1. Introduction
From the mid-1970s South Africa grew increasingly isolated within the international community, including the medical community, and in 1976 the Medical Association of South Africa (MASA) decided to withdraw from the World Medical Association (WMA) because diplomatic pressure had prevented it from attending two of the international organisation’s World Medical Assemblies. Yet despite an international academic boycott, even as late as the 1980s, some South African civil society organisations with cordial relations with the country’s government continued to enjoy membership of certain prestigious international organisations, such as the WMA. Indeed, in August 1980 the American Medical Association (AMA) launched a campaign for their South African counterparts in the MASA to be readmitted to the WMA. The transnational anti-apartheid activists who opposed the MASA’s readmission to the world body argued that, in their exoneration of the doctors who had failed to treat the fatally injured Steve Biko whilst he was in police detention in September 1977, the MASA had failed to uphold the principles enshrined in the WMA’s Tokyo Declaration against torture and the Geneva Declaration (an updated version of the Hippocratic Oath). The WMA readmitted the South Africans at its meeting in Lisbon in September 1981. Anti-apartheid health activists within South Africa and their international allies, continued to campaign for the MASA’s expulsion, however, and framed its readmission to the WMA as ‘a matter of conscience’.Footnote 1 By contrast, their opponents in the WMA derided them as individuals concerned with ‘politics’, something they thought could be distinguished from medical ethics. Anti-apartheid activists’ efforts in this regard were unsuccessful as the MASA was not subsequently expelled from the WMA. Its defiance of the international academic boycott against South Africa did, however, cost the WMA its relationship with the World Health Organisation (WHO) and meant that many national medical associations disaffiliated from the former. South Africa’s membership of the WMA only ceased to be a serious politically difficult issue for the international medical association when the country became democratic in 1994.Footnote 2
This article explores the paradox of South Africa’s readmission to the WMA in the wake of the Biko doctors’ scandal, despite an international academic boycott. It describes the ways in which anti-apartheid activism led to internal rifts within the WMA.Footnote 3 The activists alleged that the WMA had engaged in unprincipled, racist and pro-free-market behaviour. This activism came to diminish the moral reputation – and the number of national member organisations – of the WMA, which was an international health organisation (IHO). The activists characterised the WMA as having conferred moral authority on the MASA, which was closely aligned to the National Party government, which followed a racially discriminatory policy of apartheid. They also held that in a Cold War context, the renewal of the MASA’s WMA membership was aimed at bolstering the AMA’s influence in the international organisation. These activists believed that this placed the AMA in an excellent position to promote free market-focused approaches to health care delivery, internationally.
The topic of Steve Biko’s death in detention has received considerable attention and it has served as an important case study in discussions of medical ethics and the nature of racial discrimination in apartheid era medicine.Footnote 4 Similarly, the diverse array of anti-apartheid health-related non-governmental organisations has also been an area of interest to historians of medicine.Footnote 5 Biko’s death in detention and the contours of health politics within South Africa in the period examined in this article are very important topics which continue to merit attention in their own rights. This paper, however, takes a different, transnational historical angle on these events and, instead, focuses on the impacts of racism in South African medicine upon the internal politics of an IHO.
While there is a small literature dealing with the history of the WMA, scholars have tended not to discuss its controversial stance during the 1976–94 apartheid era in detail. Instead, studies have predominantly focused on how the organisation’s ethical projects were shaped by post-war revelations that some European physicians had perpetrated Nazi atrocities, as well as on its declarations and role in formalising ethical standards for research involving human subjects.Footnote 6 A critical exception to this is Laurel Baldwin-Ragaven et al.’s book An Ambulance of the Wrong Colour, which is based upon testimony given at the Health Sector Hearings of South Africa’s Truth and Reconciliation Commission (TRC) in 1997.Footnote 7 But while Baldwin-Ragaven et al. briefly mention the controversy around the MASA’s readmission to the WMA in 1981, they do not provide a detailed analysis of the development of domestic and transnational advocacy against it.
Such multi-country advocacy can be understood within a wider framework of transnational activism, which Margaret Keck and Kathryn Sikkink have termed ‘activism beyond borders’.Footnote 8 According to Keck and Sikkink such transnational activism occurs when activists based in different countries communicate, share resources and work together to press for changes to policies of which they are critical.Footnote 9 There is a rich literature on transnational anti-apartheid activism, which points to the importance of shared, morally resonant framings of apartheid in generating support for the anti-apartheid movement in diverse countries. For example, Håkan Thörn has argued that exchanges of information, knowledge and symbolic practices between activists in different countries were key activities in the transnational anti-apartheid movement.Footnote 10 Similarly, Audie Klotz has argued that the enforcement of an international norm of racial equality – promoted by anti-apartheid activists – led to the isolation of South Africa.Footnote 11
Focusing on the influence of transnational anti-apartheid health activism on the internal politics of the WMA, this article develops the literature on transnational anti-apartheid activism in general by describing activists’ roles in opposing racism in international medicine. The transnational anti-apartheid health activism discussed here is relevant to our understanding of IHOs in the enforcement of medical ethics. In particular, it points to the deficiencies of an international medical professional association such as the WMA as an adjudicator of last resort in a case where serious human rights violations had been perpetrated by physicians.
2. Background: The MASA’s Resignation from the WMA in 1976
The WMA was founded in Paris in 1946. The MASA was a founder member association and attended the WMA’s first General Assembly in 1947. This IHO had a range of objectives including upholding the reputation and interests of the medical profession and assisting the world’s people in attaining an improved state of health. The fledgling association quickly developed codes of medical ethics and established a relationship with the WHO. From its earliest days, the WMA was dependent upon funding from the American Medical Association (AMA) for its financial survival and a substantial proportion of this came from the leaders of US pharmaceutical companies.Footnote 12 Among the ‘principles of social security’ the WMA adopted in 1947 were the ideas that all medical services should be controlled by physicians, and that doctors should not be full-time salaried servants of the government or social security bodies – a position which was very similar to that taken by the AMA in the 1950s and 1960s.Footnote 13 The AMA was also plagued by racial conflict in this period: its 1968 conference was interrupted by Civil Rights activists who expressed their opposition to the exclusion of black physicians from membership of some southern chapters. It voted to end such discrimination at the same gathering, however, perceptions that racism lingered in the organisation persisted among many black physicians.
