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Discrimination against women in the South African medical profession
Sm. Sci. Med. Vol. 20, No. 12, pp. 12534258,
1985
0277-9536/85 $3.00+ 0.00 PergamonPressLtd
Printed in Great Britain
DISCRIMINATION AGAINST WOMEN IN THE SOUTH AFRICAN MEDICAL PROFESSION BERYLUNTERHALTER Department of Sociology, University of the Witwatersrand, 1 Jan Smuts Avenue, Johannesburg 2001, South Africa Abstract-The paper examines discrimination against women in the medical profession in the South African context. To measure the extent of the problem data was obtained from the records of one of the largest South African medical schools-the University of the Witwatersrand Medical School. This medical school is one of the most liberal in South Africa and does not discriminate against women in its admission policies and the number of women graduated as doctors has increased steadily. Despite this, women take a secondary place in the South African medical profession. Evidence for this was collected from official records and supplemented with guided interviews with 15 women doctors. Special attention is given to the serious under-representation of Black women doctors in South Africa.
INTRODUCTION-ANHISTORICAL OVERVIEW In all Western societies, doctors constitute an elite professional group highly respected and well remunerated because they perform one of society’s most essential functions-the definition and treatment of disease. Zola [ 1, pp. 487-5041 has also commented on the present-day extension of the doctor’s power and authority to many ‘non-medical’ areas of life which formerly were the preserve of the family, the church or the legal system. He calls this the medicalization of society and sees that in numerous situations, today, it is the doctor who is the final arbiter. The growth of the medical profession is of particular sociological interest as it illustrates the relationship between technological innovation and professionalization. It also illustrates the way in which important institutions, like medicine, replicate wider social, class and sex divisions within a society. This paper discusses discrimination against women within the profession, but this discrimination must be seen as part of the value system of the wider society in which it occurs. To understand the roles of women in medicine it is necessary to examine the historical antecedents of the modem medical profession as we know it. It would perhaps be salutary for many doctors to know that medicine did not always have authority and prestige. In pre-industrial Europe, doctors did not understand the underlying causes of most ailments, they had few cures and their rudimentary surgical techniques often maimed the patient horribly or led to death from shock or infection. In a world of casually-trained or untrained doctors, women frequently participated along with men in the provision of health care. Oakley [2, p. 231 suggests that the healing powers of Europe’s wisewomen or good women were often superior to those of the physicians of the day. The wisewomen had, according to Oakley, developed over the centuries a pharmacology of pain killers, digestive herbs and anti-inflammatory drugs. In their communities they were entrusted with delivering babies and caring for women after the birth of children. These functions gave them some knowledge of anatomy and made many of them into shrewd psycho-therapists. Oakley [2, p. 241 quotes from let-
ters and diaries written in pre-industrial England which comment favourably on the skill of the female healer/midwife in preference to her male counterpart. Thomas [3, p. 141is of the same view and quotes the opinion of Francis Bacon that “empirics and old women were more happy many times in their cures than learned physicians”. But the pre-emption of the medical profession by men was already under way. From the 14th century many European cities began to close their doors to all those doctors who did not have a university licence to practise medicine, thus automatically debarring women as they were not admitted to the universities. Thomas describes this process for the City of London when in 1518 the Royal College of Physicians gained the right to supervise and license all physicians practising in London and within a 7 mile radius of the city. The physicians were all university-trained men. However, the poor and the rural population continued to use their local wisewomen; qualified physicians were too few in number and too expensive for all but the gentry. Not that the services of the physicians ensured superior medical care to the upper classes. Sydenham, the greatest physician of the 17th century remarked that “many poor men owed their lives to their inability to afford conventional treatment” [3, p. 141.This was an age in which the patient was as likely to die from the cure as from the disease. It can thus be seen that even prior to the birth of a truly scientific medicine, the nascent medical profession has already established monopolistic practices along class and sex lines. This process continued with the great technological innovations in medicine beginning with the work of Pasteur, Lister and Simpson from the middle of the nineteenth century. Doctors now understood disease causation, had scientifically-based cures, as well as relatively safe surgical techniques. Qualified doctors were in demand in all strata of society and the medical profession started to reach the eminence and authority with which we are familiar. It was now that the more extensive ousting of women as healers, occurred. As medicine established an impressive body of scientific knowledge, it could only be imparted systematically at licensed medical schools, and in duly approved clinical teaching situations. The new medical schools
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BERYL UNTERHALTER
which developed in the nineteenth century continued along the lines of the older university establishments in excluding women. A recent book which analyses the position of women in American medicine from 1835 to 1975 is entitled “Doctors wanted-no women need apply” [4]. This indeed could have been the motto engraved over the doors of the medical schools of Britain and the United States of America. (British and American data have been used because they are easily obtained but it is unlikely that the situation was different in most European countries.) The medical profession based the refusal of entry on the unsuitabilityi of women for the profession. L’Esperance [5, p. 1181 says that the demand for access to medical education by women, beginning in the late 185Os, aroused the medical establishment to heights of greater anger and disgust than any other aspect of the campaign for changes in society’s attitude to women. According to this author the case against women doctors rested on the argument that menstruation and pregnancy made “women unfit to be entrusted with the life of a fellow creature” and secondly, that “female purity would inevitably be destroyed in women learning anatomy and physiology especially alongside male medical students”. The inconsistency of allowing the nurse access to patients was not confronted, but it demonstrates the way in which this ideology operated. Nurses were females in subordinate positions, perpetuating masculine hegemony and as such they represented no challenge to the medical profession. But a woman doctor would by the very nature of her work, step out of the female ‘servant’ role. One has only