Comparative Social Policy at the University

Contributors 259 

of Oxford, with a focus on health policy. Prior to Oxford, Gregory spent five months at a consulting firm, where he advised large multilaterals and NGOs on global health movements, and a year at the Institute for Health and Social Policy, McGill University, where he analysed healthrelated issues ranging from physician migration to health systems development. Laurence Monnais is professor of history at Université de Montréal. She is a specialist of the history of medicine in Southeast Asia and holds the Canada Research Chair in Health Care Pluralism. Her publications include Médecine et Colonisation. L’Aventure Indochinoise, 1860–1939 (1999), Médicaments coloniaux. L’Expérience Vietnamienne, 1905–40 (2014), and the co-edition of Southern Medicine for Southern People: Vietnamese Medicine in the Making (2012) and Global Movements, Local Concerns: Medicine and Health in Southeast Asia (2012). Sasha Mullally is an associate professor of history at the University of New Brunswick. She researches and publishes in the history of rural health care, the intersections of gender and medical practice, and, with David Wright, the history of international medical graduate experiences in mid- to late twentieth-century Canada. She has a forthcoming book on the interwar history of rural medicine in the transborder northeast, under contract with the University of Toronto Press. Parvati Raghuram is professor of geography and migration at the Open University. She has published widely on skilled migration, gender, and care. Her most recent book is Global Migrations and Gendered Social Reproduction (Palgrave). She is also a co-editor of the Palgrave PIVOT book series Mobility and Politics. Julian M. Simpson initially trained as a journalist, doing a first degree at Sciences Po in Paris and then studying at the École Supérieure de Journalisme de Lille. After a career in journalism and broadcasting, he worked in the voluntary sector as a campaigner and policy adviser. He went on to do an MA in history at the University of Northumbria and a PhD at the University of Manchester and is now a contemporary historian whose research focuses on migration, health care, and how history can inform policy debates. He is completing a monograph on the role of doctors from the Indian subcontinent in the development of British general practice.

260 Contributors

Stephanie J. Snow is senior research associate in the Centre for the History of Science, Technology & Medicine, University of Manchester, United Kingdom. She is the co-author (with Emma L. Jones) of Against the Odds: Black and Minority Ethnic Clinicians and Manchester, 1948–2009 (2010) and author of articles on the history of the U.K. National Health Service and immigration. She is focusing on global and local health policies on stroke and promotes the use of history as an analytical tool in policymaking. John Weaver is professor of history at McMaster University and a Fellow of the Royal Society of Canada. He has published widely on legal and urban history and land acquisition in the British world. His most recent research projects focus on the history of self-destruction, and include A Sadly Troubled History: The Meaning of Suicide in the Modern World (2009) and Sorrows of a Century: Interpreting Suicide in New Zealand, 1900–2000 (2014). David Wright is professor of history and Canada Research Chair in the History of Health Policy at McGill University. He is the author and co-editor of eight books and three dozen peer-reviewed articles and chapters, primarily on the history of disability, the history of children’s hospitals, and transnational themes in the history of medicine. His DOWNS: The History of a Disability won the 2013 Dingle Prize from the British Society for the History of Science.

Index

AB Astra, 83 accreditation: AMA examinations and, 110; medical migration and, 11; royal colleges and, 185. See also licensing; reciprocity; registration(s) African medical students: in India, 145; at Makerere College, 144–5; women, 144–5 African-Americans, as Vietnam War draftees, 168 Aftonbladet, 78 Aga Khan Hospital (Nairobi), 154 Albuquerque, Manõel Francisco (Manuel Francisco) de, 146–7 Ali bin Hamud, sultan of Zanzibar, 146 American Joint Distribution Committee, 58 American Medical Association (AMA): annual census, 178; Choice of Medical School, 104; Classification of Foreign Medical Schools, 100–1; Committee on Foreign Medical Credentials, 99–100, 102, 104; Council on Medical Education and Hospitals, 99, 101, 102, 103;

and Educational Commission for Foreign Medical Graduates, 110; and foreign medical practitioners applying for licensure, 98–9; and Irish medical schools, 100, 104–8; list of approved foreign medical schools, 96–7, 99, 100–1, 102–3, 106–8, 111–12; on post-war doctor immigration, 98; visits to foreign medical schools, 100, 102, 111 Amrith, Sunil, 5 Amulree, Lord, 187, 188 Anderson, Donald G., 99, 104–5 Anderson, Oswald, 32–3 Andersson, Oscar, 84–5 Andrade, L.A., 145 anti-Semitism: in Australia, 54, 64; and Central European medical refugees, 217; and Jewish physicians, 78, 80; and Jewish refugee physicians, 73; protectionism and, 49; in Sweden, 73, 75, 78, 79, 80, 85, 89 Apothecaries Hall (Dublin), 97 Armstrong, John, 8, 186, 212, 218 Association of Colleges of Medicine of Canada (ACMC), 178

262 Index Austin, David, 37n32 Australia: administration of medical migrants in, 42–3; army medical services branch, 61; debates regarding medical migrants in, 42–3; doctor migration to, 6; Flying Doctors program, 62; Great Depression in, 63; Italian credentials and, 54–8; Italian doctors in, 46; Jewish medical refugees in, 42; lack of reciprocity from other countries, 62, 63; medical boards in, 44; Medical Practice Act of 1938, 53; migration of South Asian doctors from East Africa to, 156; refugee routes to, 58–9; registration in, 50, 61–3; Scottish medical graduates and, 6. See also names of states Australian doctors: attitude towards refugee doctors, 49, 55, 60, 61–2; in military service, 61–2; post-war re-establishment of practices, 62; shortage of, 63; supply/national self-sufficiency in, 10 Australian Imperial Force, 62 Austria: BMA and refugee doctors, 48; doctors in Sweden, 88; medical graduates in Ireland, 111; refugee doctors in Australia, 50; refugee doctors in Shanghai, 58–9; refugee physicians in Sweden, 87, 88; Supreme Sanitary Council, 111 Bansal, Suchel, 206n38 Barbados: Canadian-trained physicians in, 24; Codrington College, 35n9; medical services in, 28; private practitioners in, 27 Barker, Creighton, 100

Belgrave, Michael, 128 Benians, Richard, 204n20 Beraha, Maurice, 56 Berg, Fredrik, 80 Berghahn, Marion, 61 Berlin Olympic Games, 50 Berry Plan, 169 Besson, William, 23, 25–6, 28–9 Bigger, J.W., 106 Bishop’s College (Lennoxville, QC), 23 Bizza Medical School (India), 247 Blackley, Donald Henry Ashdown, 138–9n38 Blackman, Peter, 31, 32, 33 Blakeney, Allan, 253n22 Bloch, L.S., 179 Bollhusmötet (Ball House Meeting), 79 Bombay, 147, 150, 153, 156; University of, 146, 152. See also Grant Medical College (Bombay) Bornat, Joanna, 10, 13, 125, 209, 210, 217 “brain drain”: Canadian physician migration to U.S. and, 231; from developing to industrialized countries, 13–14; South Asian medical diaspora and, 231 Bremmer, J. Douglas, 166–7 Britain: Caribbean doctors in, 8, 9; Medical Registration Act, 22; Medical Society for the Care of the Elderly, 188; multi-directional flow with colonies, 121; New Zealand medical migrants in, 8, 118–19; reciprocal agreement with Ireland, 8, 97; South Asian physician migration to, 8–10; specialized training/ specialties in, 118–19; as top ten donor/recipient country, 14. See also Scotland; United Kingdom (U.K.)