In 1972 the AMA left the international medical body because of what Tessa Richards has framed as ‘disagreements over funding and voting strengths’.Footnote 14 The withdrawal of the Americans from the organisation caused a crisis of legitimacy – the Soviet Union had never been a member and the People’s Republic of China had no presence in the organisation and so with the AMA’s exit, it did not include doctors from three of the world’s great powers. The departure of the Americans also influenced the Canadians in their decision to leave. In 1974 the organisation moved its secretariat from New York to Ferney-Voltaire in France.
From the mid-1970s there had been increasing efforts by certain governments to isolate South African professional organisations, including its Medical Association because of its government’s policy of apartheid. In 1975 the Japanese government refused South African delegates visas to visit the country to attend the World Medical Assembly which was held in Tokyo that year. The MASA expressed its fury at its representatives being declined visas by the Japanese government by arguing that ‘As a founder member of the WMA, in good standing’ it had an ‘absolute right to be allowed to attend all World Medical Assemblies’.Footnote 15 The following year, the Ghanaian government followed suit when Ghana hosted the World Medical Assembly.Footnote 16 That same year, 1976, the MASA resigned from the WMA in disgust at this diplomatic pressure.Footnote 17
In 1979, after negotiations with the Belgian surgeon Dr André Wynen, who was then the part-time secretary-general of the WMA, the Americans re-joined, on condition that the international medical body changed its bylaws so that the number of votes a national body had within the IHO depended upon the number of members it had declared – i.e. paid for.Footnote 18 This meant that a wealthier nation such as the US with more doctors who were potential members of its medical association (in this case, the AMA) had far more votes at the WMA than a less affluent country such as Nigeria, with a medical association which was poorer by virtue of having fewer members. By 1983 the USA had thirty five votes, West Germany fourteen, Japan fourteen and the rest of the forty-seven member countries had only one or two votes each.Footnote 19 As shall be demonstrated, this disparity in national member associations’ voting strengths within the WMA was controversial in the case of the vote to readmit the MASA to the international association.
3. The Biko Doctors’ Controversy within South Africa
The dispute over the role of physicians in relation to Biko’s maltreatment and death in detention was central to the development of a rift within the WMA over apartheid. The Soweto uprising of 1976 was inspired by Biko’s Black Consciousness (BC) writings. Biko had studied at Natal University’s Medical School, whose student-body was all black.Footnote 20 On 18 August 1977, Biko was detained under the Terrorism Act No. 83 of 1967. This legislation broadly criminalised extra-parliamentary opposition as it defined ‘terrorism’ as consisting of any act aimed at changing the economic or social system or fostering animosity between the races. Biko died from brain injuries at a Pretoria hospital twenty-six days into his detention. The depth of the international outrage over Biko’s death in detention and the wider crackdown on anti-apartheid opposition which had occurred post-Soweto was also reflected in the United Nations Security Council’s unanimous vote in favour of Resolution 418 which instructed states to stop supplying armaments to South Africa.Footnote 21
In November 1977 an inquest was held into Biko’s death in detention in which no one was found responsible for the loss of his life.Footnote 22 The presiding magistrate referred part of the evidence which had been presented to the South African Medical and Dental Council (SAMDC, hereafter referred to as the Medical and Dental Council). In terms of section 45 of the Medical, Dental and Supplementary Health Service Professions Act No. 56 of 1974, courts were to send the Council evidence which appeared to implicate doctors in having engaged in ‘improper or disgraceful’ professional conduct.Footnote 23
A group of physicians also lodged a complaint with the Medical and Dental Council about the behaviour of the two doctors, who had treated Biko in detention. This group consisted of members of the black Transvaal Medical Society and physicians with relevant specialist expertise who supported the organisation, including the head of a renal unit, a general medical lecturer and a neurosurgical registrar. The Transvaal Medical Society was ‘a voluntary organisation’ of black ‘medical doctors, dentists, pharmacists, nurses and paramedics’.Footnote 24 Their complaint was largely based upon evidence given at the inquest by the doctors who had treated Biko. The black Medical Society and their physician supporters argued that ‘a reading of the inquest record clearly shows a prima facie case of improper and/or disgraceful conduct on the part of Lang and Tucker’, the doctors who had treated Biko in detention.Footnote 25
Three years after Biko’s death, the Medical and Dental Council reached a decision on the anti-apartheid doctors’ complaint. On 24 April 1980, the Committee of Preliminary Inquiry of the Medical and Dental Council found that there was no prima facie evidence of disgraceful conduct by the doctors involved in Biko’s care. Jonathan Gluckman, a private pathologist based in Johannesburg, had performed a post-mortem examination on Biko’s body at the request of his family. Gluckman was also a member of the Federal Council of the MASA, to which he sent a letter signed by thirty-eight of its members calling for it to conduct an inquiry into whether Tucker was fit to remain a member of the organisation.