to contrast the bitter opposition to the woman doctor in the nineteenth century with the prefatory remarks in 1874 by a doctor in a handbook for hospital services. He wrote “Nursing is the medical work of women.. . it furnishes an outlet for the tender power and skill of good women of almost every class” [6, p. 1131. One is amazed at the persistence of women like Elizabeth Blackwell, who overcame all barriers and finally graduated as a doctor in the U.S.A. in 1849. She inspired Elizabeth Garrett to follow her into medicine in Britain, but for 12 years these were the only two women on the medical register on both sides of the Atlantic. As the 19th century drew to its close, a few more ‘token’ women entered the profession in Britain and the U.S.A., but their numbers remained negligible. Opposition did not come only from the medical schools. Queen Victoria threatened to withdraw her patronage from a medical conference if women were admitted and, as late as 1914, women doctors were only reluctantly accepted into the British Army Medical Services, provided that they were neither commissioned nor given any badges in recognition of their status [7, p. 261. It was not only the training and licensing of doctors that were controlled by the influential medical profession which established itself in Britain and the United States of America. The profession also extended its control to the allied health professions such as nursing, physiotherapy, occupational therapy and pharmacy. All of these (except the latter) were traditionally women’s areas of medicine. The last bastion to fall under male professional dominance was the occupation of the midwife. Women retained
control over midwifery until the last decades of the 19th century, mainly because men did not want this work. In 1827, the President of the British Royal College of Physicians said of obstetrics that “it was foreign to the habits of a gentleman of enlarged academic education” [2, p. 311 but eventually medicine had to concern itself with this important area of health. From 1886, British doctors were required to have a professional training in obstetrics and doctors took over the care of pregnant women and the delivery of babies. However, midwives were not totally eclipsed and in many communities, the poorer classes particularly in less developed countries, still rely on their services, while women of higher status engage the services of male doctors. It can be seen from this necessarily brief overview, that it is almost axiomatic in Western capitalist societies, that the higher the status of an occupation, the more likely it is to be exclusively male and middle class. (In societies where there are ethnic minorities, they too would be excluded from the higher status professions.) This is true not only of medicine but of the other senior professions like law, engineering, architecture and accountancy. Despite all the barriers to entry into medicine, women albeit in small numbers, have gained admission to the medical profession. To use Britain and the U.S.A. again as examples, women are 8% of American doctors and 22% of British doctors [7, p. 431 and it is expected in both countries that this proportion will increase considerably in the 1980s. There has been a substantial increase in the number of women students now enrolled in the medical schools-20% currently in the U.S.A. [8, p. 1911. This could only occur because the medical instutition has not been completely unyielding. There have always been in Western society, liberal values which recognise the injustice of excluding any individual from opportunities on the basis of race, sex or class. Since World War II there has been a fusion of liberal and interventionist ideologies resulting in a recognition of the need to redress social inequalities wherever possible. The medical profession has not been immune to these ideological shifts and the result has been increased opportunities for women and minority groups in the medical profession. (The experience of the United States in the 1960s has accelerated this process still further.) There is an additional factor-women have not been entirely passive in accepting discrimination in the medical schools, and their persistence has frequently won them the rights of admission. It is interesting in this context to note that the upward trend in the enrolment of women in the medical schools of Britain and the United States of America coincides with the growth of the women’s movement in both countries and the new consciousness this movement has promoted. As a matter of historical experience, the benefit has elevated the status of middle rather than working class women, but the consequences are undoubtedly there in the number of women who wish today to enter the medical profession. THE SOUTH
AFRICAN
SITUATION
What of South Africa? In this country where private
Discrimination
against
women
in the South
enterprise medicine is entrenched, it is financially rewarding to be a member of the medical profession. Doctors also have high status in their communities and these two factors make medicine a much soughtafter career. There is intense competition for entry into the medical schools and as in many other countries, both race and gender are important bases for discrimination. This can be illustrated by an examination of the percentages of South African medical graduates in the years 1980-1983. In this period Whites (17% of the total population) were 81% of the medical graduates, Asians (3.3% of the population) 8.3% of medical graduates, Coloureds (10% of the population) 2.3% of the medical graduates and Blacks (Africans) (70% of the population) 8.3% of the medical graduates. These recent figures for Blacks represent an improvement in the past 3 years. A new Black medical school, Medunsa graduated its first 38 doctors in 1982, but ministerial permission is still required for Black students to enter White medical schools and all the problems associated with socio-economic and educational disadvantage have resulted in a situation where South Africa has produced only 300 Black African doctors over 25 years. This is only 2% of the 21,000 doctors registered with the South African Medical and Dental Council [9, 542-5461. Women have fared somewhat better than Blacks and Coloureds as regards entry into the South African medical profession. In 1979 13.3% of all doctors were female. This figure will probably increase in the next decade, as 16% of all medical graduates were women in 1980, but the upward trend is not pronounced [lo, p. 11. METHOD
In order to test the existence of discriminatory practices which restrict women in the South African medical profession, the following enquiries were made: (i) the admission records, class lists and examination results of the University of the Witwatersrand Medical School (UWMS) were analysed*. This medical school is known to be the most liberal in South Africa with regard to admission and general policies. It would therefore provide the optimal conditions for women medical students; (ii) guided interviews were held with 15 women doctors practising in Johannesburg. There was no attempt to select these doctors by random methods. They were approached at a large general hospital and asked to assist with the investigation. No woman doctor refused the interview but the data from these interviews are impressionistic only?; (iii) the registers of doctors maintained by the South African Medical and Dental Association and the Medical Graduates Association were examined.