Index 263  British Association of Physicians of Indian Origin, 190, 222 British Commonwealth: and doctor migration to U.K., 185–6, 191; doctor migration within, 211, 212– 13; Indian physicians’ emigration to, 9; migrant doctors in NHS as form of aid to, 212; recognition of qualifications throughout, 8 British East India Company, 9 British Empire: dismantling of, 211; and doctor migration to U.K., 185–6; Indian doctors’ migration opportunities within, 8–10, 145; Irish doctor emigration to, 97–8; medical schools in, 21–2; migrant doctors in U.K. from, 214; racial discrimination in determining suitability for colonial service, 20; and South Asian doctors in Canada, 233–4; universities in, 21–2 British Geriatrics Society, 188, 190 British Journal of General Practice, 209 British Medical Association (BMA): and Australasian medical boards, 44; domination of, 119; and Jewish doctors in Central Europe, 48; New South Wales branch, 54; New Zealand branch, 59, 60; protectionism of, 51, 82; and refugee doctors, 44; and registration through Ordine dei Medici, 46–7; South Asian migrant doctors and, 221; and wartime registration, 61 British Medical Register, Irish medical graduates in, 7, 97, 98, 107 British Medical Women’s Federation, 123 Brown, Ian MacDiarmid, 199

bubonic plague, 4, 146–7 Bush, Alice, 123–4 Calgary, University of, medical school, 178 Calliste, Agnes, 254n31 Campbell, Carl, 27 Canada: British “brain drain” to, 13; Caribbean medical students in, 24; Department of Veterans Affairs, 188; economy, 234; foreign medical graduates in, 112n2; geriatrics in, 188–9; health care/ medicare in, 184n54, 188–9, 234–5; health-care provider growth in, 234–5; immigration policies, 233, 236; in-/out-flows of medical migrants with U.S., 178–9; Jewish doctors from Soviet Union in, 13; licensing in, 235; Medical Care Act, 178, 184n54; medical students in Irish medical schools, 7; Operation Retrieval, 178–9; outmigration of physicians from NHS to, 236; percentage of migrant physicians in, 179; protectionism in, 49; reciprocal agreement with U.S., 8, 112n2; and refugee doctors, 49; Scottish medical graduates and, 6; Sikh migration to, 233; supply/shortages of doctors, 49, 178, 234–5; as top ten donor/recipient country, 14; universal health insurance in, 167, 179–80, 234; Vietnamese health professionals in, 13; West Indian medical students in, 7, 24; women doctors emigrating from U.S. to, 183n32; women in healthcare system, 209. See also drafted

264 Index doctors; South Asian doctors in Canada Canadian doctors: in geriatrics in U.K., 189; in U.S., 178–9, 231 Canadian Medical Association, 49, 235 Canadian Medical Association Journal, 178, 254 Canadian Medical Directory (CMD), 172, 182n30, 235–6, 237 Canadian medical schools: growth in number of health-care providers and, 234–5; medical manpower shortage and, 234–5; Operation Retrieval and construction of new, 178; racial discrimination in, 24; West Indian medical students in, 7, 24. See also names of individual schools Cargill, C.S., 32 Caribbean area. See West Indies Caribbean doctors. See West Indian doctors Carter, Jimmy, 175 Castles, S., 208 Catholic Church. See Roman Catholic Church Central European doctors/refugee doctors: anti-Semitism and, 217; area of specialty, 217; in Australia, 57–8; caregiving to other European migrants, 217; in NHS, 211, 212, 216; and psychiatry, 217; in remote locations, 217; in Shanghai, 58–9; in U.K., 214 Chandler, Loren R., 100 Charcot, Jean-Martin, 186 Chatterjee, Satya, 221 Choice of Medical School (AMA), 104 cholera, 4 Choy, Catherine, 15

Churchill, Winston, 29 Classification of Foreign Medical Schools (AMA), 100–1 Coates, F.G.C., 56 Codrington College (Barbados), 35n9 Cohen, Jack, 199 Collet, Wilfred, 29–30 Collins, Kenneth, 47–8 Colonial Medical Service: and colonial government powers to determine junior appointments, 30; European doctors in, 7; non-white West Indians in, 30; numbers of non-white West Indian physicians in, 39–40n76; racism in, 31–3; schools of tropical medicine and, 21 Colonial Medical Services Committee, 29–30 Colonial Office, 28, 29, 30, 32, 33 colonialism: medical migration and, 5–10, 211–12. See also British Commonwealth; British Empire Commonwealth Alien Doctors Board, 62 Commonwealth Immigrants Acts (U.K.; 1962, 1968), 190 consultancies: migrant doctors in NHS and, 216; overseas-trained geriatricians in, 193; South Asian doctors in U.K. in, 191 Cooke, A., 28 Cork medical school, 97, 101–2, 105, 107, 108 Costello, John, 106 Council on Medical Education and Hospitals (AMA), 99, 101, 102, 103 crisis migrations, 42, 64 Crosby, Alfred, 4 Crowther, Ann, 6 Crozier, Anna, 142

Index 265  Cueto, Marcos, 5 Curtin, John, 62 Czechoslovakia, refugee doctors from, 50 Dahlberg, Gunnar, 79, 90n11 Dammery, David, 6 Dar es Salaam: medical conditions in, 153; medical schools in, 152; University College, 144 Davison, William, 207n56 de Albuquerque, Manõel Francisco (Manuel Francisco). See Albuquerque, Manõel Francisco (Manuel Francisco) de De Barros, Juanita, 7–8 de Sousa, Alex Caetano Lactancio, 148–9, 150, 151, 154 de Sousa, Mary Mathilda, 148–51, 154, 157 de Souza, Braz Antonio, 145 de Souza, Valente, 146 de Valera, Eamon, 106 Dean, Eric, 166–7 deprived/underserviced geographical areas: foreign-trained doctors in, 12–13; medical migration to, 10; migrant doctors in NHS in, 219; migrant doctors in U.K. in, 210; South Asian doctors in NHS in, 216 Desai, Manilal A., 149 developing countries, medical migration to industrialized world, 12, 14, 231–2 Diehl, Harold S., 100 Digby, Anne, 6 displaced persons, as priority in immigration of doctors, 89 doctor draft: about, 167–71; foreigntrained U.S. physicians and, 175–7,

179; and physician migration, 14, 167; U.S. citizenship and, 176; and women doctors, 182n22. See also drafted doctors Dompke, Paul, 102 Dorst, Stanley, 100 Douglas, James Sholto, 23 Douglas, T.C. (Tommy), 252n20 Doyal, L., 212 draft (Vietnam War): AfricanAmericans and, 168; avoidance of, 168, 170–1, 174–5; deferment of, 168; doctor, 167–71; and highly skilled occupations, 168–9; lottery system, 168, 169–70; socioeconomic inequalities and, 168; unwillingness towards, 171; and women, 182n22 drafted doctors: deferment, 176; draft-motivated volunteers and, 170; and escaping draft, 170–1; as medical examiners, 170–1; resistance to Vietnam War, 171, 174; service in U.S. vs. Vietnam, 170–1. See also doctor draft Dublin: Apothecaries Hall, 97; Trinity College, 97, 106, 110, 116n58, 117n67; University College, 105, 106–7, 108, 110; University Colleges of Dublin (UCD), 97; University of (see Trinity College (Dublin)) Dufferin Fund, 17–18n25 Dunstan, A.A., 62 Dupree, Marguerite, 6 Dyhouse, Caroline, 128 East Africa: Africanization in, 151–2, 156; British in, 143; development of health-care facilities in, 148; doctor

266 Index shortage in, 143; early colonial phase, 145–7, 156–7; high colonial phase, 148–51; higher education in, 144–5; independence of countries of, 151–2, 156; Licentiate in Medicine and Surgery, 144; medical boards, 148; medical conditions in, 145; medical education in, 143, 144–5; medical migration to and from, 145; postcolonial phase, 151– 3, 157; Protectorate, 143; segregated hospitals in, 154–5; South Asian migration to, 143. See also South Asian doctors in East Africa East Africa, University of, 144 East African Indian National Congress, 149, 151 Ebola, 3 Edinburgh: Irish medical schools compared with, 105; Royal Colleges of Edinburgh, 146; West Indian Student Association, 25 Edinburgh, University of: British Caribbean medical students at, 23– 4; West African medical students at, 25; West Indian students in, 25 Educational Commission for Foreign Medical Graduates (ECFMG), 110 Edwardson, John P., 77, 78, 87, 91n17 Eire: Department of Health, 98; medical council/registration system in, 97. See also Dublin; Ireland Elias, Peter, 171 Engberg, Arthur, 73 Eskasoni First Nation, 230, 249 Esmail, Aneez, 10, 12, 189, 192 eugenics, in Sweden, 76–7, 79, 85 European Union doctors: in NHS, 211; in U.K., 214