A critical component of the dispute which evolved over the Medical Association’s presence in the WMA was the decision the South Africans subsequently took on this issue. The Cape Midlands Branch of the MASA discussed the issue and found that ‘a charge of unethical conduct’ against Dr Tucker could ‘not be sustained’ and ordered that the case be closed.Footnote 26 Following the Cape Midlands Branch’s decision on Tucker, the Federal Council of the MASA decided that as far as it was concerned the case was also constitutionally and legally closed.Footnote 27
4. The AMA’s Campaign for the South Africans to Rejoin the WMA
In August 1980, a month after the MASA closed the case against Tucker, the AMA extended an invitation to their South African counterparts to attend their annual meeting in Chicago. Dr Marais Viljoen, the Secretary-General of the MASA was quoted in a South African newspaper as having said that ‘The friendly invitation of the A.M.A. to attend their meeting in Chicago later this year is an indication of the acceptance of South Africa in medical circles’.Footnote 28 The same report stated that there ‘were also indications that the AMA would be sending a delegation to South Africa in the near future to examine the system of medical services there’.Footnote 29 According to an article in one of the MASA’s publications, Dr Wynen, the head of the WMA, also apparently offered his support for the MASA.Footnote 30 MASA representatives who attended the Chicago meeting found that
The only false note sounded during the meeting, as far as SA [South Africa] is concerned, took place during a meeting of the American Medical Association’s Board of Trustees which had been requested by the Secretary of the Nigerian Medical Association, Dr Beko Ransome-Kuti, during which he criticised SA [South Africa] for its alleged policies of discrimination against blacks in general and black doctors in particular. The criticism was, however, short-lived when the AMA trustees pointed out to him that many of them had been to SA and that his facts were incorrect.Footnote 31 Ransome-Kuti of the Nigerian Medical Association was the brother of the famous musician Fela Kuti, and publicly shared his anti-apartheid views. Like his musician brother, the doctor was involved in broader activism for human rights and democracy in Nigeria. Both came from a family tradition of vocal civil society advocacy: their mother campaigned against unfair colonial taxation of women and their father had been an Anglican priest and founder of the Nigerian Union of Teachers.Footnote 32
In February 1981 a group of the AMA’s office-bearers visited South Africa.Footnote 33 Dr Jack Sammons, the Executive Vice-President of the AMA said that ‘the world’s best medical services were to be found in the US, South Africa, Canada and Australia, with West Germany following closely’.Footnote 34 An article translated from the largely pro-government Afrikaans-language Die Burger by anti-apartheid health activists provided a similar picture of Dr Sammons’s impressions of South Africa during his visit and quoted him as having said ‘In South Africa we can learn a lot about various aspects of medical care, such as financing, manpower utilisation and the organisation of a complex such as Groote Schuur [a large teaching-hospital in Cape Town], which has many services’.Footnote 35
Such a position bore critical similarities to the concept of ‘constructive engagement’ which was an approach to US foreign policy towards South Africa developed by Dr Chester Crocker, the Assistant Secretary of State for African Affairs in the Reagan administration.Footnote 36 At the core of constructive engagement was Crocker’s optimism that the administration of President P. W. Botha was meaningfully and incrementally reforming the apartheid system, developments which were thought to be deserving of encouragement by means of maintaining a friendly relationship with leaders of the South African government.Footnote 37 This policy was criticised by its opponents as overly circumspect about the possibility of offending Pretoria and insufficiently informed of the demands of the black opposition. It was doubtless also shaped by the fact that South Africa was deemed by hawks in Washington DC to be a strategically important bulwark against the infiltration of foreign Soviet-aligned forces into the region of southern Africa.
An article in a South African journal by and for anti-apartheid health activists also published in February 1981 was much more critical of the AMA’s trip to the country. It noted that the visit by the AMA delegates was ‘in spite of an academic boycott on links with South Africa’, a boycott which had been called by various international organisations including the United Nations General Assembly, the Commonwealth Conference and the Organisation of African Unity.Footnote 38 The aim of such boycotts was to isolate South Africa financially, militarily, academically and in the arena of sports, and to thereby ‘exert peaceful pressure on South Africa to end apartheid’.Footnote 39 Anti-apartheid health activists who contributed to and edited the journal feared that the AMA delegation’s visit could have been ‘a prelude to M.A.S.A’s attempt to gain readmission to the World Medical Association and part of South Africa’s policy to seek credibility and acceptance in the international community’.Footnote 40 The AMA’s visit would ‘thus give the impression that South Africa and its health care are “not so bad” and that international contact will help promote change in this country’.Footnote 41
The South African anti-apartheid health activists feared that subsequent to the visit, the AMA would probably claim to have conducted its own ‘unprejudiced’ examination of medical care in South Africa and would offer to exert pressure on the South African doctors to make positive changes to the health system.Footnote 42 They correctly thought that the visit would focus on the adequacy of South Africa’s training of physicians and the quality of care provided in hospitals and private practice and not on whether the country’s health system met the needs of all its people. The anti-apartheid health workers suspected that the AMA delegation would not ‘come into contact with the migrant labour system, forced population relocation, the Bantustan policy and the oppression and unemployment that are the background to health problems in South Africa’.Footnote 43 Any report which would have resulted from the visit would have been inaccurate in the activists’ view and, therefore, they saw ‘little hope’ of any ‘meaningful change’ resulting from the Americans’ visit which they condemned as a ‘breach of the academic boycott’.Footnote 44 In the light of the Biko controversy, the anti-apartheid health workers were dismayed that The [AMA] group notably declined to comment on South African hospital overcrowding or the treatment of detainees, because of their “lack of knowledge” [my emphases]. This was the type of response we expected from this group and it is obvious they ignored (or were not shown) the desperate lack of health facilities in rural areas and black urban areas.Footnote 45