African
medical School, Professor P. V. Tobias, is gratefully acknowledged. tThe guided interviews and the data collected were carried out by a group of M.B.B.Ch 111 students as part of an elective in 1982 by the Department of ^ . project^ - supervised -. Soctology of the University of the Witwatersrand.
profession
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Statistics were also obtained from the South African Department of Statistics. Using the data from these three sources this paper examines the following aspects of discrimination against women in medicine in the South African context: (i) the selection of women students into the medical school; (ii) the attainment of women students within the medical school; These two sections draw largely upon the experience of one of the largest medical schools in the country, the University of the Witwatersrand Medical School (UWMS); (iii) sexual stratification among qualified doctors. (i) The selection of women students into the medical school In South Africa the propotion of women selected for entry into medical schools other than the UWMS varies between 20-30x. This figure was obtained by writing to all the South African medical schools for information. 5 out of 7 medical schools replied. Of these two acknowledged the existence of female quotas for entry into the first year-in one case women were restricted to 20% of the first year intake and in the other to 30%. (At the request of the medical schools concerned, their names have been withheld.) When no such quota system operates, as at the UMWS, there has been a steady increase in female admissions into the first year of study over the past decade. In 1973 women constituted only 10% of first year admission. By 1977 they were just over a quarter of the class (27%) and in 1982 a third (33%). Last year, 1983, the percentage had risen to 41.5% of the 220 students in the first year class and it is likely that parity will be achieved within the next few years. To what extent do these gains affect White women rather than Asian, Coloured or Black women? To assess this the admission statistics for a 5 year period for the UWMS were examined (Table 2). In interpreting Table 2, it must be pointed out that admission to the UWMS for all students, other than White is governed by ministerial consent and therefore reflects government policy rather than any racial discrimination in admission policy on the part of the medical school. There were years in which no Black students were admitted to the medical school and the table indicates a serious under-representation of Coloured and Black admissions of both sexes. It would be highly desirable to have a significant increase of Black and Coloured doctors, of whom at least a half should be women as the health problems of women
Table 1. Proportion of women accepted into the first year of the medical degree UWMS 1977-1983 Year
*The co-operation and encouragement of the Dean of the
medical
1977 1978 1979 1980 1981 1982 1983
y0 Women
in the first year 27.18 29.33 32.50 26.34 31.63 33.17 41.5
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BERYLUNTEWLAL~R Table 2. Distribution of first year students accepted into the UWMS 1977-1983 White
Asian
Women as a % of Total total Male
Female
Women as a % of Total total Male
Male
Female
1977 1978 1979 1980 1981 1982 1983 Total
194 189 192 169
53 59 59 46
247 248 251 215
21.4 23.7 23.5 21.3
9 12 9 32
3 3 4 9
12 15 13 41
25 20 30.7 21.9
2 2 4 9
-
113 121 85 1063
68 53 68 406
181 174 153 1469
37.5 30.4 44.4 27.6
14 17 19 112
3 12 9 43
17 29 28 15s
17.6 41.3 32.1 27.7
5 4 6 32
-
and children are among the most pressing in the Black and Coloured communities. Table 2 shows that Asian admissions over the 5 year period form a satisfactory proportion of the total (9.5%). Within their ethnic groups how do women fare? Table 2 shows that the percentage of female admissions does not vary greatly between the ethnic groups. From 1977 to 1983 White women were 27.6% of white admissions, Asian women 27.7x, Coloured 23.8% and Black women 25.4%. Over the past two years, 1982 and 1983, when White women have made their largest gains in admissions, the White and Asian female admissions are 37 and 36% respectively. The data does not lend itself to the drawing of any inferences about special discrimination which Black or Coloured women experience in medical school admissions, as their numbers are so small. (ii) Attainment of women students within the medical school From the examination results for final year students over a 5 year period (1977-1982) at the UWMS it seems that there was little disparity between male and female students. The average aggregate per student was 61.9% for females and 60.6% for males. Leeson and Gray [7, p. 461 report similar findings in British studies which show that women students perform as well or even slightly better in their examinations. Even more important than performance within the medical school is the number of women who graduate as doctors. Do they ‘drop out’ from medicine and is their acceptance into the medical school a waste of resources? As Table 3 indicates, this is not the case at the UWMS. In some years, the number graduating exceeds the number admitted 6 years earlier because some women may take longer than 6 years to finish their course, but over the five year period under review, 91% of women entering medicine graduate as doctors. In general, the situation of women within the UMWS may be described as satisfactory in that the percentage of women graduating as doctors is increasing steadily as Table 4 indicates. The really significant increase which will visibly affect the proportion of women to men doctors will however, come only in the 199Os, when the present intake of women students, graduate. South
African
equivalent
of the
American
intern.
