2 Founding the British Commonwealth Medical Conference

The late 1940s was a challenging era in medical, domestic and world politics. As the BCMC was coming into being, the BMA was engaged in an acrimonious dispute with Britain’s Labour government over the creation of the NHS, a dispute which saw the BMA back down at the last minute in summer 1948. The BMA was acutely conscious, too, of the still simmering conflict between its New Zealand branch and that country’s Labour government; and of an almost contemporaneous dispute between its Australian branch and its Labor government. What united these disputes was the hostility of the medical profession, especially in the so-called ‘White Dominions’, to socialised medicine and state intervention.Footnote ⁶

Resistance to socialised medicine was also manifested in the founding in 1946 of the World Medical Association (WMA) with BMA sponsorship. As James Gillespie shows, the WMA, too, was ‘part of a wider campaign against state medicine’ despite a close relationship with the WHO, a body which contained more radical elements. Initially dominated by the British, from 1948 the WMA came increasingly under the influence of the American Medical Association, vigorous opponent of socialised medicine. Although in some respects constrained by the more collectivist tendencies of, for example, many of its European members, the WMA nonetheless continued to insist that health was essentially a matter for the individual.Footnote ⁷ More pertinently for this article, though, and as we shall see, the WMA was also to have problems with South Africa in the last quarter of the century.Footnote ⁸

Returning to the late 1940s, it was almost certainly the case by this point that the BMA envisaged a new Commonwealth body as both more sympathetic to its own ambitions and world view and more tractable than the WMA, as well as being able to build on much vaunted commonalities in training, language and medical cultures. The broader context is also important. On the international stage by the late 1940s, the Cold War was intensifying while Britain’s Labour government was seeking to consolidate links with the Empire and especially with the Dominions.Footnote ⁹ And, of particular importance for this article, in 1948 South African voters installed the National Party in power and the new, Afrikaner, government was soon vigorously to pursue its racially discriminatory policy of apartheid while remaining, until 1961, a Commonwealth member. Even before the advent, apartheid South Africa’s racial policies had been denounced by India at the United Nations in 1946, although in the country itself the immediate post-war period was one of liberal optimism. As Saul Dubow remarks, the late 1940s were thus ‘an interregnum’. Liberal optimism was still possible while the ‘intentions and strength of the new apartheid government still remained uncertain’.Footnote ¹⁰ All this, though, soon changed and it is against a background of increasing international hostility to apartheid that the commitment of its medical association to remain a member of the Commonwealth organisation needs to be seen.

Turning specifically to the BCMC, in July 1947 the BMA’s Secretary, Charles Hill, wrote to what were described as the ‘Commonwealth Medical Associations’ (CMAs), the national medical bodies of the countries noted by The Medical Journal of Australia. Some of these organisations were still branches of the BMA. Others were independent, for example that of South Africa, which had declared its own autonomous organisation in 1945 while remaining a BMA affiliate.Footnote ¹¹ This ongoing relationship with a ‘British’ organisation by the Medical Association of South Africa (MASA) is revealing in itself. As Conway and Leonard point out, Britons in South Africa had ‘always existed in liminal spaces’ in contrast to other ‘old’ Commonwealth countries, such as New Zealand, where they had a ‘foundational place’. And to this can be added the further complicating factor of Afrikaner hostility to Britain and its empire.Footnote ¹² Hill’s letter explained that BMA Council had recently resolved to encourage closer links between Commonwealth doctors and their associations.Footnote ¹³

Hill’s approach was well received. So, for example, MASA’s medical secretary, A.H. Tonkin, wrote that his federal council had approved the proposal, which, at a recent MASA dinner, had been further received ‘with enthusiasm’.Footnote ¹⁴ The Canadian Medical Association was slightly more circumspect, notwithstanding the editorial noted above. Its general secretary expressed concerns, for instance, about a possible conflict of interest with the WMA, a potentially undesirable outcome from the Canadian point of view. The end result was again an expression of interest and an agreement to ‘co-operate’ in its establishment.Footnote ¹⁵ Canadian concerns about the role of the Conference and its successor recurred in the coming decades, part of Canada’s broader desire to resist too close involvement with the Commonwealth and to align itself more closely with the United States.Footnote ¹⁶ Here we have an early sign that the dynamics of Commonwealth relationships were going to change significantly in the next two decades. This was to affect the BCMC/CMA not only with respect to Canada, but also in terms of the place of the Southern African associations within it. Overall, such changes can be attributed to the changing composition of the BCMC/CMA as, on the one hand, decolonisation took place and, on the other, the ‘White Dominions’ slowly began to weaken their links with Britain.

