As I look back it seems that I have been involved in social conflict and in medical problems from an early age. This page describes those experiences.
I grew up in a five-doctor country town where my father was a general practitioner. My mother had been a nurse. There was no such thing as health care insurance. All comers were treated. A doctor's fees were tailored to the ability to pay and not the service provided. The rich paid for the poor.
THE GREAT DEPRESSION THEN WAR
The railway was the main link to the outside world. My father held a contract to provide care to the railway community in the town. This small stipend was a lifeline during the depression years as none of the community could pay.
The town was largely Afrikaans and pro-Nazi with only a small English community. This contract was very useful in supporting the family during the 1939-45 war. My father, from an Irish catholic family had a family hooked nose and local rumour was that he had Jewish blood. Patients were pressured to leave him. A number came to apologise and explain that they had no choice. Despite these temporary setbacks I remember him as always busy, coming home for rushed meals and often out at night.
Because of the tensions in the local schools I was sent to boarding school at the age of six. Swastikas were the fashionable graffiti on the town's walls. During the school holidays we would turn swastikas into union jacks by completing the outline and then run for our lives!
General practice in those days was a 7 days a week, 24 hours a day business. My early recollections are of the strong sense of personal responsibility for patients and to colleagues. This was particularly evident when my father sold his practice. It was not so much a case of selling the practice as finding someone to whom he could entrust the care of his patients. The person he considered for selection was required to do a locum for each of the doctors in town while they took their annual holidays. The extent to which he fitted into the medical and lay community was a consideration in the final decision. It was cooperation and contribution to the community which were considered - not competition.
I believe that a sense of individual responsibility and trustworthiness is the essence of medical practice. This is why the care of the sick can never be turned into a series of products to be traded in the marketplace. While I appreciate the need for doctors to have a life, the current trend to roster doctors and to delegate the care of patients to an after hours "service" of unknown doctors still sits uncomfortably. The individual doctor must be there for his or her patient when there is a real need - even when not rostered. Not to be there in a time of need is a breech of trust.
In 1947 the family moved to a largely English city where my father took another railway contract to assist in building his new practice. He was unhappy about the way in which some of the other doctors working under similar contracts were fulfilling their professional responsibilities to these patients.
SCHOOL AND UNIVERSITY
I went to an English church school that was moderately liberal in outlook. It challenged the new Nationalist government and its apartheid policy by holding sporting competitions with black schools, something unheard of at that time. It was much later one of the first white schools to admit black students.
The University of Cape Town where I trained was strongly anti-government. We still had mixed race students but black students had been barred. There were marches, protests and confrontations with government but these were mostly peaceful. The "flame of academic freedom" was formally extinguished at a university ceremony. There were lengthy discussions and much political activity. I participated but did not take an active part.
Cape Town was fairly conservative medically and we looked with some concern at the commercial practices in Johanessburg. It was considered to be more like the USA. The commercial emphasis of the US system and its heavy reliance on expensive investigation rather than clinical skill was frowned on.
University staff were full time employees without any right to private practice. The new Afrikaans medical school in nearby Stellenbosch allowed university staff to have private practices and the general view was that their university work suffered because they gave their private practices priority. University duties it was believed became very much part time.
In the 1960's the National Health System (NHS) in the UK was very different to South Africa. The vast bulk of the work at that time was full time. Many specialists had small private practices and I sometimes assisted with operations and helped to look after these patients. The private patients usually got a reasonable deal but there were one or two specialists who would play on the patients' anxiety in order to build their reputations.
The sort of relationships and bonds of trust established in the private sector are usually more rewarding for the medical profession and for the patients but the system is more costly and open to abuse. The profession has not been as effective in dealing with problems as it should have been.
The NHS was not all a bed of roses. There were hospitals where care was not all it should be and where senior staff did not supply the oversight and supervision required. The bureaucracy was cumbersome and unresponsive. Salaries were low and promotion was slow. Staff were not always satisfied and morale was sometimes low.
Fellow registrars returning from a spell of training in the USA in 1964 told stories describing the consequences of the commercial pressures in that country. There were many unethical practices and the payment of kickbacks was widespread in some parts. The mainstream US professional colleges were very concerned and were taking steps to control what was happening.
This was soon after the introduction of Medicare in the USA and the early days of corporate medicine. As this site shows Medicare proved to be an invitation to the greedy and unscrupulous. Corporate groups were established in the 1960's and grew on the largesse of this system. Patterns of business thinking developed which made it legitimate to exploit the system to its legal limits and beyond. Company staff had a fiduciary duty to shareholders to maximise profits.