In August 1981, with the September meeting of World Medical Assembly in Lisbon a mere month away, anti-apartheid activists from various countries swung into action to counter-act what they saw as the AMA’s campaign for the readmission of the South Africans to the WMA. The anti-apartheid American Committee on Africa sent a memorandum to the British Anti-Apartheid Movement’s Health Committee on the issue in August 1981, in which they outlined their opposition to the South Africans’ proposed readmission to the WMA.Footnote 46 They pointed out that the country’s Medical and Dental Council had taken two and a half years to reach a ruling on the Biko doctors and had seen no reason for disciplinary action against them.Footnote 47 Then they asked for their British counterparts to join them in opposing the AMA’s expression of support for the South Africans’ readmission and argued that ‘To allow them back into the world body would be to condone both racism and the operation of a vicious double standard in the application of the Hippocratic Oath’.Footnote 48
Similarly, in August 1981, the Nigerian Medical Association had lodged a complaint with the Australian embassy in London about the latter’s national Medical Association’s support for their South African counterparts.Footnote 49 The Australian government joined the anti-apartheid groups in opposing the AMA’s support for South Africa’s readmission to the WMA. The Australian Medical Association’s president Dr Lionel Wilson was quoted as having said of their support for the South Africans’ bid for readmission to the WMA that ‘it was a difficult decision to make’ but the Australian body had decided to support colleagues in South Africa because they believed that ‘solutions to SA’s [South Africa’s] racial problems’ were ‘most likely to come through the efforts of compassionate, educated people who have been exposed to world opinion’.Footnote 50 Indeed, Wilson argued that ‘We [the Australian Medical Association] believe Masa is one of the few liberal organisations in SA [South Africa]’.Footnote 51
In September 1981 it was reported that the British Anti-Apartheid Movement had sent to the Portuguese embassy in London a memorandum written by fifteen anti-apartheid organisations and addressed to all the WMA’s members, which had had to be smuggled out of South Africa.Footnote 52 According to the report, when the WMA considered the proposal to admit the Transkei Association and readmit the South Africans, the medical associations of Nigeria, Ghana and Liberia threatened to leave the world medical body.Footnote 53
The strength of opposition to the South Africans’ readmission by many Africans from other nations on the continent was demonstrated by a position paper on the issue which was written by two Nigerian physicians, Dr O. O. Adekunle and Dr Beko Ransome-Kuti and sent to the British Anti-Apartheid Movement. Adekunle and Ransome-Kuti contrasted the opposition of the Nigerian, Liberian and Ghanaian medical associations with the visit to South Africa of the AMA delegation who, they thought, ‘were perfectly happy with the conditions there [in South Africa]’.Footnote 54 They then moved on to note that in their view there was a critical disjuncture between the WMA’s declarations and the MASA’s behaviour. By contrast, the MASA had been silent on human rights violations in the country, and, the Nigerian doctors went on to state that There is a saying that silence means consent 
$\ldots$ all evidence points to its acquiescence with discriminatory health policies of the apartheid government. The M.A.S.A. is obviously towing the line of its sister organisation the South African Medical and Dental Council which itself has only two coloured members in a country of over 80% non-white [people].Footnote 55
One of the memoranda sent by South African opponents of the MASA’s readmission to the WMA was penned by the Natal Health Workers Association. It outlined The role of MASA in directly and indirectly implementing the state’s policy of apartheid and thereby perpetuating this form of oppression against the majority of its citizens; the same policy of apartheid which the international community had committed itself to eradicate.Footnote 56 The Natal Health Workers’ Association accused the MASA of practising ‘apartheid medicine’ on ‘the majority of our people [black South Africans]’ and thereby violating ‘all codes of medical ethics’ and negating ‘all considerations of human rights’.Footnote 57 Its memo went on to describe key facets of apartheid medicine: systematic racial discrimination in medical training (fewer black doctors were trained); racial disparities in rates of mortality and disease and an unduly high death rate among black patients due to substandard provision of medical care for them, partly due to a shortage of health professionals who were employed to cater for their needs. The Natal Health Workers Association held that the MASA had failed to ‘uphold the highest traditions and ethics of the medical profession’ and to ensure racial non-discrimination in health care.Footnote 58 Therefore, it called on the WMA ‘and all its progressive and democratic members to reject the application by MASA for membership’.Footnote 59
MASA office-bearers hit back against their black critics who opposed the association’s readmission to the WMA by attacking their credibility. In the days leading up to the vote on South Africa’s readmission to the world body, Dr Marais Viljoen, the secretary-general of the MASA was quoted as having asked of the black health groups ‘Who are they? Whom do they represent? What are their objectives?’Footnote 60 He apparently claimed that his organisation did ‘not condone the findings of the Medical and Dental Council regarding the conduct of the doctors treating Mr Biko, but ‘noted’ the council’s findings’.Footnote 61 Dr Viljoen was also said to have rejected allegations that the Medical Association had ‘not maintained its objectives or upheld the highest traditions and the ethics of the medical profession’.Footnote 62
This transnational campaign against the South Africans’ readmission to the WMA proved unsuccessful and the breakdown of votes on 25 September 1981 was reported as follows:
∙ Australia, Belgium, Brazil, Cuba, Taiwan, West Germany, Italy, Japan, Portugal and the United States voted in favour of South Africa’s readmission.
∙ France, Korea and Spain abstained.
∙ Ten votes recorded against the MASA which were mostly African and Asian countries, including India.Footnote 63
Professor Guy de Klerk, speaking on behalf of the MASA, said that it welcomed its readmission to the WMA as a ‘recognition of the high standards of medical ethics and care in the country’.Footnote 64
Anti-apartheid activists in Britain swung into action to denounce the outcome of the WMA’s vote. This was yet another example of transnational anti-apartheid activists challenging the moral authority of the Nationalist government and civil society groups perceived as being aligned to it. In late September 1981, Dr Johnny Fluxman of the British Anti-Apartheid Movement’s health committee argued that ‘The WMA voting system enables a handful of Western countries to dominate the organisation and stifle any criticism by Third World countries’.Footnote 65 He also pointed out that it did not represent any African, Scandinavian or socialist countries, and that countries such as ‘Taiwan and Transkei, not recognised by the UN’ were members.Footnote 66 Fluxman added that fifteen anti-apartheid organisations within South Africa had written to the WMA asking it not to readmit the country’s Medical Association but, ‘Instead approval has been given to MASA and its cover-up of the murder of Steve Biko, and to South Africa’s Bantustan policy—the Transkei Bantustan has been admitted as a member alongside MASA’.Footnote 67 He concluded his letter by calling upon the British Medical Association (BMA) to resign from the WMA, noting that they had already stated their opposition to the South Africans’ readmission.