Nonetheless, the organising of the inaugural conference went ahead. A meeting of representatives of the BMA’s Overseas Branch was told by Hill in the summer of 1948 that Council felt that ‘the time had come to establish a body which was in a sense superior to the medical associations or branches in the Dominions’. What was to be the inaugural conference would take place in London later that year and the invitation to it ‘had been accepted with alacrity by practically every Dominion’. It was thus hoped that the new body would ‘effect a liaison between the Dominions in term of complete equality’.Footnote ¹⁷ This notion of complete equality was part of a broader reshaping of the relationship between Britain and the Dominions and seen as a key component of the Commonwealth medical network.

In advance of the meeting three papers were sent out in addition to the proposed agenda. The first dealt with another BMA initiative to bind Commonwealth medical associations closer together, the Empire Medical Bureau. Set up in 1947, the Bureau’s purpose was to answer queries from doctors from other parts of the Commonwealth and to help such doctors when visiting Britain.Footnote ¹⁸ The second paper dealt with the proposed constitution and specifically claimed that, for example, there would be no conflict of interest with the WMA. The rationale for the new body was, as might be expected, that the participating medical associations not only ‘share common ideals and traditions which are peculiar to the peoples of the Commonwealth, but they are faced with similar problems and difficulties in the sphere of medical service’.Footnote ¹⁹ Just what such ‘problems and difficulties’ might be was flagged up in the title of the third document, ‘The Medical Revolution in Great Britain’, an account of the BMA’s negotiations with the government over the NHS.Footnote ²⁰ This was, to say the least, a somewhat one-sided depiction of what had taken place.Footnote ²¹ But, as the Canadian delegate reported to his association’s executive, the ensuing discussion ‘provoked a great deal of interest and indeed sharp criticism from those outside Great Britain’, the latter presumably over the BMA’s purported capitulation to the government. The British delegates had, though, ‘quite stoutly defended the scheme in general’ while indicating disagreement ‘on particular points or principles’.Footnote ²²

All this alerts us to two important characteristics of the BCMC and, later, the CMA. First, attendance was limited to a small number of delegates, for the most part senior figures in their respective medical associations. These individuals had spent much of their later careers formulating and negotiating their associations’ policies on health care organisation. They were thus medical politicians primarily devoted to advancing what they saw as their profession’s interests. The idea was that these senior figures, after discussions and exchange of information at Commonwealth level, would return home and disseminate conference findings more widely. Second, papers at these meetings were predominantly of two types: first, and of paramount interest to members, on the profession’s relationship with the state; second, issues in medical science and clinical practice.

As noted, the BCMC’s creation had been welcomed by Commonwealth medical opinion. In Britain, too, it was acclaimed by the profession’s leaders. Alfred Cox, another veteran BMA negotiator, used the commonly expressed notion of the Commonwealth as a ‘family’, claiming that the BMA had thus taken, through the BCMC and the Empire Bureau, a considerable step in promoting familial solidarity.Footnote ²³ Commenting on the Inaugural Meeting a BMJ leading article reiterated the notion of the ‘common link between medical men and women in the Commonwealth’. Overseas doctors drew ‘inspiration’ from Britain and often returned ‘home’ to pursue, for instance, postgraduate education. All Commonwealth doctors spoke ‘a common tongue’ and all were equal partners in the BCMC. And, in a passage which hints at a broader unease about the tense nature of global politics, it was hoped that ‘common association and common aims (might) stem the forces of disintegration so painfully manifest’ in the world. The piece concluded by noting the venues of future conferences, including South Africa in 1951.Footnote ²⁴ The BMA can thus be seen as contributing to the ‘Commonwealth of Knowledge’ identified by Dubow.Footnote ²⁵

3 Southern Africa

But a political issue which was to prove increasingly troublesome within the organisation itself was South African and Rhodesian membership. As noted, a conference had been scheduled to take place in South Africa in 1951 and, as was to become the practice, this was to be timed to run alongside the BMA’s annual meeting. But neither of these meetings took place and the underlying issue was the South African government’s commitment, since 1948, to apartheid. As The Medical Journal of Australia reported, an initial attempt by BMA Council, the body which ran the Association and generally consisted of members of the medical elite, to withdraw from the events planned for Johannesburg had been rejected by a meeting of the Association’s representative body. The latter had a broader base than Council and was thus more attuned to the views of doctors in general. This was not the last time these two bodies would be at odds over Southern Africa. More immediately, though, MASA had approached the Minister of the Interior seeking assurances that there would be not obstacles to any BMA member seeking to enter South Africa. The Minister had declined to give such an assurance. Without it ever being made explicit, it is clear that the issue here was doctors from the Indian sub-continent and the hostility they might face if, for instance, they sought to enter segregated areas. As the journal put it, BMA Council ‘could not continue in a course of action which might expose members to affront or discourtesy or other unpleasantness’. The piece concluded that Australian BMA members ‘will affirm their feelings of kinship and cordiality towards members of the Association in all other countries and towards members of associations affiliated with it in different parts of the British Commonwealth’.Footnote ²⁶ Given that their country was vigorously pursuing a ‘White Australia’ policy at the time, and had a poor track record in its treatment of Aboriginals, this might be seen as rather self-serving, although possibly sincere enough in its own terms.