Evans, Grimley, 186 Eversley, J., 217 exclusion. See marginalization/ exclusion Fabian, Ernst, 57 Fein, Rashi, 179 Fenton, Colin, 136n11 Fetherston, R.H., 61 First Nations: Eskasoni, 230, 249; poverty, 246 First World War: and Caribbean, 29; and colonialism phrases in East Africa, 144; and Germanborn refugees in Australia, 53, 61; and medical specialization development, 135n10; and practice across national boundaries, 45; and Sweden’s restrictive immigration policy, 74; and women practitioners, 122 Fletcher, John, 26–7 Flexner Report/reforms, 98, 99, 111 Flying Doctors program, 62 Fox, Eric, 54–5 France: Nazism in, 85; U.K. doctors in, 45; Vietnamese health professionals in, 13 French doctors (Médecins sans frontières). See Médecins sans frontières (French doctors) Frenz, Margret, 10, 12, 22, 27 Frikart, Eliza, 122 Galway medical school, 97, 101–2 Gavin, Michael, 220 General Medical Council (GMC): and AMA approved list of foreign schools, 100; Indian Medical Service and, 9; and Irish medical

Index 267  schools, 97, 98, 101–2, 105–7, 109; and Italian reciprocity, 56–7; and Makerere College, 22, 144; migrant doctors and, 222; and migrant physicians in Canada, 236; and overseas doctors in NHS, 215; and recognition of equivalent qualifications, 45; recognition of Indian medical degrees, 9 general practice: autonomy within, 221; as “dirty work,” 220; foreign/ non-white medical practitioners dominating, 12; migrant doctors in, 208–9; migrant doctors in NHS and, 216, 220, 221; South Asian doctors in, 192, 210, 220 Gerhard, Karl, 74 geriatrics: advancement/development by South Asian doctors in U.K., 202–3; British-Canadian migration in, 189; in Canada, 188–9; good practice/centres of excellence in, 198–200, 202; history of, 186–9; marginalization of, 197–8, 202, 220; migrant doctors in, 12, 194, 208, 216, 220; New Zealand women in, 125, 131; in NHS, 201–2, 216; overseastrained doctors and, 192–3; racism and, 217; refugee doctors and, 199; research centres, 188; staffing crisis in, 192; in Sunderland hospital, 198–200, 201; types of hospitals hosting, 196–7, 198; in U.K., 189; in U.S., 188; women doctors in, 193. See also South Asian geriatricians (SAGs) in U.K. German doctors: in Australasia, 50; in Australia, 53, 61; immigration regulation/policies and, 44; registration through Ordine dei

Medici, 46–7; in Shanghai, 58–9; Sweden and, 73–4, 75–6, 85, 88–9 Germany, reciprocity with Britain, 47 Giblin, Lyndhurst Falkiner, 61 Glatt, Max, 217 Goa Medical College, 145, 147 Goan Voice, 149 Goodenough Report, 97–8, 101 Gordon, Doris, 124 Gorsky, M., 215 Grant Medical College (Bombay), 145, 146, 148 Great Britain. See United Kingdom (U.K.) Great Depression: in Australasia, 63; in Sweden, 73, 77 Gustav Adolf, Crown Prince of Sweden, 92n25 Guyana: appointment policy in medical services, 30; Besson in, 28–9; indentured South Asian workers in, 27–8; medical systems, 38n54; private practitioners in, 27 Gyllenswärd, Curt, 82–3, 85, 93n43 gynaecology/obstetrics: in Nairobi, 151; New Zealand women doctors in, 130–1; South Asian women doctors in East Africa in, 153; women doctors in, 157–8 Hahnemann, Samuel, 57 Hajela, Virasal Prajal, 207n60 Hall, Anthony, 176–7 Hampton, Lynn, 166 Hamud bin Muhammed, sultan of Zanzibar, 146 Hardy, Thomas E., 109 Harrogate hospital (U.K.), 201 health-care services/systems: in Canada, 188–9, 209, 234–5;

268 Index centrality of immigration to British, 215; and employment of physicians on salary, 86–7; foreign-trained doctors and evolution of, 14–15; and Indian diaspora of personnel, 231–2; influence of medical migrants on evolution of, 12; Jewish refugee physicians and, 75; medical manpower shortage vs. growth in number of providers, 234–5; medical migrants and, 3–4, 11–12, 85, 87–8, 89, 191; NGOs and, 5; out-migration of allied practitioners and, 15; parallel private/stateadministered delivery of, 11; postSecond World War transformation of, 11, 21; self-interest of medical profession vs., 89; for seniors, 167; socialization of, 86–7; in Sweden, 75, 76–7, 85, 86–8, 89; in U.S., 167. See also National Health Service (NHS) health/medical tourism, 15, 56 Health Resources Infrastructure Fund, 178 Henry, Leroi, 10, 13, 125, 209, 210, 217 Heslop, Barbara, 123, 124, 128 heterophobia: and geographical/ professional clustering, 220; and migrant doctors in NHS, 218; in NHS, 210, 218; and opportunities of graduates, 220; racism vs., 218 Hibbert, G.S., 56 Hildick-Smith, Marion, 193 histories of medicine: absence of foreign-trained doctors from, 14–15; global health histories vs., 14–15; medical migrants/migration in, 13–15 Hogan, David B., 188

Höjer, Axel: as anti-fascist, 81–2; attacks against, 85, 86–7, 93n43; on Austrian refugee physicians, 87, 88; comparisons of Sweden with other countries, 76, 85; and eugenics, 76– 7, 79, 85; and foreign physicians to replace Swedish in service, 83–4; as general director of Royal Medical Board, 75, 76; and immigration of physicians for open health care, 87–8; and immigration/licensing of foreign physicians, 79; and Jewish refugee physicians, 75–6, 80, 81, 83, 89, 93n41; Krig eller kultur? (War or culture?), 81; memoirs, 92n30, 93n41; on prioritization of displaced persons, 88; public health/social reformation plans, 76–7, 85, 86, 89; and refugee specialists, 82, 85, 88; in Social-Democratic movement, 77; and socialization of health care, 86–7; on supply of physicians, 76, 81, 82; Swedish Medical Association vs., 85, 86, 87 Höjer, Signe, 74, 75, 77 Holm, Stig, 93n43; Krig eller kultur? (War or culture?), 81 Holmgren, Israel, 78 Holt, Thomas, 25 Homburger, Freddy, 100 Home Office (U.K.), 47, 48 Horowitz, Dr (Cairns, Queensland), 55 hospitals: age-related admissions policy, 199; general vs. teaching, 219; geriatrics in, 196–7, 198; Irish (see Irish hospitals); in London, 119; migrant doctors in, 219; in Nairobi, 154; segregated, in East Africa, 154–5; specialized training in, 118– 19; type offering opportunities to

Index 269  South Asian doctors in U.K., 196–7. See also names of specific hospitals, and under placenames house surgeons, South Asian doctors as, 243, 244, 247 Hunt, G., 212 Hutchinson, J.S., 56 Hutton, Philip, 199 Iliffe, John, 142 immigration policies, 233; in Canada, 236; and German refugees, 44; infectious diseases and, 4–5; physician shortage and, 11–12; preferred nations of origin vs. skilled manpower in, 11–12; of Sweden, 74 Imperial College of Tropical Agriculture (Trinidad), 35n9 India: African students studying medicine in, 145; Indo-East Africans in, 10; Indo-South Africans in, 10; medical colleges in, 9, 145 (see also names of specific hospitals, and under placenames); Medical Service, 9; National Congress, 151; partition, 9; universities in, 22 Indian doctors: British Empire and migration of, 145; emigration to Britain and Commonwealth, 9; GMC recognition of medical degrees, 9. See also headings beginning South Asian doctors Indian Health Services (U.S.), 169, 170 Indian Medical and Dental Association (Nairobi), 149 infectious diseases, 3, 4–5. See also bubonic plague; cholera; Ebola; malaria; smallpox; tuberculosis