After a further 2 years working at teaching hospitals in Cape Town I went into practice in a coastal city - first in private practice and then full time. Patients either paid personally or else belonged to an insurance scheme paid by their employers. The bulk of the profession practised good medicine ethically but there were a significant number who exploited the system. Some of these were among the wealthiest and most successful practitioners.
One secretary applying to be my receptionist immediately demanded double the salary I had offered. She explained how the wealthy group she had been working for made their money. She promised that by doing my billing she would double my income.
A greater problem was the presence of contracts - usually with sections of the government. These contracts attracted the least ethical members of the profession. Generally the contracts paid a reduced fee per item of service in return for a monopoly. The patient had to go to the doctor awarded the contract.
Soon after I entered practice I was asked to do the locum of a surgeon who had a contract with a large government department. A group of radiologists had the contract for the Xrays so I had to use them. After two weeks I realised that my suspect diagnosis was always correct. The films taken were too few and too inadequate to support the diagnosis. They were skimping on costs and simply issuing reports confirming my diagnosis. I was unable to collect sufficient material to do anything about it. Some time later the surgeon left town hurriedly for other reasons.
Similar contracts with general practitioners created incentives to take on more work than could be done. It created a set of second class patients, many of them black. Doctors were often too busy to do the work properly and some did not feel too much conscience about this. I was referred some of these patients and clashed with the doctors because they had neglected their patients. I remonstrated with some for taking on too much, particularly the doctors I knew well because I had trained them. I lost support but it had no other impact.
I looked for instances that I could use to have doctors misusing contracts suspended from practice, but by this time I was being kept well out of the loop. Some eventually failed to provide care for the black activist Steve Biko and when his death became an international issue they were finally suspended from practice.
CONFLICT WITH GOVERNMENT
While in London I met with many who had fled South Africa and learned much more about what was really happening in the country. On my return I met briefly with some of their families but did not get directly involved.
When I later took up a full time post in a hospital for black patients conflict with government became inevitable. Black doctors were paid a third as much as white doctors doing the same work and it was a constant battle to get the equipment we needed. We had repeated conflicts with government and we learned how to outwit them, work the system and steadily wind back some of the limits imposed by apartheid. As members of the white community we could take action which would have landed our black colleagues in prison.
At the time we were highly motivated and it was only the insights of the black theorist and activist Steve Biko which made us realise that our efforts were actually counterproductive. One of the major evils of apartheid was the destruction of a sense of identity in the black community - of confidence in themselves. As Biko explained we had destroyed their history and so their sense of who they were - an insight equally applicable to Australia's aborigines. The battle against apartheid was a black problem and in fighting it they were rebuilding and re-establishing themselves - creating a new history and new myths with which to identify. Each time we took action on their behalf we undermined their growing confidence. Despite the personal costs they needed to do it themselves and as white liberals we had to allow them to do so.
This was a time of reflection and personal insight. I felt that I was no longer contributing usefully and I did not see a secure future for my growing family. I eventually decided to take my family elsewhere.
AN ACADEMIC INTEREST
I grew up during the second world war and had a long interest in the holocaust, then in apartheid and finally in dealing with doctors who experienced no personal conflicts when not properly caring for their patients. I became interested in the way in which ideology worked and in its impact on individuals - the way they thought. It was clear that people really believed that what they were doing was legitimate, even desirable. The strategies used by otherwise very reasonable people to justify and rationalise were revealing. I was fortunate in having close contacts across the spectrum of society - people separated by social barriers, each with totally different understandings of the same events. I came to realise how their understandings were influenced by their position in society and the context of their lives.
I became interested in the way in which people develop ideologies and personal explanations in response to the situations in which they find themselves - often beliefs and explanations which do not stand up to objective scrutiny. I started work towards a degree in social sciences but with a particular interest in the interaction of individuals with their culture and their response to the context of their lives - how their thinking changed. This was to prove extremely valuable years later when dealing with corporate culture and marketplace ideology. It allowed me to deal with individuals and individual situations within a broad context. I was better able to use actual situations to address broad issues. These insights and theoretical understandings have been developed further during the last 10 years and surface at multiple points on the www site. I have written some pages which are primarily theoretical.
CLICK HERE -- for an account of my battle with Tenet/NME