/ 8 February 2013

McCord Hospital: Defending a legacy of healthcare integrity

McCord Hospital served black people from a 'white area' during apartheid and survived all attempts to remove it.
McCord Hospital served black people from a 'white area' during apartheid and survived all attempts to remove it.

The people of KwaZulu-Natal have reacted with shock to news of the options faced by Durban's non-profit McCord Hospital: impending closure or a state take-over of this most important facility.

In the South Africa of the next century we can ill afford to lose winning institutions with the credibility of McCord. Faced with the news that they would lose their state subsidy,  McCord's leaders realised they either had to raise patient fees to the level of private hospitals or close.

It seems that despite its credibility and record McCord has now had to accept being taken over by the state. This loss of a third way for South African hospitals is enormous. If the idea becomes hegemonic that state money cannot be granted to well-managed and efficacious, self-run entities, we may all be the losers.

South Africa is in the midst of creating a new system of healthcare financing – referred to as the National Health Insurance (NHI) system – the stated goals of which are to ensure that everyone has access to appropriate, efficient and quality health services, phased in over a decade or more. In the policy document that inaugurated this commitment, and the subsequent national debate about the efficacy, methodology and cost implications of the NHI, much of it conducted in the pages of this newspaper, the history of South Africa's attempts at health reform are summarised.

Our country is portrayed as a society with a two-tier health structure (private and public) with inequitous divisions of race, region and class bias layered into place over the past century. Largely accurate, this summary ignores a massively important exception: the few mission-origin health institutions in South Africa that survived their takeover by Bantustan formations under the National Party's Balkanisation of the country in the 1960s. Pre-eminent among these is McCord Hospital.

The history of McCord Hospital is unique. For a century the hospital, its clinics, its educational and outreach and service divisions, have all occupied a remarkable place in KwaZulu-Natal and South Africa. McCord Hospital was the only institution in the country to survive all national and local attempts to remove an institution serving black people from a "white area".

McCord pioneered and developed new areas of health education and medical service for the poor in fields as diverse as occupational health, midwifery, tuberculosis care and,  most famously, in HIV treatment and care. Over and above this legacy of stoicism and innovation, McCord Hospital also occupies a prominent place in the history of South African health management systems and is seen locally and internationally as a progressive and pioneering locus of medical practice. Winning accolades from profit-generating medical groups as well as national bodies and international health advocates,  McCord Hospital has long provided an exemplary "third way" for the development of health institutions working in partnerships between sectors.

Nurse probationers
Always a non-profit hospital, McCord survived by charging minimal fees to patients (some of which were paid in kind rather than in cash), by continuous fundraising, and by providing services that the state needed – and thus obtaining a state grant in aid. This system was established more than 100 years ago.

In every round of state negotiations McCord has had to prove that its service has been of great worth to the people of the region and that it has been well managed. The value that McCord's staff and funding initiatives have added to the services received by state-aided patients has always been regarded as an asset and not a drain on the public purse. Even at the height of apartheid, officials conceded this.

Staff salaries and wages over the century have been below those of private and public sector levels. Nurses and doctors at McCord have repeatedly asserted the value and job satisfaction generated by the ethos and atmosphere of co-responsibility in the work culture of the institution.

Many of McCord's senior staff have been at the hospital for decades – some more than 30 years. They started off as nurse probationers, medical interns or junior support staff. This has been true for the five generations of committed people who built McCord over the century.

Affectionately known as McCord Zulu Hospital for many years, it was inaugurated 103 years ago on a high ridge overlooking the port city of Durban. It was first established as a dispensary and surgery through the efforts of the United States-born and trained Dr James McCord, his South African-born wife, Margaret McCord, and his nurse assistant and cultural broker, Katie Makanya.

This hospital was supported not only with funds from the progressive non-conformist Christians in the US in the Congregational Church (whose efforts also saw the establishment of the Inanda Seminary for Girls and Adams College), but also by the efforts, ongoing commitment and local fundraising efforts of the region's South African Indian business community, the Zulu royal house, professional black people across the region, a small but dedicated number of local white progressives and many generations of working-class women and men of the city of Durban and its hinterland.

McCord has been defended by some of South Africa's greatest leaders: supported by John L Dube, caring for many members of the ANC, the Indian Congresses, the trade union movement and activist groups in Durban's history, the hospital drew Chief Albert Luthuli on to its board in the 1940s.

From the 1960s to the early 1990s McCord was regarded as a beacon of hope for progressive health workers and professionals and stood in the face of yawning gaps between medical services for black and white South Africans.

Aids denialism
After 1994 new targeted donor funding from state, educational and civic groups in Europe, Canada and especially the US again channelled resources and powerful institutional linkages between McCord and the wider network of health and medical education and research.  McCord Hospital and its related institutions also created a platform for emerging leaders, boasting an illustrious alumni – including many of South Africa's current leaders in politics, business, medicine, nursing, education, science and the arts.

McCord's legacy is crucially that of an institution that used its independence to stand firm in the face of struggles against prejudice, and against epidemic diseases such as tuberculosis and HIV, with tenacity, necessitating the hospital's expansion.

From its early beginnings the hospital fostered the growth of progressive alliances, and these stood the facility in excellent stead as it faced the tsunami of HIV-related illnesses in the mid-1990s. The growth and development of the Sinikithemba Centre at McCord Hospital has been pivotal to research, the care of and medical treatment for people living with HIV, especially children, and provided a model for state services after the era of Aids denialism was shelved.

South Africa is a young country and an even younger democracy. We have very few institutions that have survived and grown for more than a century, and even fewer that have done so with their integrity and legitimacy intact in the face of segregation and apartheid, and through the birth pangs of our even younger democratic South Africa. And in the entire country there is only one health institution – McCord Hospital – that can boast this legacy.

The hospital pioneered a method of working with communities it served, civic groups, health activists, scientists and local and state stakeholders. This is a foundation that we should build on and respect, not undervalue.

Dr Catherine Burns is a historian based at Wiser, the Wits Institute for Social and Economic Research at the University of the Witwatersrand.

She is the co-author, with Dr Julie Parle and Dr Vanessa Noble of the University of KwaZulu-Natal, of a history of McCord Hospital that will be  published in 2013