Markku Hokkanen

Medical middles were among the most mobile individuals in colonial Southern Africa, moving as they did between mission, government and private sector employment, and across local and regional boundaries. As Nancy Rose Hunt has pointed out in her study of colonial Congo, local and regional mobility was a significant part of the identity of African medical middles. By 1940, Dr Hastings Banda seemed to be well on track to become the first African doctor in government service in anglophone East Africa, and his precedent was expected to have an impact well beyond Nyasaland. As the new leader of the nationalists, Banda was keen to recall at least some other medical migrants. Daniel Sharpe Malekebu's remarkable return to the protectorate, relatively soon after the 1915 rising, was secured through international missionary networks. Protestant mission networks facilitated the mobility of a number of Malawian medical personnel.

in Medicine, mobility and the empire
South Asian doctors and the reinvention of British general practice (1940s– 1980s)

The NHS is traditionally viewed as a typically British institution; a symbol of national identity. It has however always been dependent on a migrant workforce whose role has until recently received little attention from historians. Migrant Architects draws on 45 oral history interviews (40 with South Asian GPs who worked through this period) and extensive archival research to offer a radical reappraisal of how the National Health Service was made.

This book is the first history of the first generation of South Asian doctors who became GPs in the National Health Service. Their story is key to understanding the post-war history of British general practice and therefore the development of a British healthcare system where GPs play essential roles in controlling access to hospitals and providing care in community settings.

Imperial legacies, professional discrimination and an exodus of British-trained doctors combined to direct a large proportion of migrant doctors towards work as GPs in industrial areas. In some parts of Britain they made up more than half of the GP workforce. This book documents the structural dependency of British general practice on South Asian doctors. It also focuses on the agency of migrant practitioners and their transformative roles in British society and medicine.

Julian M. Simpson

31 1 The making of a cornerstone Before exploring in detail the way in which migrant South Asian doctors shaped general practice and the NHS, I first want to situate their story within the broader context of the history of British healthcare, empire and of post-​war migration to the UK. The role of migrant doctors in the NHS is not confined to general practice. They were disproportionately represented in junior positions, less prestigious types of medicine and in geographical areas that were unpopular with local medical graduates. I will say more about the

in Migrant architects of the NHS
Julian M. Simpson

behaviours that can be linked to a narrow definition of racism as related to perceived biological differ­ ence, and those that can be ascribed to the more wide-​­ranging notion of ‘heterophobia’—​literally the fear of difference.5 South Asian migrant doctors could find themselves at a disadvantage because of racism but equally as a result of attitudes toward accent, gender, class, alcohol consumption, nationality, religion and other factors. Racism was a driver of the development of healthcare but so was, more generally, the tendency of many of those working in the NHS to

in Migrant architects of the NHS
Nyasaland networks, 1859–1960
Author: Markku Hokkanen

David Livingstone's Zambesi expedition marked the beginning of an ongoing series of medical exchanges between the British and Malawians. This book explores these entangled histories by placing medicine in the frameworks of mobilities and networks that extended across Southern Africa and beyond. It argues that mobility was a crucial aspect of intertwined medical cultures that shared a search for therapy in changing conditions. The Malawi mission stations were the first permanent sites in which Western medicine was made available to Africans. Livingstonia's medical practice began in Cape Maclear in 1875, moved to Bandawe in the early 1880s and expanded to Ngoniland and north Lake Malawi. Lacking effective therapies to deal with the high levels of ill health and morbidity that plagued them, Europeans sometimes sought out cures and protection from indigenous African, Asian and American healers, many of whom were women. The lay practice of 'doctoring' African employees with elements of trickery continued into the later colonial period. Medical middles were among the most mobile individuals in colonial Southern Africa, moving as they did between mission, government and private sector employment, and across local and regional boundaries. The Second World War brought about major changes in the types of antimalarials available in the Nyasaland Protectorate and the wider empire, as quinine became a scarcer resource and new synthetic anti-malarials became more available. Western medicine became recognised as one resource among others in a pluralistic medical culture, but African medicine, for Europeans, became mainly an object of ethnographical and anthropological interest.

Abstract only
Historicising a ‘revolution’
Julian M. Simpson

, which helps to account for the post-​war flow of doctors to Britain. I have highlighted the structural dependency of British general practice on the labour of migrant doctors prepared to take on specific roles within the NHS. I have drawn attention to the agency of migrants who were able to shape their social and professional environment. This book has brought to the fore the influence of racism and discrimination on the grounds of difference on the development of British medicine. It has highlighted that medical migrants need to be recognised as agents of the

in Migrant architects of the NHS
Julian M. Simpson

metropole. I will then give an indication of the scale of the dependency of the NHS on migrant doctors and other healthcare workers, exploring how existing colonial networks were drawn upon to meet the staffing needs of a new and expanding organisation. Finally, I will discuss the evolving nature of the social and political space in which doctors migrated and how it was shaped by post-​war debates around ‘race’7 and migration. There was a time lag between the formal end of the British Empire and the (partial) dismantling of its legacies such as the freedom of doctors to

in Migrant architects of the NHS
Doctors’ organisations and activist medics
Julian M. Simpson

evidence of their agency at a local level. At times, this social and political engagement extended beyond local contexts and resulted in them taking on national roles. South Asian doctors set up voluntary organisations which had an impact on policy and more generally provided a setting in which migrant practitioners could access training and socialise. They also acted to change British medicine in a number of ways. This chapter describes how migrant doctors became involved in medical politics and in addressing social questions. They added new dimensions to British

in Migrant architects of the NHS
Memories of practice on the periphery
Julian M. Simpson

. If migrant doctors provided labour they also served to perpetuate the existence of what might be termed a medical frontier zone, where practice developed in parallel with mainstream healthcare provision and in ways that politicians and the medical profession had limited influence on. Referring to these areas as peripheral is of course not to say that their status was a natural product of their location (they were not peripheral from the perspective of those who lived in them) but to describe their position within the British healthcare system. Doctors’ accounts of

in Migrant architects of the NHS
Abstract only
Writing the history of the ‘International’ Health Service
Julian M. Simpson

to root out the ‘evil’ that was the link between the provision of medical care and the ability of the patient to afford it.7 The establishment of the NHS sought to remove this barrier by making access to care free. Recourse to migrant labour enabled the British government to achieve this aim. In the chapters that follow I  explore the impact that South Asian migrant doctors had on British medicine and more generally British society. In so doing, I seek to draw on history’s ability to inform our understanding of the present and to contribute to a reflection around

in Migrant architects of the NHS