The BMA also received support from other BCMC members. The Executive Committee of the Canadian Association, for example, wrote to BMA Secretary Angus Macrae that it ‘fully appreciates the necessity of these decisions and concurs in the action taken’ – namely, that the meeting should be cancelled.Footnote ²⁷ But the issue had not gone away. In late 1951 Tonkin wrote to BMA headquarters in London about his proposed attendance at the next BCMC meeting, to be held in Calcutta in 1952. Tonkin noted the ‘somewhat strained diplomatic relations which exist between India and South Africa’, although correspondence with the Indian Medical Association had resulted in reassurances over the issue of his entry.Footnote ²⁸ To put Tonkin in his broader context, and as background to his speeches at BCMC meetings, it has been argued that ‘the language and debates of MASA under apartheid came to reflect a conservative, white, male profession comfortable within a racist society’. There was, therefore, and unsurprisingly, on its part ‘no questioning of disastrous impact of apartheid policies on the majority of South Africans’.Footnote ²⁹ Vanessa Noble similarly sees the South African body at that time as ‘largely white and apartheid aligned’.Footnote ³⁰ It is worth noting as well that only two years previously Johannesburg had hosted the African Regional Scientific Conference with around one hundred delegates from Africa, Europe and the United States as well as observers from United Nations organisations such as the WHO.Footnote ³¹ So, in these two years we can discern a hardening of attitudes on both sides over apartheid.

In the event, Tonkin did attend the Calcutta meeting, as did a delegate from Southern Rhodesia. Tonkin also addressed the conference in its opening session, noting his pleasure at bringing greetings to the Indian Medical Association from his own association. The latter had many Indian members, Tonkin continued, and ‘I bring special greetings from them to you’. Despite the tense relations between their two countries, he concluded, ‘I can assure you that members of the Indian Medical Association would be cordially received in my country, just as I have been received in India’.Footnote ³² But the Calcutta meeting posed another problem for vexed BMA officials in London, for Southern Rhodesia’s medical association offered to host the next BCMC, in 1955. Macrae wrote to his Rhodesian counterpart shortly afterwards. After admitting his personal unfamiliarity with ‘conditions in your country’ he noted first the cancellation of the Johannesburg conference. He then continued that he knew ‘that there is no Government racial policy in Southern Rhodesia in any way comparable with that of the Union of South Africa’. Nonetheless Macrae sought assurance that there was ‘nothing in the social customs of your country which would give any cause to India, Pakistan and Ceylon to hesitate to send delegates … or which would be likely to cause the slightest embarrassment to such delegates if they did attend’.Footnote ³³ The Rhodesian association then withdrew its offer on the grounds of problems of accommodation.Footnote ³⁴ While accommodation may indeed have been a problem, it is not unreasonable to infer that the association was also deliberately avoiding a potentially embarrassing dispute.

Up to and including the Calcutta conference, one characteristic of BCMC meetings had been that the majority of papers had been given by delegates from the host country. But in 1953 Tonkin suggested a change in format for the next conference, to take place in Toronto in 1955. Writing to Macrae, he remarked that each participant must have problems of medical practice unique to it but which ‘may be of interest to the representatives of other countries’. So, he continued, ‘it occurs to me that it might interest members of the Conference to know something of what is being done for the vast non-European population’ in South Africa.Footnote ³⁵ Further correspondence ensued and Tonkin wrote again to Macrae just under a year later to inform him of what had so far occurred. Apart from the South Africans, the only association to take up his suggestion had been Canada’s. In his view, though, the matter should not be allowed to rest there. It would be useful to hear about Australia’s Aboriginals and New Zealand’s Maoris. Tonkin then raised the stakes. ‘I think more might be told to us’, he went on, ‘regarding the care of under-privileged persons in India, Pakistan and Ceylon.’ This would contribute to mutual knowledge of the participating countries ‘as I do feel that a reasonable estimate of the value of a country’s health services can be got from a knowledge of the work that is done for its so-called submerged peoples’.Footnote ³⁶

It is difficult to know conclusively whether Tonkin was being naïve, or malicious or was genuinely interested in this issue (although discussion below yields some clues), but it certainly gave Macrae cause for concern. As he told a Canadian colleague, A.D. Kelly, in advance of the Toronto meeting, while he was not concerned with Tonkin and the use of the expression ‘native populations’, he was ‘thoroughly scared’ about what the South Africans might say. Macrae’s inclination was to ask Tonkin to confine his comments ‘strictly to the medical care of native African populations in South Africa’ (emphasis in original). Were he to include Indians with Africans under the general rubric of ‘non-Europeans’, this would be bound to ‘give offence to our colleagues from the East’, that is delegates from the Asian associations. Macrae further suggested that, while it would be acceptable for Australian and New Zealand delegates to make contributions on the topic, those from India and Pakistan ‘might resent any reference to “submerged races” in these countries’.Footnote ³⁷ Given that both India and Pakistan had only recently gained independence from British colonial rule, Macrae’s concern not to cause offence is understandable.