Inghe, Gunnar, 93n43 Insley, Morag, 204n18 Institut Pasteur (Paris), 5 internal medicine: New Zealand women doctors in, 130, 131; South Asian doctors in Canada and, 237, 239, 243 International African Service Bureau, 32 International Red Cross, 5 internships/residencies: British medical graduates and, 98; Canadian doctors in U.S. and, 178; and doctor draft, 169; for foreign medical graduates in U.S., 110; foreign-trained physicians and, 244; foreign-trained physicians in U.S. and, 110; and Irish doctors in U.K., 98; Irish doctors in U.K. and, 98; Irish doctors in U.S. and, 110; refugee doctors and, 44, 59; South Asian doctors in U.K. and, 244; South Asian physicians in Canada and, 244, 247, 248; in Sweden, 77 Ireland: Austrian medical graduates in, 111; College of Surgeons, 116n58; Commission on Higher Education, 111; connections with U.S., 96–7; Department of External Affairs (DEA), 103; emigration of doctors from, 96; Great Famine of 1840s, 7; independence/partition, 7, 97, 112; Medical Registration Council, 103; partition, 97; reciprocal agreement with Britain, 8, 97 Irish doctors: acceptance of qualifications abroad, 97; AMA approval of, 96–7, 100, 104–8, 112; Irish medical school overproduction and, 6–7;

270 Index migration, 6–7; GMC and, 97; Irish medical school overproduction for, 6–7, 101; in NHS, 212, 216; Irish doctors in Britain/British Empire: demand for, 111; as destination of majority, 96; eligibility within, 97; special relationship between Ireland and U.K. and, 211; in U.K., 97 Irish hospitals, Irish medical schools and, 101–2, 111 Irish Medical Association, 103, 107 Irish Medical Register, 98 Irish medical schools: AMA and, 96–7, 100, 102–3, 104–8, 112; Apothecaries Hall (Dublin), 97; British medical education reforms and, 97–8; change/reform in, 106, 107–10, 111; in Classification of Foreign Medical Schools, 100–1; and clinical teaching, 108, 111; colleges comprising, 97; Commission on Higher Education and, 111; Cork, 97, 101–2, 107, 108; ECFMG and, 110–11; Edinburgh and Vienna compared to, 105; facilities, 101–2; Galway, 97, 101–2; GMC and, 97, 101–2, 105–7, 109; hospital relationships, 101–2, 111; Irish medical graduates in U.S. on, 107–10; and Irish Medical Register, 98; and medical graduates in U.S., 105; and national pride, 97; numbers of, 101; overproduction of graduates for emigration, 6–7, 101, 109; Queen’s University/Medical School in Belfast, 96, 97, 100–1; recognition by New York State Licensing Board, 103–4; reduced demand for medical manpower and drop in recruitment, 111;

Rockefeller visit, 101; squeezing of resources, 101; U.S./Canadian medical students in, 7. See also under Dublin Irish Times, 105 Irish Universities (Medical) Club, 103, 107–8, 108–9 Israel, Jewish doctors from Soviet Union in, 13 Italy: Australia and medical credentials, 54–8, 57, 61; and Central European refugee doctors in Australia, 57–8; doctors in Australasia, 46; Jewish doctors in, 54; Jews in medical schools in, 46; neutrality, 54; Ordine dei Medici in, 46–7, 55, 56; reciprocal agreement with U.K., 45–7, 56–7, 61; reciprocal agreement with Victoria, 57; refugee doctors and credentials, 45–7, 54–8; U.K. doctors in, 45 Jackson, Mark, 14–15 Jamaica: 1870s university college proposal, 35n9; appointment policy in medical services, 30, 31–4; Canadian-trained physicians in, 24; medical systems, 38n54; private practitioners in, 27; Scottishtrained physicians in, 24 Japan, and Central European refugee doctors in Australia, 57–8 Jefferys, Margot, 189–90, 193, 202 Jewish doctors: anti-Semitism and, 78, 80; BMA and, 48; in Central Europe, 48; in Italy, 54; Nazism and, 49–50, 74; Ordine dei Medici registration, 46–7; from Soviet Union, 13 Jewish Home and Hospital for the Aged, 188

Index 271  Jewish refugee doctors: administration of, 42–3; antiSemitism and, 64, 73; in Australia, 42–3; Höjer and, 75–6; and networks, 43; in New Zealand, 42; questions regarding competence of, 83; specialist, 81, 82; in Sweden, 73, 74–6, 80, 81, 82–3, 89 Jewish refugees: humanitarian aspects of reception, 82; Nazis promoting departure of, 58; routes to Australasia, 58–9; Sweden and, 74, 75 Johnson, Ryan, 38–9n58 Johnson, Victor, 99 Johnsson, Vera, 93n43 Joint Council for the Understanding between White and Coloured People, 26 Jona, J. Leon, 47 Jones, Esyllt, 252n21 Jones, Greta, 6–7 Jones, Margaret, 21, 27 junior posts: migrant doctors in U.K. in, 216, 218, 219; as part of postgraduate medical training, 212; relationships with seniors, 128 Käärik, Uno, 86 Kampala: Makerere College medical school, 22, 144–5; new medical schools in, 152 K.A.R. Hospital, 150 Karolinska Institute (Stockholm), 79 Kelly, Leo, 103 Kennedy, John F., 167 Kenya: Asian emigrations from, 152; independence, 148; Magadi Hospital, 146; medical boards in, 148; numbers of doctors in, 152; segregation in, 154

Khalifa bin Harub, sultan of Zanzibar, 146 Khanna, Pradip, 206n45 Kingston Town Council (Jamaica), 32, 33 Knutson, Dag, 78, 86–7, 91n20, 93n43 Krig eller kultur? (War or culture?; Holm; Höjer), 81 Lady Grigg Indian Maternity Home, 149, 150, 151, 154, 155 Lady Grigg Welfare League, 150 Lahore Medical College, 9 Larsmo, Ola, 90n11 Lawrence, Ralph, 222 League of Coloured Peoples (Britain), 26, 31 League of Nations, 74 Leendt, Johan Philip van, 63 Leman, Craig B., 171 licensing: in Australia, 10, 61; in Canada, 235, 236; of foreign graduates vs. medical schools, 99, 100, 110; in New Zealand, 10; of South Asian physicians in Canada, 246; in Sweden, 79, 89; in U.S., 98, 99, 100, 101, 109, 110, 113n8. See also reciprocity; registration(s) Licentiate in Medicine and Surgery (East Africa), 144 Licentiate of the Medical College of Canada (LMCC), 236, 246, 247 Liljestrand, Göran, 79, 90n11 Lippard, Vernon, 100 Lister, Philip Cunliffe, 27 Liverpool School of Tropical Medicine and Hygiene, West Indian medical students at, 25–6 Lorber, Judith, 127