Black
Male
Female
total
Women as a % of total
20 10
_
_ _
_ _
_ _
20 53 23.8
13 14 16 44
3 6 6 15
16 20 22 59
Women as a
Year
*The
by ethnic group and sex
Coloured
Female
I 1
I 7 10
% of total
Total 2----2 5 10 5 5 13 42
*
18.7 30 27.2 25.4
(iii) Sexual stratification within the medical profession Within the medical profession in South Africa there is a well-defined hierarchy based on specialist qualification and income levels. The two are usually linked, and as much of South African medicine is practised at a private entrepreneurial level, private practice gives doctors access to the greatest financial rewards. Prestige in the South African medical system is also accorded to doctors in positions in the teaching hospitals who attain eminence in their specialities. Many South African specialists combine hospital practice in the large teaching hospitals with private practice so that they are able to ‘rate’ in the profession in terms of occupational prestige and income. General practitioners in this country rank below specialists in status and within speciality training there is a hierarchy too with the ‘high-powered’ specialities like surgery and internal medicine in the top rank. A count from the register of the South African Medical and Dental Council on the basis of doctor’s names, showed that of the 4082 specialists listed for 1981 only 259 (6.35%) were female. One or two errors are possible where first names could not be easily classified but the trend is unmistakable. Some reasons for this overwhelming difference were obtained from the interviews with the 15 women doctors. It seems that today many young doctors who wish to specialize, extend their statutory 1 year period as house officer or houseman* for a further year. They then proceed to the required further 3 years of full-time hospital training combined with further academic study in their chosen speciality. According to our informants, most young women doctors embark on marriage and child-bearing in the years immediately after graduation. The requirements for specialist training are in direct conflict with their child-bearing Table 3. First year intake of women compared with number graduating as doctors 6 years later at UWMS Graduates N
Year
First year intake N
1971 1972 1973 I974 1975 1916 1977
36 33 46 45 38 54 56
35 42 30 32 43 47 51
Total
308
280
(1977) (1978) (1979) (1980) (1981) (1982) (1983)
Discrimination against women in the South African medical profession Table 4. %Women
graduates
in medicine
at the UWMS
1975-1981
No. of female No. Year 1975 1976 1977 1978 1979 1980 1981 1982 1983
graduates 27 24 35 42 30 32 43 47 51
of male graduates
Total
% Female
122 129 130 163 150 157 144 142 134
149 153 165 205 180 189 187 189 185
18.0 15.6 21.2 20.4 16.6 16.9 22.9 24.8 27.5
and child-rearing roles so that specialist training is postponed. Once her children are old enough to become relatively independent, the woman doctor often finds she cannot confront full-time specialist training in the hospital and often fears the return to academic medicine, as many fields of medicine change rapidly over a 2 or 3 year period. Many of the women doctors interviewed considered that young women would undertake specialist training more readily, if the regulations were altered to make parttime specialist training possible. There seemed to be no doubt that the lack of specialist status relegates women doctors to the lower ranks of the profession. Women doctors have little influence in the powerful medical profession itself and cannot exert pressure to change the regulations governing specialization. In a recent article Barlow [1 1] comments on the fact that only 2 women had been branch presidents of the South African Medical Association and 1 woman doctor had sat on its Federal Council. This situation could well change as young women doctors graduating today develop a greater feminist consciousness (there is a growing women’s movement at the University of the Witwatersrand). What of the choices of speciality by those South African women doctors who complete specialist courses? From the register of the Medical and Dental Council they are to be found in dermatology where they are 16% of specialists, pediatrics (15x), psychiatry (12%), anaesthetics (lo%), pathology (10%) and radiology (9%). In gynacology and obstetrics they are only 5% of the specialists, in internal medicine 3% and in surgery and neurology less than 1.6%. The point of view expressed by the women doctors interviewed, was that women choose specialities because of regular hours and freedom from night calls. It is possible too that women doctors experience resistance from patients and that some of the specialities chosen (e.g. pathology, radiology and anaesthetics), involve less patient contact. This is a subject which requires further investigation, but more importantly the restricted number of women specialists results in few women filling the most important teaching roles in the clinical departments of the medical school. This reinforces among medical students the stereotype of women as ‘second class’ doctors. A few of the women doctors interviewed *Women doctors in South Africa have formed the South African Association of Medical Women. With the projected growth in the number of women practitioners in the next decade, this organisation could become increasingly members.