Having received reassurance from Kelly that he was at one with his proposal, Macrae then wrote directly to Tonkin. He observed that there was no reason why, in the course of discussion, Australian and New Zealand delegates could not talk about Aborigines and Maoris. He then pointed out that in India and Pakistan ‘the native race is the ruling race’ and that it would thus be ‘inappropriate’ to invite those countries’ representatives to talk about ‘submerged peoples’. Moving on to Tonkin’s own contribution, Macrae suggested that he would be ‘well advised’ to talk only of ‘the native African races in South Africa’ (emphasis in original). The last thing desired in ‘our friendly little conference’ was a ‘bitter controversy about the racial policy of the South African Government’, a clear reference to apartheid. Including Indians, Macrae concluded, ‘with Africans under the general heading of non-Europeans … might cause grave offence to our colleagues from the East’.Footnote ³⁸ Tonkin responded that he had no intention of including ‘Asiatics’ in his speech, although he would respond to any questions on the subject, and that in any event most of them received private medical care, with the rest being treated ‘in the same way as all indigents … regardless of race, colour or creed’. He had no fears about dealing with this although, revealingly, he recalled ‘the Ceylon delegate, Professor da Silva, asking a very provocative question at the last meeting in Canada’.Footnote ³⁹ The last point further suggests that Southern African racial politics were of some concern to at least some BCMC members and they were certainly recognised as such by the London leadership.

The Toronto conference welcomed delegates from eleven countries – Australia, British Guiana, Canada, Ceylon, India, the Republic of Ireland, New Zealand, Pakistan, South Africa, Southern Rhodesia and the UK.Footnote ⁴⁰ During the session on ‘Medical Care of Native Populations’ some rather misleading, if not downright erroneous, claims were made. The Southern Rhodesian delegate, for instance, argued that Africans were ‘at liberty to seek advice from the private practitioner but had been provided with a non-contributory health scheme by the Government and the local authorities’. Services in the countryside involved a ‘system of outlying dispensaries under the control of a district physician, and the urban services included dispensaries, clinics and hospitals of a high standard’. Tonkin’s contribution started with an historical overview claiming that in 1857 the Cape governor had ‘sought to bring the benefits of European medicine to the Africans and had established Grey’s Hospital in (King William’s Town) in an attempt to counteract the witchcraft which was still a powerful influence today’. He stressed the role of the missionaries and the army in promoting health and claimed that health services developed by the gold industry were ‘probably second to none in the world’. Nowadays it was generally the case that ‘medical services provided for the African … differed little from those provided for the rest of the community’. Increasing numbers of African nurses were being trained ‘to care for their own people, and the new medical school in Durban was designed particularly to meet the needs of the African people’.Footnote ⁴¹ These were highly sanitised accounts of Southern Africa’s medical history.Footnote ⁴²

We have no record of the response to these claims, although it is unlikely to have been uniformly positive, but overt tensions over the membership of South Africa and Rhodesia appear to have abated for around fifteen years. Not that this was a period of unchanging calm in either the BCMC or the Commonwealth. The former reconstituted itself as the Commonwealth Medical Association in the early 1960s. During the relevant discussions, Tonkin suggested that the new body did not need a constitution as the

This was an important re-statement of South African views, once again stressing familial, organic and professional connections between Commonwealth members while highlighting the longstanding relationship between doctors in South Africa and in Britain.

4 The Expulsion of South Africa and Rhodesia

With further decolonisation, the number of associations represented continued to grow and this brought changes in the dynamics of the Commonwealth, as did changing attitudes among existing CMA members. On the latter point, for example, a leading figure in the Medical Association of New Zealand wrote to the leading CMA official in London in 1968 suggesting that his country’s ties with the ‘Old World’ were loosening while those with Asia and the Pacific were becoming ever closer. The BMA’s response again invoked the ‘common heritage and common aims’ of Commonwealth doctors, hence the essential need to meet collectively every two years to discuss ‘matters of mutual interest’.Footnote ⁴⁴ But a key aspect of concerns such as those expressed from New Zealand was Britain’s own changing relationship with the Commonwealth as she moved nearer to Europe, in the first instance economically through membership, from 1973, of the European Economic Community. Nonetheless, the 1968 meeting, held in Canberra, recorded delegates from twelve associations, including that of South Africa, and observers from fourteen more. For technical reasons, the Rhodesian association had to reapply for full membership and this was proposed by the South African and Canadian delegates and unanimously agreed upon. The Ghanaian delegate noted that his association had considered Rhodesia’s application and had taken no exception to it.Footnote ⁴⁵