272 Index Lourenco, Margarida Candida, 147 Lukes, Haida, 128 Lundborg, Herman, 79 Mackay, Ian, 252n21 Macpherson, A.D., 46–7 Macrossan, Neal, 48 Madhvani, Muljibhai, 145 Magadi Hospital (Kenya), 146 Maguire, F.A., 61 Mair, Alex, 53–4 Makerere College (Uganda), 22, 144–5 Makonnen, T.R., 32–3 malaria, 5, 21, 147 Manchester: Baguley Hospital, 221; migrant doctors in, 12, 210, 216, 217, 218–20 Manlove, F.R., 99, 103, 107, 117n64 marginalization/exclusion: of foreign-trained doctors, 12–13; geographical-professional overlap, 218–21; of geriatrics, 197–8, 202, 220; from infrastructures, 196; and interstitial elites, 12–13; of medical migrants, 10; of migrant doctors in NHS, 202, 215; of psychiatry, 220; and selection process, 8; of South Asian doctors in East Africa, 27, 143; of South Asian geriatricians in U.K., 196 Margulies, H., 179 Maurillo, Dr, 103 Maxwell, W., 54 McFarlane Report of 1965, 178 McGill University medical school, 7, 24 McLaglan, Eleanor, 124 McMaster University medical school, 178

Médecins sans frontières (French doctors), 3, 15 medical boards: attitude towards refugee doctors, 65n9; attitudes in host countries, 44; in Australia, 10, 44; in East Africa, 148; medical schools vs., 45, 65n9; in New Zealand, 10, 44; protectionism by, 45; and registration of refugees, 63 Medical Care Act (Canada), 178, 184n54 Medical Corps (U.S.), 169 medical missionaries, 5, 15, 58 Medical Registration Council of Ireland, 103 Medical Research Council (New Zealand), 124 medical schools: African students, 144–5; African women students, 144–5; in AMA Choice of Medical School, 104; AMA list of approved foreign, 96–7, 99, 101, 102, 108, 110–12; AMA visits to, 100, 102, 111; ambivalence regarding medical migration, 11; in British Empire, 21–2; Canadian (see Canadian medical schools); Classification of Foreign Medical Schools and, 100–1; construction of, 11, 12; in East Africa, 143; in India, 9, 145; Irish (see Irish medical schools); Jews in Italian, 46; and licensing in U.S., 100; limits on numbers of refugee students, 53; medical boards vs., 45; and refugee doctors, 65n9; and registration, 45; Second World War and European vs. U.S., 99; in Spanish-speaking Caribbean, 35n9; in U.S. compared to foreign, 96; women in, 122–4, 183n32. See

Index 273  also names of individual schools; and under names of countries medical tourism. See health/medical tourism Medicare, 184n54, 234–5 Mejía, Alfonso, 14, 231 Melbourne, University of, 51, 52 Mello, Rodolpho de, 145 Mellor, J., 212 Memmi, Albert, 218 Memorial University medical school, 178 Menezes, Eugene, 145–6 mentorship: New Zealand women specialists and, 127–8; undergraduates’ patronage connections and, 8 Military Hospital (Zanzibar), 162n19 Military Selective Service Act of 1967 (U.S.), 167–8, 176 Millard, Peter, 32–3 Miller, M.J., 208 Mirski, Meyer, 58 Mombasa: hospitals in, 154 Mondal, Bijoy Krishna, 207n62 Monnais, Laurence, 118–19 Moody, Harold, 20, 25, 26, 30, 31, 32, 33 Morton, Eric, 204n19 Moulin, Anne-Marie, 15 Moulton, Natasha, 166 Mount Sinai Medical School, 188 Moyne Commission, 32, 33 Mullally, Sasha, 10, 13, 133 Mullan, Fitzhugh, 160n5 Munich Agreement, 50 Myhrman, Gunnar, 85, 93n43 Naidu, Sarojini, 151 Nairobi: Asian female doctors in, 150; European Hospital, 154;

Goan Housing Estate, 149; Goan Institute, 149; Goan Overseas Association, 149; hospitals in, 154; Indian Medical and Dental Association, 149; medical schools in, 152; numbers of doctors in, 152; obstetrics/gynaecology in, 151; plague epidemic, 147; Ribeiro in, 147; Royal Technical College, 144; South Asian doctors in, 147, 148–51; Welfare League, 149 Namboze, Josephine, 144 Nanavati, Arti, 251n17 Narayan, Anant, 207n50 Nascher, Ignatz, 186 National Association for the Advancement of Coloured People (NAACP), 26 National Board of Medical Examiners (NBME), 98 National Catholic Welfare Committee of New York, 103 National Health Service (NHS): Central European doctors in, 211, 212, 216; discrimination in, 223; establishment of, 208; European Union doctors in, 211; exodus of doctors from, 119; favouring of local graduates, 219; geriatrics in, 125, 187–8, 189, 190, 201–2; heterophobia in, 210, 218; hierarchical nature of, 191–2; institutional discrimination, 218; Irish doctors in, 212, 216; and out-migration of doctors, 219, 222, 236; Powell and centrality of migrant doctors in NHS, 213; racism in, 191–2, 210, 218, 223; recruitment of overseas staff for, 191, 192; reliance on migrant doctors as form of aid to

274 Index Commonwealth, 212; staffing crisis in, 9; workforce shortages in, 219 National Institute of Health (Bethesda, MD), 169 National Security Act (Australia), 62 National University of Ireland (NUI), 97, 105, 106, 108, 109, 110, 117n67 Native City Hospital (Nairobi), 154 Native Civil Hospital (Mombasa), 154 Native Medical Institution (Calcutta), 9 Nazism: and destruction of set of doctors, 44; and Jewish doctors, 49–50, 74; promoting departure of Jews, 58; refugee doctors from, 43 Nerman, Ture, 73 New South Wales: refugee doctors in, 52, 53–4; registration in, 52, 63 New York State Licensing Board, 103–4 New Zealand: Department of Health, 124, 127; doctor supply/ shortages in, 10, 63; Family Planning Association, 139n39; Great Depression in, 63; history of medicine, 133; Italian doctors in, 46; Jewish medical refugees in, 42; Medical Association, 124; medical boards in, 10, 44; Medical Council, 46, 59–60, 65n10, 124, 126, 139n39; Medical Research Council, 124; medical schools, 8 (see also Otago Medical School (NZ)); Nelson Hospital Board, 60; population, 118, 130; postgraduate medical training in, vs. overseas, 120–1; refugee doctors in, 43, 50, 53, 59–60; refugee routes to, 58–9; registration in, 50, 59–60; relationship with Britain, 119; School Medical Service, 139n39;

and Scottish Conjoint Diploma, 48; Scottish medical graduates and, 6; specialties practised in hospitals, 138n37 New Zealand doctors: as internationalists, 8; lack of networking opportunities, 121–2; 118; overseas training, 118–19; registration system for, 137n31, 137–8n33; relationships with British colleagues, 119–20; Second World War and overseas military service, 121; social interactions, 128, 129; specialists, 118–20; women, 122−34 New Zealand Medical Journal, 124–6 New Zealand medical migrants: in Britain, 118–19; completion of degrees overseas, 120; gender and rates of, 127; in London, 119; in organ vs. demographic specialties, 130–2; overseas postgraduate experience/qualifications, 118; for postgraduate medical training, 120–1; in Scotland, 119; Second World War and networks/ connections, 121 Nigeria: medical schools, 22, 245; South Asian physicians in, 245 Nixon, Richard, 168 non-governmental organizations (NGOs), 3, 5. See also Médecins sans frontières Noronha, Francisco da Piedade Paixo. See Piedade Paixo Noronha, Francisco da North Sydney, NS, 230 Nuremburg Laws of 1935, 49–50 nurses: African-Caribbean, 254n31; migration of, 15; racial