important
in promoting
the interests
of its
1257
commented on the ‘lack of ambition’ shown by women doctors in general. They said that married women doctors are frequently prepared to work for low salaries because they can depend on their husbands’ incomes. They were also critical of women in the profession for not ‘doing more’ to better their situation. These comments indicate an awareness of women’s collusion in their own oppression and it is to be hoped that this awareness will be one of the factors which could improve the status of the woman practitioner within the medical profession*. In South Africa women doctors are underrepresented not only in the specialities, but also in private practice. They tend to concentrate in full-time salaried posts or in part-time salaried posts. The solution of part-time work combines work with family responsibilities, but as Hillier [12, 1601 points out in writing of British women doctors, part-time work carries a degree of stigma. The part-time practitioner is seen as less committed to work and is usually disqualified from promotion. Table 5 shows that 44% of male doctors are in private practice-25% in full-time private practice and 18% combining private and public practice. Only 12% of women are in full-time or part-time private practice. Most women doctors are in full-time salaried or part-time salaried appointments. There can be no doubt that they are doing work which is essential in their communities. It is the women doctors who staff Black clinics, run immunization and blood transfusion services and work in the crowded out-patient departments of hospitals, but the work they do is in many cases of lower status in the medical profession, and is frequently rejected by their male colleagues because of low salaries or its routine nature. Maykovich [8, p. 1951commenting on a very similar situation in the American medical profession, suggests that women doctors avoid competition with men by keeping out of entrepreneurial private practice. This author also quotes a number of American studies which show that women concentrate in certain ‘reserved’ specialities like psychiatry, public health and paediatrics. CONCLUSIONS
This paper has examined some of the ways in which women are discriminated against in the medical profession. An attempt has been made to show that even when liberal values assert themselves and a medical school tries to promote equality in the admission of women to the medical school, the structure of the wider society restricts the role of the woman doctor. This does not mean that it is not laudable to try to redress perceived inequalities (medical schools which restrict the admission of women, are to be censured), but ameliorative action is limited when the mechanisms of subordination continue both within the medical profession and in society as a whole. In the South African context, the subordination of women in medicine can be seen in their low status in the profession itself, their ‘failure’ to enter specialist ranks in substantial numbers, and their concentration in traditional women’s fields of public medicine rather than private practice. Their lack of power
1258
BERYL UNTWIALTER Table 5. Fields of practice of male and female doctors calculated from information from the Census of Health Services 1979’
Private practice Part-time private practice Salaried part-time Salaried full-time Awaiting employment Age retired Retired (other reasons) Total
Males
Females No. %
No.
“/.
125 74 297 895 31 72 181
834 2020 334 5065 98 358 254
25.9 18.4 3.0 46.2 0.9 3.3 2.3
1675
7.5 4.4 17.7 53.4 1.9 4.3 10.8 100
10.963
100
*This census was based on information from 12,638 questionnaires returned by practising doctors to the Department of Statistics Health Services 1979: Medical Practitioners: Department of Statistics: July 1981: pl (13).
within the profession is further demonstrated by their inability to achieve even minor organisational changes which would enable them to specialise on a part-time basis. The medical profession can be seen as a microcosm of the society it serves. In all countries (and South Africa is one) where medicine is practised largely on a private entrepreneurial basis, the profession is largely a male preserve. It is of interest to note that in socialist countries where fee-for-service medical practice has been abolished, women take their rightful place in the medical profession. For example, in Poland 46% of women are doctors and in Russia 74% [7, p. 461. What makes any profession male or female is not the nature of the work itself but the power relations which exist in that society. In South Africa as in many other Western societies, the medical profession reflects the all-pervasive patriarchal relations of the wider society which continue to subordinate women. Doyal [14, pp. 21-301 has recently pointed out that one of the major areas of struggle for the women’s movement has been in the field of health and that action on health issues has often provided a unifying link for feminists. The main focus of the struggle has been the oppression experienced by the woman patient particularly with regard to the control of women’s reproductive functions. While this struggle must continue, there is a further facet to sexism in medicine-the inferior status of the woman health worker in a profession in which women predominate numerically. Within the profession, the woman doctor has a higher status than that of other health professionals such as the nurse, physiotherapist or occupational therapist, but her role is generally inferior to that of the male doctor. Women doctors have fought for the right of entry into the medical profession, but their gains will be illusory if they do not attain equal opportunities within that profession.
REFERENCES
1. Zola I. K. Medicine as an institution of social control: the medicalizing of society. Am. social. Rev. 20, 487-504, 1972. 2. Oakley A. Wisewoman and medicine-man: changes in the management of childbirth. In The Rights and Wrongs of Women (Edited by Mitchell J. and Oakley A.), pp. 17-58. Penguin, London, 1976. 3. Thomas K. Religion and the Decline of Magic. Weidenfield & Nicholson, London, 1971. 4. Walsh M. R. Doctors Wanted: No Women Need Apply. Yale University Press, New Haven, CT, 1977. 5. L’Esperance J. Doctors and women in the 19th century society: sexuality and role. In Health Care and Popular Medicine in the 19th Century England (Edited by Woodward J. and Richards D.), pp. 105-127. Croom Helm, London, 1977. 6. Gamamikow E. Sexual division of labour: the case of nursing. In Feminism and Materialism (Edited by Kuhn A. and Wolpe A. M.), pp. 96123. Routlcdge & Kegan Paul, London, 1978. 7. Leeson J. and Gray J. Women and Medicine. Tavistock, London, 1978. 8. Maykovich M. K. Medical Sociology. Alfred, Sherman Oaks, 1980. 9. S. A. Institute of Race Relations. Survey of Race Relations in South Africa 1982. Tbe Natal Witness, Pietermaritzburg, 1983. IO. Denartment of Statistics. Census of Health Services 1979. Medical Practioners: Statistical News Release. Central Statistical Services, Pretoria, 1981. II. Barlow M. R. Women doctors. S. Afr. med. J. 63, 29-32, 1983. 12. Hillier S. M. Women as patients and providers. In Sociology as Applied to Medicine (Edited by Patrick D. L. and Scrambler G.). Cassel, London, 1982. 13. Department of Statistics. South African Statistics 1982. Government Printer, Pretoria, 1982. 14. Doyal L. Women, health and the sexual division of labour: a case study of the women’s health movement in Britain. Crir. Sot. Polic. 7. 21-33, 1983.