The broader context is crucial. Tonkin’s ‘bond of affiliation’ speech came in the same year, 1961, as South Africa’s exit from the Commonwealth and less than a year after the Sharpeville massacre.Footnote ⁴⁶ By this point, as Stuart Ward puts it, the idea of ‘South African “Britishness” had long since lost credibility’.Footnote ⁴⁷ But, as we have seen, a purported intimate relationship was a central part of Tonkin’s argument and was to remain so. Re-confirmation of Rhodesia’s membership, meanwhile, came three years after that country’s Unilateral Declaration of Independence. And yet there was no attempt to terminate CMA membership of either association. Tonkin had also engaged in an extensive correspondence about his inability to attend the Karachi meeting in 1966, but this was to do with visa problems – Pakistan and South Africa did not have diplomatic relations – rather than unwillingness to attend on his part or exclusion by the CMA.Footnote ⁴⁸ But that year also saw the beginning of a chain of events which was to lead to the expulsion of South Africa and Rhodesia in 1970.

In early summer 1966, D.P. Stevenson, the BMA secretary, began a correspondence with John Chadwick, director of the Commonwealth Foundation, which resulted in the latter contributing £1,250 to enable delegates from India, Ceylon, Ghana, Malaysia and Singapore to attend the Karachi meeting.Footnote ⁴⁹ This was one of the Foundation’s earliest awards.Footnote ⁵⁰ On the initiative of the British government, which felt that tensions within the Commonwealth were posing a threat to the latter’s existence, the Commonwealth Foundation had been set up in 1965 with the agreement of Commonwealth heads of government. It sought to encourage co-operation and interaction between professionals and professional bodies within the Commonwealth. In principle an autonomous organisation, and a registered charity, the Foundation was by 1971 funded by twenty-eight Commonwealth governments and had an annual income of £350,000. Although medical organisations were by no means the only recipients of Foundation grants, in its first five years over a fifth of its disposable grant income went to the field of medicine, including to the CMA.Footnote ⁵¹ Immediately prior to the Karachi conference, a meeting took place in London between the Commonwealth Foundation and the BMA. Chadwick, while unable to give a definite commitment, nonetheless suggested that ‘it was more than possible’ that applications to fund future CMA events ‘would receive sympathetic consideration’.Footnote ⁵² As we shall see, though, there would be conditions attached.

External events also flesh out the context. In the spring of 1969, the BMA, along with journalists, medical members of parliament and the Labour Party-affiliated Socialist Medical Association (SMA), received briefing notes from the UK-based Anti-Apartheid Movement (AAM). As the latter’s annual report noted, this intervention had been prompted by the strike in April by African, Indian and coloured doctors in South Africa in pursuit of pay equality with their white counterparts. This dispute centred on the Durban Medical School, which played an important part in the struggle against apartheid. As a result of the AAM’s approaches, the dispute had received coverage in the medical and general press.Footnote ⁵³ So, for instance, the AAM’s executive secretary, Ethel de Keyser, wrote to Labour MP and leading SMA member, David Kerr, asking him if he would approach the Medical Practitioners’ Union (MPU) and ‘if you think it worthwhile … the British Medical Association, asking for support for the African, Indian and Coloured doctors’. The MPU was a trade union, affiliated to the Trades Union Congress, and as such could adopt a much more militant stance than the BMA. Among her other correspondents were leading MPU activist, H.C. Faulkner, and another prominent SMA member, Harry Keen.Footnote ⁵⁴

This agitation appears to have had some effect. In June, a BMJ leading article deprecated the South African practice of medical remuneration according to race. ‘Salary scales which are based on distinctions which are an offence to biology as much as humanity’, it observed, ‘must seem peculiarly irksome to medical men and women’, a point which was to be reiterated the following year. The recent disturbances among non-white medical staff were therefore ‘not surprising’. Medicine transcended ‘national frontiers’ and, more specifically, there were numerous ‘friendly links’ between British and South African doctors. Many of the latter trained in Britain and their respective medical organisations were both members of bodies such as the WMA and the CMA. The South African body had long opposed apartheid in medicine and a recent issue of the South African Medical Journal had reaffirmed this position.Footnote ⁵⁵ Given the impending South African rugby union and cricket tours, the politically contentious issue of British arms sales to South Africa and Rhodesia’s declaration of a republic, the late 1960s and early 1970s was thus an era when Southern Africa featured heavily in British political consciousness.Footnote ⁵⁶ It is also worth recalling that, in reality, MASA did little to oppose apartheid, whatever its own claims and indeed those of the BMA.Footnote ⁵⁷