Index 275  discrimination and students, 26–7; Vietnam War and, 166 Nya Dagligt Allehanda, 85–6 obstetrics/gynaecology. See gynaecology/obstetrics Odelberg, Axel, 80 O’Donovan, James, 107 Office International d’Hygiène Publique, 4 Olbrich, Oscar, 199 Ontario: reciprocal agreement with United Kingdom, 49; and refugee doctors, 49 Ontario College of Physicians and Surgeons, 49, 174–5 Operation Retrieval, 178–9 O’Rahilly, Alfred, 105, 108, 116n58 Ordine dei Medici (Italy), 46, 47, 55, 56 Ornstein, Otto, 83 Osborne, W.A., 52 Otago Medical School (NZ): history of, 120; licensing of, 120; and limits on practice of foreign doctors, 59– 60; and refugee doctors, 53; refugee doctors studying for registration at, 43; women at, 122, 123, 124 Otolaryngology (ENT), 129, 130, 131, 172, 237 Overseas Doctors’ Association (ODA), 222 Pacific War, and refugee doctors, 60 Packard, Randall, 21 Padmore, George, 31, 32, 33 Page, Earle, 50 Palmer, Steven, 5 Pan American Sanitary Bureau (later Pan American Health Organization), 4

pan-Africanism, 21, 25, 31 Pandya, Jagannath B., 154 Pandya Memorial Clinic (Mombasa), 154 pharmacology, medical refugees and, 217 Piedade Paixo Noronha, Francisco da, 142, 145, 161n19 Poland, reciprocity with U.K., 56 Pondicherry School of Medicine (India), 10 post-traumatic stress disorder (PTSD), 166–7 Powell, Enoch, 213 Preston, Frances, 123 Princess Margaret Hospital (Dar es Salaam), 153 Pringle, Rosemary, 128, 140–1n61 private practice: “foreign” physicians and, 10; South Asian physicians in Canada in, 245–6; West Indian returnee doctors in, 27 protectionism: accreditation vs., 11; and anti-Semitism, 49; Canada and, 49; doctor shortage and, 51; medical boards and, 45; medical migrants and, 10; New Zealand medical council and, 59–60; Queensland and, 51; and refugee doctors, 45, 49; Scottish Conjoint Diploma and, 49; in Sweden, 77; in Victoria, 51–2 psychiatry: Central European medical refugees and, 217; domination by foreign practitioners, 12; marginalized/stigmatized populations in, 220; medical refugees and, 217; migrant doctors and, 208, 220, 223; migrant doctors in NHS and, 216; women doctors and, 125

276 Index public health: medical migration and history of, 4–5; post-war revolution in, 11, 21. See also health-care services/systems Queen’s University (Kingston, ON), 24; medical school, 7 Queen’s University/Medical School in Belfast (QUB), 96, 97, 100–1 Queensland: German immigrants in, 47; Medical Board, 50; protectionism in, 51; refugee doctors in, 43, 51, 54–7, 60; and Scottish Conjoint Diploma, 48 Quinn, Dr (Queensland), 55, 60 race/racism: in British Empire, 20; British in East Africa and, 143; and British medical qualifications, 26–7; Canadian medical schools and, 24; in colonial medical system, 26–7, 31–3; culture vs., 80; and East African health-care facilities, 148; eugenics in Sweden and, 79; and geographical/professional clustering, 220; and geriatrics, 217; and heterophobia, 218; and medical/nursing students, 26–7; and migrant doctors, 197; and migrant doctors in NHS, 218; in NHS, 210, 218, 223; in Scotland, 26; and South Asian doctors in East Africa, 143, 151, 154–6; and South Asian doctors in U.K., 190, 191, 202; and suitability for colonial service, 20, 26–7, 28–30; West African Medical Staff and, 38– 9n58; in West Indian government medical services, 20, 28–30; West Indian medical migration and,

20–1; and West Indian medical students, 7; and West Indian migrants, 25; and West Indian physicians, 20–1, 34 Radhe, S., 78 Raghuram, Parvati, 10, 13, 125, 209, 210, 217 Rappoport, Dr (Brisbane), 55 reciprocity: between Britain and Ireland, 8, 97; between Canada and U.S., 8, 112n2; between Great Britain and Germany, 47; between Italy and Victoria, 57; lack of, for Australia, 62, 63; and registration, 51; between U.K. and Italy, 45–7, 56–7, 61; between United Kingdom and Ontario, 49. See also licensing; registration(s) Reece, E.W., 24 registrar posts: migrant doctors in NHS and, 216; overseas-trained doctors in, 193 registration(s): British Caribbean physicians and, 22–3; British Medical Registration Act, 22; German doctors and, 53; Ireland Medical Registration Council, 103; of Irish medical migrants, 97; Italian credentials for, 45–7; medical boards and, 63; in New South Wales, 52, 63; of New Zealand specialists, 137n31, 137–8n33; Ordine dei Medici, 46–7; Otago Medical School and refugee doctor students, 43; racial discrimination and, 26–7; reciprocal agreements and, 51; of refugee doctors, 45–7; of refugee doctors in Australia, 43, 44, 50, 52–3, 61–3; of refugee doctors in New Zealand, 50, 59; Second World

Index 277  War and, 61–3; in South Australia, 52; U.K. medical schools and, 22; in Victoria, 51–2, 62. See also licensing; reciprocity residencies. See internships/ residencies Ribeiro, Ayres Lourenco, 147, 152 Ribeiro, Manuel, 147, 152 Ribeiro, Rosendo Ayres, 147, 149 Riksföreningen Sverige-Tyskland, 83 Rivett, Geoffrey, 215 Rockefeller Foundation, 5, 99, 101, 111 Rohlehr, John Monieth, 23, 24 Roman Catholic Church: and College of Surgeons, 116n58; and Irish medical education, 110; and Irish medical graduates in U.S., 103–4; and Trinity College Dublin, 116n58 Ropschitz, Izydor, 54, 56, 58 Rotherham hospital (U.K.), 200–1 Rousthöi, Peter, 78 Royal Canadian Mounted Police, 175 Royal College of General Practitioners, 220–1 Royal College of Physicians (U.K.): overseas-qualified doctors and membership in, 197; recognition of Yaba Medical Training College diplomas, 22; South Asian physicians in U.K. and membership in, 244 Royal College of Surgeons (England), 123–4 Royal College of Surgeons (Ireland), 97, 110, 117n67 Royal Colleges of Edinburgh, 146 Royal Commission on Health Services in Canada, 177–8 Royal Medical Board (Sweden): and Austrian physicians, 88; and

doctor supply, 81; on foreign physicians already in country, 84; and German Jewish doctors, 78, 83; Höjer as general director of, 75, 89; and import of foreign physicians, 84, 85; and Jewish medical refugees, 93n41; Swedish Medical Association vs., 75, 80, 81; and work permits, 92n30 Royal Technical College (Nairobi), 144 Rudd, Thomas, 204n21 Rush, Anne Spry, 23 Rushbrooke, J.H., 26–7 Sandler, Richard, 92n30 Sappier, Michael, 231 Sastry, Dwarak, 207n52 School Medical Service (New Zealand), 139n39 School of Tropical Medicine (London), 21 Scotland: medical diaspora from, 6; medical schools, 6, 23–4; New Zealand doctors in, 119; race relations in, 26; Scottish Conjoint Diploma, 47–9, 51, 52. See also Edinburgh Scully, William A., 103 Second World War: and doctor supply/shortage(s), 49, 61–2, 76, 82; and doctors in overseas military service, 61, 121; and European vs. U.S. medical schools, 99; and lowering of barriers for medical migrants, 42–3; and migrant doctors in U.K., 214; and refugee doctors, 53–4, 60–3; and registration in Australia, 61–3; and Sweden, 82–3 Selective Service Act of 1948 (U.S.), 181n16