1985
0277-9536/85 $3.00+ 0.00 PergamonPressLtd
Printed in Great Britain
DISCRIMINATION AGAINST WOMEN IN THE SOUTH AFRICAN MEDICAL PROFESSION BERYLUNTERHALTER Department of Sociology, University of the Witwatersrand, 1 Jan Smuts Avenue, Johannesburg 2001, South Africa Abstract-The paper examines discrimination against women in the medical profession in the South African context. To measure the extent of the problem data was obtained from the records of one of the largest South African medical schools-the University of the Witwatersrand Medical School. This medical school is one of the most liberal in South Africa and does not discriminate against women in its admission policies and the number of women graduated as doctors has increased steadily. Despite this, women take a secondary place in the South African medical profession. Evidence for this was collected from official records and supplemented with guided interviews with 15 women doctors. Special attention is given to the serious under-representation of Black women doctors in South Africa.
INTRODUCTION-ANHISTORICAL OVERVIEW In all Western societies, doctors constitute an elite professional group highly respected and well remunerated because they perform one of society’s most essential functions-the definition and treatment of disease. Zola [ 1, pp. 487-5041 has also commented on the present-day extension of the doctor’s power and authority to many ‘non-medical’ areas of life which formerly were the preserve of the family, the church or the legal system. He calls this the medicalization of society and sees that in numerous situations, today, it is the doctor who is the final arbiter. The growth of the medical profession is of particular sociological interest as it illustrates the relationship between technological innovation and professionalization. It also illustrates the way in which important institutions, like medicine, replicate wider social, class and sex divisions within a society. This paper discusses discrimination against women within the profession, but this discrimination must be seen as part of the value system of the wider society in which it occurs. To understand the roles of women in medicine it is necessary to examine the historical antecedents of the modem medical profession as we know it. It would perhaps be salutary for many doctors to know that medicine did not always have authority and prestige. In pre-industrial Europe, doctors did not understand the underlying causes of most ailments, they had few cures and their rudimentary surgical techniques often maimed the patient horribly or led to death from shock or infection. In a world of casually-trained or untrained doctors, women frequently participated along with men in the provision of health care. Oakley [2, p. 231 suggests that the healing powers of Europe’s wisewomen or good women were often superior to those of the physicians of the day. The wisewomen had, according to Oakley, developed over the centuries a pharmacology of pain killers, digestive herbs and anti-inflammatory drugs. In their communities they were entrusted with delivering babies and caring for women after the birth of children. These functions gave them some knowledge of anatomy and made many of them into shrewd psycho-therapists. Oakley [2, p. 241 quotes from let-
ters and diaries written in pre-industrial England which comment favourably on the skill of the female healer/midwife in preference to her male counterpart. Thomas [3, p. 141is of the same view and quotes the opinion of Francis Bacon that “empirics and old women were more happy many times in their cures than learned physicians”. But the pre-emption of the medical profession by men was already under way. From the 14th century many European cities began to close their doors to all those doctors who did not have a university licence to practise medicine, thus automatically debarring women as they were not admitted to the universities. Thomas describes this process for the City of London when in 1518 the Royal College of Physicians gained the right to supervise and license all physicians practising in London and within a 7 mile radius of the city. The physicians were all university-trained men. However, the poor and the rural population continued to use their local wisewomen; qualified physicians were too few in number and too expensive for all but the gentry. Not that the services of the physicians ensured superior medical care to the upper classes. Sydenham, the greatest physician of the 17th century remarked that “many poor men owed their lives to their inability to afford conventional treatment” [3, p. 141.This was an age in which the patient was as likely to die from the cure as from the disease. It can thus be seen that even prior to the birth of a truly scientific medicine, the nascent medical profession has already established monopolistic practices along class and sex lines. This process continued with the great technological innovations in medicine beginning with the work of Pasteur, Lister and Simpson from the middle of the nineteenth century. Doctors now understood disease causation, had scientifically-based cures, as well as relatively safe surgical techniques. Qualified doctors were in demand in all strata of society and the medical profession started to reach the eminence and authority with which we are familiar. It was now that the more extensive ousting of women as healers, occurred. As medicine established an impressive body of scientific knowledge, it could only be imparted systematically at licensed medical schools, and in duly approved clinical teaching situations. The new medical schools
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BERYL UNTERHALTER
which developed in the nineteenth century continued along the lines of the older university establishments in excluding women. A recent book which analyses the position of women in American medicine from 1835 to 1975 is entitled “Doctors wanted-no women need apply” [4]. This indeed could have been the motto engraved over the doors of the medical schools of Britain and the United States of America. (British and American data have been used because they are easily obtained but it is unlikely that the situation was different in most European countries.) The medical profession based the refusal of entry on the unsuitabilityi of women for the profession. L’Esperance [5, p. 1181 says that the demand for access to medical education by women, beginning in the late 185Os, aroused the medical establishment to heights of greater anger and disgust than any other aspect of the campaign for changes in society’s attitude to women. According to this author the case against women doctors rested on the argument that menstruation and pregnancy made “women unfit to be entrusted with the life of a fellow creature” and secondly, that “female purity would inevitably be destroyed in women learning anatomy and physiology especially alongside male medical students”. The inconsistency of allowing the nurse access to patients was not confronted, but it demonstrates the way in which this ideology operated. Nurses were females in subordinate positions, perpetuating masculine hegemony and as such they represented no challenge to the medical profession. But a woman doctor would by the very nature of her work, step out of the female ‘servant’ role. One has only to contrast the bitter opposition to the woman doctor in the nineteenth century