It was against this background that the build-up for the August 1970 CMA meeting, to be held in Kuala Lumpur and Singapore, took place. In April, the Malaysian Medical Association informed the BMA that it appeared unlikely its government would admit Rhodesian or South African delegates, that the Singapore government had already denied access to Rhodesians and that it might also do the same to South Africans.Footnote ⁵⁸ Because of visa problems, the Rhodesian delegate duly pulled out. However P.D. Combrink, MASA associate secretary, informed the BMA that he had obtained a visa and planned to attend.Footnote ⁵⁹ Three months before the meeting was due to take place, Stevenson wrote to all CMA members stressing the desirability of a good attendance. This was on account of recent discussions with the Commonwealth Foundation with regard to an advisory role which the CMA might be able to perform for the former, which would both benefit the CMA and ‘which we hope would be supported by funds from the Foundation’. No mention was made, though, of any conditions which the latter might attach.Footnote ⁶⁰

When the conference convened it became clear from the outset, as an Australian observer subsequently reported, that the ‘membership of South Africa and Rhodesia would come under attack’.Footnote ⁶¹ At the first, closed, session in Kuala Lumpur, the Ghanaian delegate complained that the representative from his country who had supported Rhodesia’s membership in 1968 had not been speaking on behalf of his association and requested that this be minuted. The delegate from Tanzania – along with Jamaica, Fiji and Sierra Leone, a new Association member – then thanked the CMA for accepting his association’s membership application, but, he continued, it would have thought twice had it known of South African and Rhodesian membership. Those countries’ racial policies were ‘thoroughly inconsistent with the noble principles laid down in the CMA Constitution’. In fact, and unsurprisingly, there had been no mention of ‘race’ when the Association had been set up, although the delegate’s reference may have been to the frequently alluded to idea of equality of status within the CMA and its predecessor. There was, the Tanzanian continued, no possibility of fostering better relationships because no relationship existed in the first place. He therefore urged Rhodesia and South Africa’s immediate expulsion. The chairman responded that he had anticipated problems over this issue, but asked that the matter be deferred until a letter from the Commonwealth Foundation had been reviewed. By a majority vote, it was agreed to revisit the subject in Singapore. A discussion of CMA finances then ensued and their reliance on Commonwealth Foundation monies became apparent. The Foundation, Stevenson reported, had offered further funding of £30,000 over three years if the CMA could broaden its membership, as it had recently done. There were only two requirements attached to this award, one of which was that it would not be available if the South African and Rhodesian associations remained members. After discussion, it was agreed to accept Stevenson’s financial statement and to send a message ‘expressing appreciation for the Foundation’s very generous offer of assistance’.Footnote ⁶²

When the meeting re-convened in Singapore, the Canadian delegate, Dr Kippen, optimistically, if illogically, suggested that the issues of the Commonwealth Foundation offer and that of membership be kept separate. However, the Ghanaian and Tanzanian representatives put forward a motion proposing that the CMA constitution be amended to exclude South Africa and Rhodesia. This was justified on various grounds, including Commonwealth Foundation funding, but the key factor was that Rhodesian and South African membership was not ‘consistent with the concept of the multi-racial character of the Commonwealth for which reasons (sic) precisely both South Africa and Rhodesia have ceased to belong to the family of Commonwealth of nations’.Footnote ⁶³ There then followed, as the Australian observer put it, ‘a vehement and intense debate’.Footnote ⁶⁴

Combrink was invited to take the floor. He expressed surprise that ‘politics had been allowed to enter the discussions of this professional association’. His organisation held the same values as the CMA; namely, the ‘promotion of medical and allied sciences, and the interests of the medical profession’. Pointing out that South Africa and Rhodesia had both continued as CMA members after leaving the Commonwealth, he suggested that what members had in common was language, roots in the BMA and adherence to the ‘British School of Medicine’. Again, these were ideas which had been much proclaimed since the late 1940s. He was not there, Combrink continued, to defend his government’s policies, his association did not support apartheid, its membership was open to all and it was in dispute with the government over various issues. The Indian delegate, Dr Bhose, in supporting the motion, claimed that apartheid also affected the South African medical profession. One of the BMA representatives then suggested that expelling South Africa could harm those it was seeking to help, non-white doctors, and indeed their patients. Opposition to expulsion also came from the Australian delegate, while Dr Mulcahy, from the Irish association, suggested that the position of ‘coloured people’ was improving fast through their own and others’ efforts. Concerned about loss of contacts, Mulcahy suggested that Irish Republic’s own ‘severance’ from Britain had been a mistake. Others, for instance the Malaysian delegate, expressed doubts about the constitutionality of what might take place. A compromise amendment was proposed which sought information from MASA and the setting up of a postal ballot to determine the future of South Africa and Rhodesia within the CMA.Footnote ⁶⁵ To put this part of the discussion in context, by the early 1970s Africans had had access to medical training in South Africa for a quarter of a century, but only 252 had qualified and, while there was one African doctor per 44 000 Africans, the white doctor to patient ratio was one to 400.Footnote ⁶⁶