278 Index Shah Hospital (Nairobi), 154 Shanghai, Central European refugee doctors in, 58–9 Shaukat Ali, Mohamed, 207n53 Sherbrooke, University of, medical school, 178 Shukla, Ragru Ban, 207n53 Silfverskiöld, Nils, 93n43 Simpson, Julian M., 10, 12, 189, 192 Simpson, William, 155 Singh, Mohan Kataria, 205n22 smallpox, 4, 5 Smith, David, 211 Snow, Stephanie J., 10, 12, 189, 192 South Africa: AMA and GMC recognition of qualifications, 107; exodus of physicians from, 6–7, 9; Indo-South Africans and medical training in India, 10; Italian credentials in, 46, 47; physician migration to, 6; and Scottish Conjoint Diploma, 48, 49, 51; Scottish medical graduates and, 6 South Asian doctors in Canada: ages, 242; British empire/ imperial context and, 233–4; British health-care system and, 233–4; and communitarian values, 232; connection to Canada, 236; diversity of, 236–7, 241–2; ethnic variation, 242; family needs and emigration decision, 247–8; and First Nations, 246; as generalists, 239; licensing of, 246; locations in variously-sized population centres, 232–3, 236, 237–42, 248; married couples among, 243, 247–8; migration from East Africa, 156; and networks/connections, 232, 246, 247; opportunities, 247;

oral interviews/history, 235–6; in private practice, 245–6; reasons for leaving South Asia, 243–4; regional/country origins, 156, 233, 242; relations with patients, 248; religions, 242, 244; residency in U.S., 244; skill levels, 237; social class, 243; and South Asian physicians in U.S., 247; specializations of, 237, 239; from U.K., 236, 243, 244, 247–8; women, 243–4 South Asian doctors in East Africa: backgrounds of, 156; characteristics of, 151; community leadership, 156; contributions of, 153; diversity among, 157; in early colonial phase, 145–7, 156–7; entrepreneurship, 143, 147, 148, 156; exclusion from British Medical Services, 153; and gender, 157–8; Goan, in Zanzibar, 145–7; in government service, 142; during high colonial phase, 148–51; historical phases of practice, 144; independence and, 152, 156; marginalization/exclusion of, 27, 143; and medical/educational infrastructure improvement, 148, 153; migration from, 156; in Mombasa, 147; in Nairobi, 147, 148–51; numbers of, 152; Piedade Paixo Noronha as first, 142; political/community involvement, 143, 147, 148, 149, 150–1, 152, 156–7; during postcolonial phase, 152–3; postgraduate migration, 145; in prestigious posts, 156; as prominent members of professional class, 142; race and, 143, 151, 154–6; responsibilities in colonial government structures,

Index 279  148; segregation and, 154–5; social status, 143, 151, 156–7; and social welfare, 142, 147, 149, 150–1; taking over institutions of colonial medicine, 152; as under-researched, 142–3; women, 148–51, 152–3, 157–8; working areas, 153, 155 South Asian doctors in U.K.: academic posts, 190; barriers to, 192; British recognition of degrees and, 9; Central European refugee doctors compared to, 212; as consultants, 190, 191; contribution to NHS, 211; exclusion and, 196; fields of practice, 186, 192; and general medical certificate, 244; in general practice, 192, 208–10, 220; in geriatrics, 125, 186, 189, 192–3, 194, 196–8, 201, 202–3, 217; in Greater London, 216; as house surgeons, 244; innovations by, 202; migration from East Africa to, 156; as natural continuation of medical education vs. as hiatus, 211; and NHS, 196; numbers of, 8–9, 214; out-migration to Canada, 244, 247–8; patterns of professional movement, 211; patronage networks and, 202; political activity, 221; preference for local graduates vs., 191–2; race/ racism and, 190, 191, 202, 217; relationships with patients, 221–2; and Royal College of Physicians membership, 197; as second-class citizens, 196; types of hospitals offering opportunities to, 196–7; and western medicine, 191. See also South Asian geriatricians (SAGs) in U.K.

South Asian doctors/doctor migrants: about, 9–10, 231–2; and BMA, 221; as “brain drain,” 231; contribution to fields of practice, 13; demography/statistics, 235; intention to return to South Asia, 243, 244–5; as interstitial subaltern group, 143; in Nigeria, 245; and royal colleges, 185; to U.K., 185; in underserviced specialties, 13 South Asian geriatricians (SAGs) in U.K.: central role in development of geriatrics, 202–3; department building, 197; dependence of geriatrics upon, 192–3; domination in field, 194; establishment of own centres, 198, 200–1; exclusion and, 196; hospitals, 196–7; innovation by, 201, 202; interviews with, 190–1; lack of colleagues’ interest in geriatrics as opportunity for, 194, 197; as leaders in field, 201; oral history, 190–1; quality of, 189; reasons for choice of geriatrics, 201; shaping of field, 198 South Asians: diaspora to Canada, 233 (see also South Asian doctors in Canada); in East Africa, 143, 145, 148, 151–2 (see also South Asian doctors in East Africa); as indentured workers in West Indies, 27–8; origins of, 143; South Asian defined, 203n1, 235 South Australia: refugee doctors in, 52; registration in, 52 Souza, Braz Antonio de. See de Souza, Braz Antonio Souza, Valente de. See de Souza, Valente Soviet Union, Jewish doctors from, 13

280 Index specialists: contribution to development of specialties/ specializations by migrant, 198; gender and rates/areas of, 125, 129; in health-care system, 85; shortage, and migrant doctors, 89; Sweden’s future need of expertise in training new, 82; travels, 133–4 specialties/specializations: in Britain, 118–19; British institutions as hubs for, 133; British women doctors and, 132; clinical population size and, 129–30; contribution to development by migrant specialists, 198; demographic vs. organ, 129–32; domination of unpopular by foreign practitioners, 12; drafted doctors in Canada and, 172; First World War and development of, 135n10; foreign-trained doctors in underserviced, 12–13; informal relationships and, 121; Jewish refugee physicians and, 81, 82, 85; of migrant doctors in NHS, 216; migrant doctors in NHS and shaping of, 209; New Zealand medical migrants and, 118–19; outside experts and establishment of, 188–9; peer support and, 133–4; in publicly funded New Zealand hospitals, 138n37; and refugee doctors in New Zealand, 59; South Asian doctors in U.K. in less popular, 192; of South Asian physicians in Canada, 237, 239; in Sweden, 81, 82, 85, 89; technical skills acquisition/ maintenance, 130; training in, 118–19; twentieth century and, 133–4 Spellman, Cardinal, 103 Spelts, Doreen, 166

Spender, Percy, 61 Spring, Joel, 250n6 Stapelmohr, Sten von, 78–9, 83 Stenhouse, Caroline, 123, 124 Stockwell, A.J., 21–2 Stosch-Wortley, Deborah, 46–7 Sunderland: hospital, 194, 198–200, 201; migrant doctors in, 216 Sundling, Carol Jean, 166 surgery: migration for training/skills in, 130; South Asian physicians in Canada and, 237; women specialists and, 132 Svenska Dagbladet, 78, 88 Svenska läkartidningen, 78–9, 80, 82, 85, 86, 89 Sweden: Aliens Act, 74; anti-Semitism in, 73, 75, 78, 79, 80, 85, 89; Austrian doctors in, 88; child health-care services in, 76; doctors supply/ shortage(s) in, 76, 82, 86; eugenics in, 76–7, 79, 85; foreign physicians and national security in, 84–5; foreign physicians in, 83; Foreigners Act, 74; future need of medical staff in, 82; German physicians in, 75–6; and German refugees, 73–4; GermanJewish physicians in, 73, 74–5, 82–3, 85, 88–9; Great Depression in, 73, 77; health-care system in, 76–7, 85, 86; immigration policy, 74; Jewish question in, 87–8; and Jewish refugees, 73, 74, 75; Medical Society of Dalarna, 93n43; medical students in, 76, 79; and political refugees, 73, 74; protectionism in, 77; Royal Medical Board (see Royal Medical Board (Sweden)); Second World War and, 82–3; specialties/ specialists in, 81, 82, 85, 88, 89;