with the prefatory remarks in 1874 by a doctor in a handbook for hospital services. He wrote “Nursing is the medical work of women.. . it furnishes an outlet for the tender power and skill of good women of almost every class” [6, p. 1131. One is amazed at the persistence of women like Elizabeth Blackwell, who overcame all barriers and finally graduated as a doctor in the U.S.A. in 1849. She inspired Elizabeth Garrett to follow her into medicine in Britain, but for 12 years these were the only two women on the medical register on both sides of the Atlantic. As the 19th century drew to its close, a few more ‘token’ women entered the profession in Britain and the U.S.A., but their numbers remained negligible. Opposition did not come only from the medical schools. Queen Victoria threatened to withdraw her patronage from a medical conference if women were admitted and, as late as 1914, women doctors were only reluctantly accepted into the British Army Medical Services, provided that they were neither commissioned nor given any badges in recognition of their status [7, p. 261. It was not only the training and licensing of doctors that were controlled by the influential medical profession which established itself in Britain and the United States of America. The profession also extended its control to the allied health professions such as nursing, physiotherapy, occupational therapy and pharmacy. All of these (except the latter) were traditionally women’s areas of medicine. The last bastion to fall under male professional dominance was the occupation of the midwife. Women retained
control over midwifery until the last decades of the 19th century, mainly because men did not want this work. In 1827, the President of the British Royal College of Physicians said of obstetrics that “it was foreign to the habits of a gentleman of enlarged academic education” [2, p. 311 but eventually medicine had to concern itself with this important area of health. From 1886, British doctors were required to have a professional training in obstetrics and doctors took over the care of pregnant women and the delivery of babies. However, midwives were not totally eclipsed and in many communities, the poorer classes particularly in less developed countries, still rely on their services, while women of higher status engage the services of male doctors. It can be seen from this necessarily brief overview, that it is almost axiomatic in Western capitalist societies, that the higher the status of an occupation, the more likely it is to be exclusively male and middle class. (In societies where there are ethnic minorities, they too would be excluded from the higher status professions.) This is true not only of medicine but of the other senior professions like law, engineering, architecture and accountancy. Despite all the barriers to entry into medicine, women albeit in small numbers, have gained admission to the medical profession. To use Britain and the U.S.A. again as examples, women are 8% of American doctors and 22% of British doctors [7, p. 431 and it is expected in both countries that this proportion will increase considerably in the 1980s. There has been a substantial increase in the number of women students now enrolled in the medical schools-20% currently in the U.S.A. [8, p. 1911. This could only occur because the medical instutition has not been completely unyielding. There have always been in Western society, liberal values which recognise the injustice of excluding any individual from opportunities on the basis of race, sex or class. Since World War II there has been a fusion of liberal and interventionist ideologies resulting in a recognition of the need to redress social inequalities wherever possible. The medical profession has not been immune to these ideological shifts and the result has been increased opportunities for women and minority groups in the medical profession. (The experience of the United States in the 1960s has accelerated this process still further.) There is an additional factor-women have not been entirely passive in accepting discrimination in the medical schools, and their persistence has frequently won them the rights of admission. It is interesting in this context to note that the upward trend in the enrolment of women in the medical schools of Britain and the United States of America coincides with the growth of the women’s movement in both countries and the new consciousness this movement has promoted. As a matter of historical experience, the benefit has elevated the status of middle rather than working class women, but the consequences are undoubtedly there in the number of women who wish today to enter the medical profession. THE SOUTH
AFRICAN
SITUATION
What of South Africa? In this country where private
Discrimination
against
women
in the South
enterprise medicine is entrenched, it is financially rewarding to be a member of the medical profession. Doctors also have high status in their communities and these two factors make medicine a much soughtafter career. There is intense competition for entry into the medical schools and as in many other countries, both race and gender are important bases for discrimination. This can be illustrated by an examination of the percentages of South African medical graduates in the years 1980-1983. In this period Whites (17% of the total population) were 81% of the medical graduates, Asians (3.3% of the population) 8.3% of medical graduates, Coloureds (10% of the population) 2.3% of the medical graduates and Blacks (Africans) (70% of the population) 8.3% of the medical graduates. These recent figures for Blacks represent an improvement in the past 3 years. A new Black medical school, Medunsa graduated its first 38 doctors in 1982, but ministerial permission is still required for Black students to enter White medical schools and all the problems associated with socio-economic and educational disadvantage have resulted in a situation where South Africa has produced only 300 Black African doctors over 25 years. This is only 2% of the 21,000 doctors registered with the South African Medical and Dental Council [9, 542-5461. Women have fared somewhat better than Blacks and Coloureds as regards entry into the South African medical profession. In 1979 13.3% of all doctors were female. This figure will probably increase in the next decade, as 16% of all medical graduates were women in 1980, but the upward trend is not pronounced [lo, p. 11. METHOD
In order to test the existence of discriminatory practices which restrict women in the South African medical profession, the following enquiries were made: (i) the admission records, class lists and examination results of the University of the Witwatersrand Medical School (UWMS) were analysed*. This medical school is known to be the most liberal in South Africa with regard to admission and general policies. It would therefore provide the optimal conditions for women medical students; (ii) guided interviews were held with 15 women doctors practising in Johannesburg. There was no attempt to select these doctors by random methods. They were approached at a large general hospital and asked to assist with the investigation. No woman doctor refused the interview but the data from these interviews are impressionistic only?; (iii) the registers of doctors maintained by the South African Medical and Dental Association and the Medical Graduates Association were examined.