Meanwhile, within South Africa, there were reports in early October that groups such as the black Transvaal Medical Society feared that ‘the acceptance of Masa into the WMA’ would lead to ‘other South African organisations clamouring for international recognition’ putting up a ‘relentless fight’.Footnote 68 For black medical bodies such as the Transvaal Medical Society, apartheid and ‘oppression’ violated ‘all codes of medical ethics’ and the MASA, ‘being a predominantly white body’, had ‘directly and indirectly condoned this state of affairs’.Footnote 69 The society also held that the WMA’s re-acceptance of the MASA would ‘forever be regarded a breakthrough for apartheid and oppression of the black majority of the country and a damning and adverse blow to resistance against the status quo and domination of man by man’.Footnote 70
The newly readmitted MASA covered the issue in an editorial in its journal, the South African Medical Journal, published on 10 October 1981.Footnote 71 The journal reported that the breakdown of votes was seventy-seven in favour of its readmission, with ten against, and eight abstentions were registered.Footnote 72 The MASA thought that the Lisbon Assembly would rather be properly remembered as ‘an assembly of doctors concerned with the practice of medicine and not infrequently in conflict with politicians (as papers read at the scientific sessions later in the week amply demonstrated). We are sure that the MASA has a contribution to make to this body and that the WMA will in no way be weakened by its presence’.Footnote 73 As the controversy over the South Africans’ involvement in the WMA deepened, the idea that a cordon sanitaire could be imposed between medical ‘ethics’ and ‘politics’, would continue to be asserted by the MASA and their international supporters.
Four months later, in January 1982, the issue was considered by the Executive Board of the World Health Organisation (WHO). The WHO was one of many UN agencies which had restricted South Africa’s membership since 1960 after agitation by the newly independent African states.Footnote 74 On 20 January 1982, H.E. Alhaji Yusuff Maitama-Sule, Nigeria’s representative to the UN who also chaired its Special Committee on Apartheid (established in 1964) sent a telegram to the Executive Board of the WHO on the matter of the MASA’s readmission to the WMA.Footnote 75 Maitama-Sule accused the WMA of violating article II of the International Convention on the Suppression and Punishment of the Crime of Apartheid of 1973: this convention defined apartheid as being a ‘crime against humanity’. The Nigerian diplomat held that apartheid was an ‘evil system’ which the ‘non-white world’ had played a leading role in opposing because it represented an ‘affront to their recently won freedom, independence, and I dare say, human dignity’.Footnote 76 He went on to add, ‘Let me take advantage of this appearance before WHO and eminent doctors to state that we in the Special Committee, and I might add in the Organisation of African Unity, consider the role being played by the MASA and WMA as not being too different from the role played by many Nazi doctors during the Second World War’.Footnote 77
Maitama-Sule then said that when ‘the time of retribution’ came, ‘the example of Nuremberg’ would ‘not be lost on the United Nations and the African people’.Footnote 78 He ended by calling on the WHO Executive Board to terminate its relationship with the MASA and the ‘so-called Transkei’.Footnote 79 An African diplomat to the UN was publicly equating the actions of the WMA, an organisation which was set up in the wake of the Nuremberg trials and which had the promotion of medical ethics as one of its core aims, with those of Nazi doctors. The WMA’s credibility as the keeper of the medical ethical creed was under serious attack at a critical international health institution.
The WHO’s Executive Board voted to discontinue official relations with the WMA on 27 January 1982 by twenty-seven votes in favour, one vote against (the US) and one abstention.Footnote 80 This decision was reversible provided the WMA expelled the South Africans. In subsequent years, this decision would be cited repeatedly by anti-apartheid activists to show that the WMA had suffered a loss of prestige and was out of step with established international norms of racial equality in relation to how to deal with its South African member organisation. By this period, there was an increasing enforcement of such norms, internationally.Footnote 81
5. The South Africans Re-enter and the British Exit
On 5 February 1982, Dr Neil Aggett a young physician and trade union organiser died in Johannesburg after having spent seventy days in detention without trial. Meanwhile, shortly after their readmission to the WMA, the South Africans were soon nominated and elected for some of its key positions. Remarkably, that same month, Dr C.E.M. (Marais) Viljoen the MASA’s Secretary-General was elected to the Council of the WMA and nominated to its medical ethics committee: a nomination he described as ‘of major importance to the South African medical profession, whose medical ethics have frequently been questioned at an international level’.Footnote 82 This was a position to which he was appointed in 1983.Footnote 83 Viljoen was alleged by anti-apartheid activists to be both a National Party supporter and a long-time member of its inner conclave, the secretive broederbond.Footnote 84
With an unsuccessful campaign against the South Africans’ readmission behind them, the Health Workers’ Association (formerly the Transvaal Medical Society) re-strategised and also began to campaign against the WMA itself. At its national meeting in May 1982, an anonymous activist gave a speech on the WMA’s history, a summary of which was kept by the organisation.Footnote 85 The full, written version of the speech is worth discussing at some length as it reveals what some anti-apartheid health workers based within the country thought the socio-economic and political forces were behind the AMA’s campaign for the readmission of their South African counterparts. The activist cited an article published in the South African Medical Journal in 1951 to claim that the best financial support for the WMA had come from ‘the great pharmaceutical firms of the United States’ many of which, as we have seen, had close ties with the AMA.Footnote 86 The activist thought that
The implications are obvious. USA through the AMA, attempted to impose its hegemony on the WMA since its inception. The global advantages for the multinational pharmaceutical industry of an American dominated WMA are obvious. Their close association with AMA would enable them to come into contact with the medical profession from many countries to whom they could promote their drugs. Furthermore, health programmes and policies that were compatible with the financial interests of American capitalism would be promoted at a global level in the WMA.Footnote 87 The anti-apartheid health activist went on to argue that part of the impetus behind forming national medical associations was to block or slow the formation of national health services.Footnote 88 The WMA had likewise critiqued the ‘barefoot doctor’ concept in the 1960s.Footnote 89 The author also argued that exiled Cuban doctors in Miami had represented Cuba in the WMA since 1959.Footnote 90
In the document’s ‘Conclusions’ the anti-apartheid health activist claimed that the WMA was an organisation which was ‘not truly representative of the world medical profession’ because less than a third of the world’s countries had medical associations affiliated to it.Footnote 91 The activist went on to argue that the WMA only allowed associations which were ‘independent’ of governments as its members and that this was ‘intended to exclude socialist governments from joining it’. The article went on to add that ‘this concept of “independent” is farcical as in most countries the medical associations are closely aligned with the state’.Footnote 92 This author again compared the WMA to the WHO, by stating that ‘While the WHO has made a significant contribution at an international level to the promotion of health care, WMA’s contribution to this sphere has been negligible’.Footnote 93 Without significant reform to the WMA’s structure it was unlikely to make a significant contribution, in the author’s view.