Back at the meeting, not everyone was prepared to take a conciliatory line. Even before the amendment was tabled, the Jamaican delegate accused Combrink of obfuscation, while Dr Mamujee from Tanzania pointed to the number of South African refugees entering his country and the evidence they brought of racial discrimination. Tanzanians thus knew that ‘the best way to improve the situation was to force South Africa to accept world pressure. The best thing to do was to boycott South Africa from all civilized contacts’.Footnote ⁶⁷ The amendment was duly put, losing six votes to nine. The original motion was then passed by twelve votes for, none against and four abstentions.Footnote ⁶⁸ As the rather terse, and somewhat misleading, press statement put it, the meeting had resolved that ‘as the conditions appertaining in the Medical Associations of South Africa and Rhodesia were inconsistent with the aims and objectives of the CMA they should cease their membership forthwith’. The constitution had been duly amended to this effect.Footnote ⁶⁹ Reflecting on the meeting, which he had chaired, Professor A.A. Sandosham noted the presence of more African and Caribbean members ‘who are in close touch with the evil effects of apartheid and segregation policies on the medical profession’ and that this made it inevitable that South Africa and Rhodesia’s membership would come into question. A compromise had been defeated on the grounds that if immediate action were not taken then the CMA might break up, and Sandosham further speculated that some Commonwealth medical associations had held back from joining because of the continuing presence of the South African and Rhodesian associations.Footnote ⁷⁰ The latter observation calls into question the Tanzanian delegate’s claim that he had not known in advance of South African and Rhodesian membership.

5 ‘Race and Commonwealth’

The BMA quickly made its own position clear. The same edition of BMJ which reported on the Kuala Lumpur and Singapore meetings carried the leading article ‘Race and Commonwealth’. This started with a brief account of the CMA’s formation, noting that MASA had been included from the outset, that this had survived South Africa’s exit from the Commonwealth and that the CMA had unanimously accepted the Rhodesian association’s re-application in 1968. The piece continued that this indicated that ‘deep political differences between countries were not alone enough’ to lead to any member’s exclusion, although of course this was precisely what had happened. Rushing over whether the recent exclusion was ‘political’, it was then argued that ‘racial discrimination is an evil that bites deep. The judgements made under its influence set it apart not merely as something uncivilized but as an offence to humanity’. Doctors found such discrimination ‘peculiarly repugnant’ since ‘their training and their daily relationship with their patients recognise the falsity of the doctrine it embodies’. In the particular case of South Africa, its government’s racial policy undoubtedly affected the whole of society. Combrink’s refusal to answer for his government was positively recognised. It was acknowledged, too, that MASA did not operate any form of discrimination in its membership; that it criticised, for example, racially differentiated salaries; and that if it challenged apartheid head on, it ‘would not survive a day’. Nonetheless, Combrink had not adequately explained separate training schools for white and non-white medical students. Such criticisms could be extended, the leader continued, to practices such as segregated wards and waiting rooms. The WMA’s code of ethics, which forbade the doctor–patient relationship to be affected by factors such as race, was then invoked. No mention was made, though, of the Commonwealth Foundation’s highly conditional support for the CMA and its activities.Footnote ⁷¹

BMA Council, in its subsequent annual report, expressed concern at the way in which the expulsion of the Southern African associations had taken place, and in particular that the issue had not been flagged up before the meeting. Nonetheless, it continued, there had been no actual contravention of the CMA’s constitution and the link of affiliation between the BMA and the South African association meant that communication between the two bodies would continue. Without relating the two issues, the Commonwealth Foundation’s grant was also noted, and this would ‘further co-operation in medical affairs throughout the Commonwealth’.Footnote ⁷²

Combrink and MASA, however, were not content to leave matters as they stood. In a contribution to the South African Medical Journal, editorially described as a ‘factual report’, Combrink described the BCMC/CMA’s origins and noted that, historically, it had been funded principally by the BMA. Moving on to more recent events, he remarked first that in 1968 Rhodesia had gained (in fact, regained) membership and that Zambia, Kenya and Mauritius had signalled their intentions to apply. Combrink then cited a letter from the Commonwealth Foundation to the BMA which clearly stated that any further funding of the CMA would not happen while the South African and Rhodesian associations remained members. Discussing the 1970 meeting, Combrink gave an account of his own contribution to the debate, which had explicitly attributed the expulsions to the Commonwealth Foundation’s stance. Among the other key points he had raised were that MASA could not be held accountable for its government’s policies, that a CMA meeting was not the place to discuss these and that there had been no questioning of South African membership when the CMA had come into being, notwithstanding that South Africa was by this stage no longer a Commonwealth member. Combrink then reported that he had been subjected to ‘torrid’ questioning during which his honesty had been disputed by some supporters of expulsion and that ‘he was obliged to enter into acrimonious individual debates with certain of (my) questioners’. He concluded by noting that MASA’s expulsion would not affect its affiliation to either the BMA or the Canadian Medical Association, and good links with certain other Commonwealth professional bodies would be maintained.Footnote ⁷³

