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The election of a democratic, nonracial government in South Africa has moved the health needs of the majority of the population to center stage. In the search for precedents, health policymakers have turned to South Africa's pioneering of health centers and social medicine in the 1940s. This paper looks at the intellectual context in which these ideas were first developed; the particular political circumstances and relationships between doctors and the state in the late 1930s, which facilitated the establishment of health centers; the role that the health centers were intended to play in South Africa's wider postwar health plans; and the reasons for the centers' failure. Contrary to conventional wisdom, it argues that the failure of the health centers and the wider health plans predated the advent of the National Party to power in 1948, and resulted mainly from the marginalization of the centers as a low-cost option for the poor, which was itself a consequence of underfunding and the vested interests of local health authorities and private practitioners. (Am J Public Health. 1997;87:452459)
Introduction
Early in 1994, in the run-up to South Africa's first nonracial democratic elections, the African National Congress published its National Health Plan for South Africa. In it, the congress roundly declared, "The foundation of the National Health System will be Community Health Centres providing comprehensive services including promotive, preventive, rehabilitative and curative care."' This central recommendation not only reflected contemporary World Health Organization (WHO) thinking, but also echoed the ideas of the National Health Services Commission report published in South Africa 50 years before and rediscovered by public health activists over the previous decade.2 Progressive for its time, the report put South Africa into the forefront of social medicine in the 1940s and led Malcolm Macdonald at the Ministry of Health in London to exclaim, "This is a report that shows us what we should be doing!"3
The National Health Services Commission was appointed in 1942 under the chairmanship of Dr Henry Gluckman to look into South Africa's contemporary crisis in health and health care. Its brief was wide ranging: "to inquire into, report and advise upon the provision of an organized national health service in conformity with the modem conception of health which will ensure adequate mental, dental,...