This activist viewed the WMA as being a ‘reactionary organisation’ which could not be ‘changed from within’ as the British Medical Association had apparently realised by this stage.Footnote 94 The Health Workers’ Association’s new strategy on this issue had to be to oppose both the MASA and the WMA at national and international levels.Footnote 95
By July 1982 the British Medical Association (BMA) had officially terminated its relationship with the MASA. In a letter to the editor of the South African Medical Journal, Dr Jonathan Gluckman outlined his version of what had caused the termination of the relationship.Footnote 96 As we have seen Gluckman had performed a post-mortem examination on Biko’s body and was also a member of the Executive Committee of the MASA and he met with the BMA council’s Executive Committee to discuss its decision to terminate its relationship with the MASA. Gluckman was a fierce opponent of the termination of the BMA’s relationship with the MASA and following his meeting with representatives of its Council he claimed that the British association – which [he said] was part of the Trades Union Congress – was ‘dominated by the politics of the extreme left in Britain, and that the effect of this is to erode the structures of the BMA to the same extent as it has eroded the structure of Great Britain’.Footnote 97 He claimed that ‘So vicious had been the attitude of the Council of the BMA’, that its representatives for the then upcoming meeting of the WMA had been instructed to vote against the readmission of the South Africans and ‘not to be influenced by any debate or arguments to the contrary which might have been forthcoming [his emphasis]’.Footnote 98
In July 1983 Dr Antonio Gentil Martins, the Portuguese President of the WMA was one of the guests of honour at the fifty-fourth meeting of the MASA in Cape Town. Also in attendance were representatives from the American Medical Association (the AMA) and the West German Medical Association. The presence of these representatives of the WMA reflected the fact that two years earlier the South Africans had been readmitted to the international medical association. Following his visit to South Africa, Dr Martins spoke highly of the South African medical profession, and, according to an anti-apartheid activist newsletter, he had said, ‘We found that the quality of health care available to all races was completely equal’.Footnote 99 He then apparently went on to argue that ‘providing medical infrastructure’ was a political issue and ‘not the responsibility of the profession’.Footnote 100
This was Dr Martins’s second visit to South Africa. On his first visit to the country, the Portuguese surgeon had been quoted as having defended the MASA’s controversial approach to the scandal surrounding Biko’s death in detention discussed above. Martins added that ‘the only member of Masa involved in the affair had been exonerated of all blame. Masa therefore could not be held responsible for the treatment of Mr Biko’.Footnote 101 He claimed to be familiar with the problem of overcrowding in South African facilities and apparently said that ‘Providing the infrastructure for adequate medical services was a political issue and not the responsibility of Masa’.Footnote 102
Martins had seen the same technology available in hospitals serving black people and those serving whites and he apparently claimed that ‘I saw no difference as far as the quality of care was concerned’.Footnote 103 He was also quoted as having argued that the low standard of education and ‘lack of family planning’ among black people were ‘among the worst problems facing South African medicine’.Footnote 104 Martins apparently went on to say that ‘No country can afford to provide hospital beds for a population growing as rapidly as that of South Africa’s Blacks’.Footnote 105 Such a racist, neo-Malthusian argument that the poverty experienced by Africans was their own fault due to their supposed uncontrolled fertility was a key element of apartheid thinking, as evident in the South African government’s disproportionate spending on the promotion and provision of family planning when compared to their spending on the other health services for black people, including maternal and child health services.Footnote 106
The MASA had invited representatives to attend the same 1983 Congress, and the president of the AMA, Dr Frank J. Jirka ‘said that health services in this country [South Africa] compared favourably with those in the United States of America’.Footnote 107 One of the delegates was Dr James H Sammons (the Executive Vice President of the AMA, as mentioned above) who was ‘named the leading medical personality in the USA for 1983 by the Times US News and World Report’, inter alia, referred to the MASA’s report on the medical treatment of prisoners and detainees.Footnote 108 He said the MASA had done a ‘superb job’ and he hoped that the recommendations would be favourably considered by the authorities’.Footnote 109 Dr Sammons argued that the maltreatment of prisoners also occurred in America and he said ‘Unfortunately it happens far too often, and although there are problems, it is not excused by the problems’.Footnote 110
There was yet another call by the MASA’s supporters to separate ‘ethics’ from ‘politics’. Dr Horst Bourmer of the West German Medical Association apparently held that ‘doctors, as doctors, should never become involved in politics, but should concern themselves with the improvement of medical care only’.Footnote 111 Bourmer called for governments to grant medical associations autonomy on professional matters and then was quoted as having said that On the other hand I believe that [the] exclusion of medical associations from international medical politics because of the policies of their governments is discrimination at its worst. “Humanity and fraternity” should be the motto of all who belong to the medical profession.Footnote 112
6. The Campaign Against the 1985 Cape Town World Medical Assembly
At its October 1983 meeting in Vienna, the WMA decided to hold its 1985 Assembly in Cape TownFootnote 113 On a clear day Robben Island – a potent symbol of racial discrimination – was visible in the distance from many parts of the city. Robben Island contained a prison where several opponents of apartheid remained detained and whose most famous resident just over a year before had been Nelson Mandela, who had recently been moved to Pollsmoor Prison on the mainland, just outside Cape Town. In this context, at its first annual national conference in Durban from 5 to 6 December 1983, the new anti-apartheid National Medical and Dental Association (NAMDA) resolved to oppose Cape Town’s hosting of the WMA.Footnote 114 The new association aimed to unite all South African doctors and dentists opposed to apartheid in one nationwide organisation. Unlike the MASA, NAMDA was affiliated with the United Democratic Front (UDF), a national anti-apartheid civil society coalition.