MASA Federal Council, meanwhile, in its report for 1970, commented on the expulsions, which it attributed, as had Combrink, to Commonwealth Foundation demands. It was regrettable that a CMA ‘Founder Member’ had been treated in this way ‘at the hands of newer members’, and that ‘we were not given the opportunity to withdraw so that the Association could have accepted the Commonwealth Foundation’s offer without embarrassment to anyone’.Footnote ⁷⁴ The last point was a new one as it does not appear to have been raised by Combrink at the meeting itself. A number of BMJ correspondents also deprecated the CMA’s decision, finding it a matter of ‘deep regret’, a ‘tragedy’ which would dishearten the Rhodesian medical profession – ‘one of the largest liberal minded groups in that country’ – and potentially ‘disastrous’ and ‘unwholesome’.Footnote ⁷⁵ Criticisms were expressed, too, at the BMA’s 1971 Annual Representative Meeting, which was ‘concerned that the constitution of the Commonwealth Medical Association allows the expulsion of member associations without prior notice of such motions being given to members’. BMA Council was therefore instructed to amend the constitution appropriately.Footnote ⁷⁶

However, the most trenchant critic was BMJ correspondent George W. Gale. Born in Durban, Gale had, in the course of a long and varied career, gained his medical training in Edinburgh and Liverpool, founded a Church of Scotland hospital in Natal in the late 1920s, been Secretary for Health in the South African government from 1946 to 1952, and acted as founding Dean of the Durban Medical School from 1952 to 1955. Thereafter, he had held professorial posts in Uganda, Thailand and Malaysia before retiring to Britain in 1969.Footnote ⁷⁷ Certainly at the start of his career, Noble suggests, Gale was a ‘person of liberal political leanings’ who had left his government post on account of the ‘reactionary views and policies’ being promoted in the Department of Health by National Party officials.Footnote ⁷⁸ It seems unlikely, then, that he would have been a wholehearted supporter of apartheid.

Gale started his letter by pointing out that nothing MASA had done was at odds with CMA objectives. The latter had thus committed an act of ‘gross injustice’ against one of its members. Combrink had been forced into discussing an issue – training facilities for ‘non-Whites’ – about which he had no first-hand knowledge and no opportunity to consult with those who did. The South African association itself did not practice apartheid except when ‘compelled to do so by the legal force majeure of the Government’. Indeed it had opposed the Government on not some ‘but on all applications of apartheid to medical men or their patients that are inimical to the true interests of either’ (emphasis in original). Gale made various other points in defence of the South African association before challenging the BMA to tackle the UK government on its ‘racially discriminatory policy on immigration’ and its renewed sale of arms to South Africa. The latter helped bolster the present regime ‘morally perhaps even more than materially, against external attack from non-White countries infuriated beyond endurance’. Should the BMA fail to do so then it should be expelled by the CMA, as should any other association failing to protest against its government’s discriminatory policies, of which Gale claimed there were two.Footnote ⁷⁹

Of course, not all BMJ readers supported such views. Barry Lewis, another recipient of correspondence from the AAM, questioned the idea, based on his contacts with Rhodesia over nine years, that its medical profession was notably liberal. While some Rhodesian Medical Association members were, commendably, anti-racist, the association had made ‘no effective protest at the innumerable ways in which racial discrimination in Rhodesia influences medical practice’. Concluding, Lewis suggested that when racial issues were as clear cut ‘as in Southern Africa, not to protest it is to acquiesce’.Footnote ⁸⁰ Nonetheless, it was those who objected to the expulsion of the South African and Rhodesian associations who shouted loudest, at least in the BMJ.

The next CMA meeting, held at Accra and thus the first to take place in Africa, was attended by representatives of over twenty member associations with new recruits including Kenya, Nigeria and Swaziland. There was much discussion of finance and, as the Australian delegate put it, a ‘lively debate’ on a British proposal that the CMA should not be influenced by ‘national or international political considerations’. The proposal was, he continued, ‘regarded as being related to the expulsion of Rhodesia and South Africa’. In the event, only the Australian and one other delegate, presumably the Briton, supported the motion.Footnote ⁸¹ This was effectively the end of the matter, at least in the short term. A few years later, South Africa was forced to leave the WMA before being controversially re-admitted. One consequence of all this was that the BMA broke off its relationship with MASA and left the WMA.Footnote ⁸²