Index 281  as temporary haven for refugee physicians, 85; welfare state in, 87 Swedish Association of Junior Doctors (SYLF), 78, 81 Swedish Association of Private Practitioners, 78 Swedish doctors: effect of migrant doctors on young, 77, 80; export of, 78; and Jewish refugee doctors, 73; protectionism for, 77; supply of, 77, 78–9, 80; training of, vs. of German doctors, 77 Swedish Institute for Race Biology, 79 Swedish Medical Association: Committee of fund-raising for exiled intellectuals and, 79; on German medical education, 77; Höjer and, 75, 84, 85, 86, 87; and immigration of displaced persons as physicians, 88; and Jewish refugee physicians, 82–3; limitations on acceptance of refugee physicians, 80; refusal of work permit from foreign doctors, 77; and relocation of refugee physicians, 80; Royal Medical Board vs., 75, 80, 81; and socialization of health care, 86, 87 Switzerland, U.K. doctors in, 45 Tanganyika: Asian emigrations from, 152; medical boards in, 148; segregation in, 154 Thifault, Marie-Claude, 209 Thunberg, Torsten, 84, 93n43 Tierney, Michael, 105, 106–7, 108, 112, 116n58 Toronto, University of, 24 Trinidad: appointment policy in medical services, 30; Imperial

College of Tropical Agriculture, 35n9; indentured South Asian workers in, 27–8; Island Scholarship, 23; medical systems, 38n54; private practitioners in, 27 Trinity College (Dublin), 97, 106, 110, 116n58, 117n67 tropical diseases, 21 tropical medicine, 21. See also tropical diseases; School of Tropical Medicine (London) tuberculosis, 5, 187 Uganda: expulsions from, 13, 151–2, 153; Makerere College, 22, 144–5; medical boards in, 148; segregation in, 154 Undén, Östen, 83, 92n30, 93n41 underserviced areas. See deprived/ underserviced geographical areas Uniformed Services University of the Health Sciences, 182n24 United Australia Party, 53–4 United Kingdom (U.K.): antiimmigrant sentiment in, 213; “brain drain” from, 13; Commission for Racial Equality, 212–13; Commonwealth migration to, 191; doctor migration from colonies to, 185–6; geriatrics in, 186–9; Immigration Act (1971), 190; Medical Act of 1886, 45; Medical Act of 1950, 98; migrant doctors as disadvantaged in, 191; NHS and out-migration of physicians, 236; numbers of medical refugees in, 43; Polish reciprocity with, 56; reciprocal agreement with Germany, 47; reciprocal agreement with Italy, 45–7, 56–7, 61; reciprocal

282 Index agreement with Ontario, 49; and Scottish Conjoint Diploma, 48; tradition of movement between South Asia and, 191; West Indian medical students in, 20, 22–3. See also Britain; National Health Service (NHS); South Asian doctors in U.K. United States (U.S.): areas of origin of medical emigrants in, 113n8; Armed Forces, 167–8; British “brain drain” to, 13; Canadian doctors in, 178–9, 231; demand for foreign medical graduates in, 110; Department of Veterans Affairs, 188; foreign-trained doctors in, 14, 175–7, 179; geriatrics in, 188; health services in 1960s/early 1970s in, 167; in-/out-flows of medical migrants with Canada, 178–9; intern/residency systems for foreign medical graduates, 110; Irish connections with, 96–7; Irish emigrant doctors in, 96, 107–10; Jewish doctors from Soviet Union in, 13; licensing in, 98, 99, 110; medical hegemony of, 111; medical schools in, compared to foreign, 96; medical students in Irish medical schools, 7; migration of South Asian doctors from East Africa to, 156; Military Selective Service Act of 1967, 167–8, 176; out-migration of foreign-trained physicians to Canada, 175–7; percentage of migrant physicians in, 179; post-war doctor immigration to, 98; reciprocal agreement with Canada, 8, 112n2; Selective Service Act of 1948, 181n16; seniors in, 167; South Asian physicians in

Canada doing residency in, 244; State Department and AMA list of approved schools, 102; Vietnamese health professionals in, 13; women doctors emigrating to Canada, 183n32. See also American Medical Association (AMA); Canadian doctors: in U.S.; doctor draft; Vietnam War universal health insurance: in Canada, 167, 234; introduction of, 11 Universal Negro Improvement Association (UNIA), 25 universities: in British Empire, 21–2; in India, 22. See also names of individual universities Valladares, R., 145 Vaz, Salome, 152–3 Victoria (Australia): doctors in military service, 61; reciprocal agreement with Italy, 57; refugee doctors in, 50–1, 55; registration in, 51–2, 62; and Scottish Conjoint Diploma, 48 Vietnam War: African-Americans in, 168; as catalyst in Canada-U.S. migration flows, 179; draftees in, 168; exodus of doctors after fall of Saigon, 13; and exodus of physicians from U.S., 14; and medical historiography, 166–7; need for physicians, 170; nurses, 166; and PTSD, 166–7; resistance to, 171, 174, 175, 177; and transnational physician migration, 167, 174–5; voluntary medical service in, 170. See also doctor draft; draft (Vietnam War)

Index 283  Virick, Mabel Ann, 231 Virick, Mohan, 230–2, 241, 242, 243, 246, 249 Waitzkin, Howard, 171 Waldenström, Jan, 79, 90n11 Warren, Marjory, 186–7, 188 Weaver, John, 10, 74, 82, 119 Webster, Charles, 215 Weindling, Paul, 43, 49, 51, 64, 65n9, 214, 217 Weiskotten, H.G., 99 Wellcome Trust, 5 West African Medical Staff, 38–9n58 West African medical students, at University of Edinburgh, 25 West Indian doctors: of African descent, 7−8, 25−6, 28−9; British qualifications, 22; Colonial Medical Service and, 7, 31–3; employment in West Indian medical services, 27–8; imperial/colonial policies/ practices and employment of, 28–30; local practice, 7; and protests/labour strikes of 1930s, 30–1; race/racism and, 20–1, 34; registration of, 22–3; returnees as private practitioners, 7, 27 West Indian medical students: in Canada, 7, 24; financing of education, 23; at Liverpool School of Tropical Medicine and Hygiene, 25–6; migration of French, 37n34; networks/ connections with other West Indians, 34; in North America, 20, 22; racism and, 7; remaining in destination after migration for postgraduate training, 8; tradition of postgraduate training in Britain,

9; in United Kingdom, 7–8, 20, 22–3; at University of Edinburgh/ Scottish universities, 23–4, 25 West Indies: Advisory Committee on West Indian affairs and, 32; outmigration for work/opportunities, 24–5; physician shortage in, 29; protests/labour strikes, 30–1; racial discrimination in medical services, 20; Scottish medical graduates and, 6; white vs. non-white employment in government medical systems, 29, 30. See also names of individual countries West Indies, University of the, 20; medical school, 7–8, 20 West Middlesex Hospital (Poor Law infirmary), 186–7 Weyman, Sura Markovitz, 54, 55, 56 Wheelan, Thomas J., Jr, 168 Williams, Eluned Woodford, 199 Willink Committee, 111, 214 Winkelmann-Gleed, A., 217 Winks, Robin, 24 Winterton, Peter, 65n5 Wolff, Gerhard, 83 women doctors: as British specialists, 132; in Canadian health-care system, 209; and demographic specialties, 132; discrimination/ discouragement and career decisions, 126; doctor draft and, 182n22; as draft doctors in Canada, 172; emigrating to Canada, 183n32; in geriatrics, 193; in government medical services, 125; in gynaecology/ obstetrics, 157–8; networks/ connections, 128–9; professional equality, 123; as refugees in

284 Index Australia, 55; relationships with senior colleagues, 129; and social interactions/functions, 128, 129; as South Asian physicians in Canada, 243–4; and status, 125. See also New Zealand doctors: women; South Asian doctors in East Africa women medical students: in Britain, 122; numbers in medical schools, 123–4, 183n32 World Conference on Medical Education, London (1953), 104–5 World Health Organization (WHO): and Ebola outbreak, 3; Höjer’s goals compared to constitution

of, 76; and numbers of physician emigrations, 179; and outmigration from developing countries, 12, 14 Wright, David, 10, 14, 118–19, 133 Wugmeister, Leon, 54, 56 Yaba Medical Training College, 22 Young, Allan, 166 Zanzibar: doctors in, 145–7; Military Hospital, 162n19; segregation in, 154; sultan of, 142, 145–7 Ziegler, Erich, 57 Zieher, Roman, 58–9