On 5 January 1984 the British Medical Association announced its decision to leave the WMA. Its press release quoted its secretary Dr John Harvard as having said that the ‘confidence’ of British doctors had been ‘eroded’ by a series of events which had cast doubt on ‘the ability and willingness of WMA to provide an international, representative forum for the resolution of important medical, professional and ethical issues’.Footnote 115 The press release mentioned that an ‘undemocratic voting block system’ had resulted in the South Africans having been readmitted to the international medical association …against the wishes of the majority of countries belonging to WMA, even though certain important issues affecting its application for re-admission had not at that time been resolved. These issues included the failure of the MASA to adequately investigate the conduct of certain doctors who had examined Steve Biko before his death in police custody.Footnote 116
The statement noted that the British Association had tried ‘to reform the WMA constitution from within’ in the years subsequent to South Africa’s readmission.Footnote 117 It also noted that the WHO had withdrawn consultative status from the WMA over the issue and questioned the representative legitimacy of members such as the Transkei Association and the Cubans who were represented by the Free Doctors of Cuba based in Miami.Footnote 118
But British doctors were far from unanimous in supporting their national Medical Association’s stance on this issue. The Lancet’s brief coverage of the withdrawal of the British Medical Association from the WMA stated that its undemocratic voting system was at the heart of its decision on the issue.Footnote 119 It also reported that a group of British doctors had formed who continued to support the WMA.Footnote 120
Such dissenters within BMA on South Africa issue held views which were in keeping with a substantial slice of British public opinion. The Conservative Party government led by Margaret Thatcher had a policy which was in many respects similar to the ‘constructive engagement’ of their American counterparts. Moreover, in the early 1980s, cultural and economic ties between Britain and South Africa remained strong, despite calls for sanctions.Footnote 121
Back in South Africa, Dr R.D. Le Roex, Chairman of the Federal Council of the country’s Medical Association mentioned in his 1984 report for that body that it had hosted Dr Lionel L. Wilson, the WMA’s Council’s former chairman and past president of the Australian Medical Association.Footnote 122 Le Roex expressed his appreciation for the role played by the MASA in supporting of improvement of medical care for South African political detainees. He stated how much he valued the South Africans’ ongoing membership of the WMA, as such ‘international contact’ was ‘essential if the lofty ideals of the WMA, viz. to achieve the highest international standards of medical education, medical science, medical art and medical ethics, and health care for all people of the world, are to be attained’.Footnote 123
Le Roex said that at the WMA’s meeting in Singapore the South Africans had had the chance to meet both those who were ‘well informed’ and ‘well disposed’ towards South Africa and its health services and those with the opposite opinion.Footnote 124 In his view their opponents were ‘frankly hostile to the system of government in South Africa and consequently also to our health care system and to the MASA’, a position which he viewed as being based on ‘ignorance or misinformation, much of which is deliberately disseminated from this country by misguided colleagues [NAMDA]’.Footnote 125 He saw NAMDA’s call for a boycott of the Cape Town Assembly as based upon a ‘malicious misrepresentation’ as the invitation was not ‘a political statement of any kind’.Footnote 126 By contrast, the MASA’s Chairman said that the South African government’s only involvement would be the granting of visas to ‘bona fide delegates’.Footnote 127
In late 1984 there were dramatic broader developments in the country’s popular politics, which had also important effects on anti-apartheid activism abroad. There was a new wave of popular protests in several townships across the country which involved the civic associations and activists aligned to the UDF and in many countries in the West images of police brutality towards the demonstrators were broadcast on television news, which broadened opposition to apartheid.Footnote 128 In November 1984 the Anglican Archbishop Desmond Tutu – an outspoken critic of apartheid – was awarded the Nobel Peace Prize. Tutu made a strong impression in the United States and his Nobel win was associated with more radical and popular American anti-apartheid activism as represented by the civil disobedience actions of groups such as TransAfrica led by Randall Robinson.Footnote 129
on 5 February 1985, three hundred physicians and other health professionals marched on the South African embassy in Washington DC – five of whom were arrested and later released.Footnote 130 Some of the thinking behind this growing US opposition to apartheid in South African medicine is suggested by a guest editorial published in the Journal of the National Medical Association in July 1985. The National Medical Association was an organisation which represented African-American physicians and members of the communities that they served. Charles H. Wright began his article stating that Dr Philip M. Smith, the President of the National Medical Association, had asked members to join him in protesting the proposed Cape Town meeting of the WMA. He then moved on to discuss the scandal around Biko’s physicians’ collusion in his torture in detention and noted that while the National Medical Association’s journal had covered the issue and ‘While many of the world’s medical societies reacted with revulsion towards South Africa’s efforts to ignore and cover up this event, the American Medical Association’s officials reacted as if it was a non-event. The Journal of the American Medical Association did not mention the controversy’.Footnote 131
Wright pointed to the AMA representatives’ two visits to South Africa and also mentioned that in 1981 the American association had cast all its votes in favour of the country’s readmission. He then stated his view that while a campaign for a cancellation of the World Medical Assembly in Cape Town was ‘laudatory’, a ‘letter-writing campaign’ to the AMA would not have ‘intrude[d] on its loyalty to its colleagues in South Africa’.Footnote 132 He then called for National Medical Association members to stop paying for AMA membership because ‘a more certain way to make sure that Biko, a former medical student did not die in vain is to divest in AMA’.Footnote 133 He ended by stating that his ‘only regret’ was that he could not join in such a protest as he had already divested from the AMA in the late 1950s when the AMA ‘showed more concern’ for Hungarian and Cuban exiles than for black doctors.Footnote 134
The WMA’s membership dwindled significantly because of its position on South Africa. In 1985 it only had 35 national medical associations as members.Footnote 135 Doubtless at least partially due to such civil society pressure on the issue, the thirty-seventh (1985) World Medical Assembly was moved to Brussels, Belgium at short notice.Footnote 136 Meanwhile, a breakaway group was formed which consisted of the medical associations of Denmark, Finland, Iceland, Ireland, the Netherlands, New Zealand, Norway and Sweden, later joined by the British, Canadians and Jamaicans. According to an article published in the British Medical Journal in 1994, the group met annually and campaigned around demands such as:
∙ Member Associations of the WMA should be ‘truly representative’ of the medical profession in their country.
∙ Member Associations should be politically independent of their government.
∙ The WMA needed to have a ‘more democratic voting system’.Footnote 137
After a 1987 meeting of this group in Canada, the group became known as the ‘Toronto group’.Footnote 138
In Johannesburg, in November 1985, litigation launched by a group of medical academics at the University of the Witwatersrand resulted in a Supreme Court decision which forced the South African Medical and Dental Council to reconsider the case of Drs Tucker and Lang in relation to their treatment of Biko.Footnote 139 Tucker was finally deprived of his medical licence. Lang continued to practise, however, and was promoted to the position of Chief District Surgeon in Port Elizabeth. For the rest of the 1980s the NAMDA and the MASA remained bitter foes because apartheid itself remained at the very heart of their dispute.Footnote 140
South Africa was never expelled from the WMA. However, the international medical association apparently responded to some of the Toronto group’s criticisms by implementing certain reforms such as agreeing with the principle that member associations should be truly representative of doctors in their own countries.Footnote 141 It also switched to granting each member country one vote per 10 000 members instead of the previous one vote per five thousand members and resolutions on ethical issues now required a two-thirds majority of delegates present to pass.Footnote 142 Most of the Toronto group re-entered the WMA in 1991. The Nordic countries and Britain had ‘only just rejoined’ as late as 1995 when a Dr Anders Milton a Swedish nephrologist became new chairman of the WMA and stated his relief that with the country’s democratic transition it ‘no longer had the political problem of South Africa’.Footnote 143 Milton acknowledged that this had been the main reason why the British and Swedish Associations had left and pledged to ‘reach out to more countries’ and ‘ensure not only that ethical declarations are taught at medical schools and discussed by practising doctors all over the world but that they are in daily use’.Footnote 144 Transnational anti-apartheid activists’ efforts to isolate South Africa and morally delegitimise the WMA for failing to do so, therefore, had had a real impact on physicians’ support for an IHO in a number of countries.
In post-apartheid South Africa, the issue of the Biko doctors was re-examined in the Truth and Reconciliation Commission’s health sector hearings in 1997. In the spirit of ‘nation reconciliation’ the NAMDA and the MASA merged in 1998 to become the South African Medical Association (SAMA). Also in 1997, the South African Medical and Dental Council (SAMDC) became the Health Professions Council of South Africa (HPCSA) as part of a broader package of reforms to the bring the regulation of doctors’ activities into alignment with the human rights values espoused in the country’s new Constitution (1996).Footnote 145
7. Conclusion: Ethics and Medical Associations in South Africa and the World
Today, the WMA is an IHO best known for its ethical declarations, including the Declaration of Tokyo on physicians and torture. Yet, one of the clearest examples of the violation of this declaration occurred almost immediately after it was passed – the maltreatment of South African activist Steve Biko by his doctors, physicians whom the country’s medical association and Medical and Dental Council were extremely hesitant to discipline until the end of the main period discussed in this article. Less documented have been the circumstances around the readmission of the MASA and the subsequent exodus of a substantial group of the WMA’s members because of perceptions that it had exonerated apartheid medicine, including physician collusion in torture – a lacuna in existing literature that this article has aspired to make modest progress in addressing.
The moral authority of the WMA around the world also dwindled as physicians who were anti-apartheid activists in Britain, the United States and South Africa repeatedly denounced the organisation as racist and campaigned against it in the same breath as they opposed apartheid medicine. These transnational activists – or ‘activists beyond borders’ – shared information with each other, including information which helped to generate morally influential framings of racial discrimination in South African medicine.Footnote 146 Yet they were ultimately unable to successfully press for the WMA to reject the MASA as a member organisation. What they were, however, able to accomplish was a diminution in the moral authority of the IHO both among many physicians in different countries and several international health officials. They successfully drew attention to the fact that in the late twentieth century, senior office-bearers of an organisation fundamentally shaped to combat the horrors of Nazi medicine had condoned medical aspects of a system of racial discrimination which had been cast in international law as being yet another ‘crime against humanity’. These activists, thereby, managed to reduce the number of member associations and press the WHO to end its relationship with the WMA.
The WMA and its supporters on this issue derided their opponents as ‘politicians’ concerned with ‘politics’, whereas as physician ‘leaders’ they were concerned with providing ‘quality medical care’ and promoting ‘ethics’. Anti-apartheid activists rejected such a division by pointing to the racism in South Africa’s health system and a lack of political freedom to highlight it. Indeed, they drew attention to the fact that a former medical student (Steve Biko) and a doctor (Neil Aggett) were among the many activists tortured-to-death in detention. For such activists, these cases demonstrated that even health workers could not freely highlight issues of ‘ethics’ without risking being branded as being ‘terrorists’ with all the dire consequences that entailed.
The full reasons why the WMA not only bucked international trends to isolate South Africa by welcoming its medical association back into its fold but also promptly thereafter invited one the South Africans to sit on its ethics committee have yet to be explored in further research. What is hard to dispute is that the WMA and the AMA (its member with the largest number of votes) generated perceptions among opponents of apartheid that it had welcomed the South Africans back as part of a wider effort to pack the body with members who would uncritically support the AMA – an organisation with stances very different to those of the WHO on the ideal roles of physicians and the private sector in health systems. Some African-American physicians opposed to apartheid saw the controversy as the latest chapter in a long history of institutionalised anti-black racism within the American member organisation. The most charitable interpretation of why some national associations chose to support South Africa’s readmission is that they might have hoped to have won them over to incremental liberal reforms to end apartheid in the manner of Crocker’s constructive engagement.
Apartheid’s demise occurred almost two decades ago, but the notions that medical ethics should be depoliticised remain current. This article has discussed an important, under-examined, late twentieth-century example of racism in international medicine. Medical ethicists have observed that the WMA’s role as an international adjudicator is limited by the voluntary nature of its international professional ‘codes’ and ‘guidelines’.Footnote 147 The history offered in this article, therefore, suggests that transnational civil society actors must remain permanently vigilant to ensure that justice prevails in cases where physicians are accused of human rights violations.