African
medical School, Professor P. V. Tobias, is gratefully acknowledged. tThe guided interviews and the data collected were carried out by a group of M.B.B.Ch 111 students as part of an elective in 1982 by the Department of ^ . project^ - supervised -. Soctology of the University of the Witwatersrand.
profession
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Statistics were also obtained from the South African Department of Statistics. Using the data from these three sources this paper examines the following aspects of discrimination against women in medicine in the South African context: (i) the selection of women students into the medical school; (ii) the attainment of women students within the medical school; These two sections draw largely upon the experience of one of the largest medical schools in the country, the University of the Witwatersrand Medical School (UWMS); (iii) sexual stratification among qualified doctors. (i) The selection of women students into the medical school In South Africa the propotion of women selected for entry into medical schools other than the UWMS varies between 20-30x. This figure was obtained by writing to all the South African medical schools for information. 5 out of 7 medical schools replied. Of these two acknowledged the existence of female quotas for entry into the first year-in one case women were restricted to 20% of the first year intake and in the other to 30%. (At the request of the medical schools concerned, their names have been withheld.) When no such quota system operates, as at the UMWS, there has been a steady increase in female admissions into the first year of study over the past decade. In 1973 women constituted only 10% of first year admission. By 1977 they were just over a quarter of the class (27%) and in 1982 a third (33%). Last year, 1983, the percentage had risen to 41.5% of the 220 students in the first year class and it is likely that parity will be achieved within the next few years. To what extent do these gains affect White women rather than Asian, Coloured or Black women? To assess this the admission statistics for a 5 year period for the UWMS were examined (Table 2). In interpreting Table 2, it must be pointed out that admission to the UWMS for all students, other than White is governed by ministerial consent and therefore reflects government policy rather than any racial discrimination in admission policy on the part of the medical school. There were years in which no Black students were admitted to the medical school and the table indicates a serious under-representation of Coloured and Black admissions of both sexes. It would be highly desirable to have a significant increase of Black and Coloured doctors, of whom at least a half should be women as the health problems of women
Table 1. Proportion of women accepted into the first year of the medical degree UWMS 1977-1983 Year
*The co-operation and encouragement of the Dean of the
medical
1977 1978 1979 1980 1981 1982 1983
y0 Women
in the first year 27.18 29.33 32.50 26.34 31.63 33.17 41.5
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BERYLUNTEWLAL~R Table 2. Distribution of first year students accepted into the UWMS 1977-1983 White
Asian
Women as a % of Total total Male
Female
Women as a % of Total total Male
Male
Female
1977 1978 1979 1980 1981 1982 1983 Total
194 189 192 169
53 59 59 46
247 248 251 215
21.4 23.7 23.5 21.3
9 12 9 32
3 3 4 9
12 15 13 41
25 20 30.7 21.9
2 2 4 9
-
113 121 85 1063
68 53 68 406
181 174 153 1469
37.5 30.4 44.4 27.6
14 17 19 112
3 12 9 43
17 29 28 15s
17.6 41.3 32.1 27.7
5 4 6 32
-
and children are among the most pressing in the Black and Coloured communities. Table 2 shows that Asian admissions over the 5 year period form a satisfactory proportion of the total (9.5%). Within their ethnic groups how do women fare? Table 2 shows that the percentage of female admissions does not vary greatly between the ethnic groups. From 1977 to 1983 White women were 27.6% of white admissions, Asian women 27.7x, Coloured 23.8% and Black women 25.4%. Over the past two years, 1982 and 1983, when White women have made their largest gains in admissions, the White and Asian female admissions are 37 and 36% respectively. The data does not lend itself to the drawing of any inferences about special discrimination which Black or Coloured women experience in medical school admissions, as their numbers are so small. (ii) Attainment of women students within the medical school From the examination results for final year students over a 5 year period (1977-1982) at the UWMS it seems that there was little disparity between male and female students. The average aggregate per student was 61.9% for females and 60.6% for males. Leeson and Gray [7, p. 461 report similar findings in British studies which show that women students perform as well or even slightly better in their examinations. Even more important than performance within the medical school is the number of women who graduate as doctors. Do they ‘drop out’ from medicine and is their acceptance into the medical school a waste of resources? As Table 3 indicates, this is not the case at the UWMS. In some years, the number graduating exceeds the number admitted 6 years earlier because some women may take longer than 6 years to finish their course, but over the five year period under review, 91% of women entering medicine graduate as doctors. In general, the situation of women within the UMWS may be described as satisfactory in that the percentage of women graduating as doctors is increasing steadily as Table 4 indicates. The really significant increase which will visibly affect the proportion of women to men doctors will however, come only in the 199Os, when the present intake of women students, graduate. South
African
equivalent
of the
American
intern.
Black
Male
Female
total
Women as a % of total
20 10
_
_ _
_ _
_ _
20 53 23.8
13 14 16 44
3 6 6 15
16 20 22 59
Women as a
Year
*The
by ethnic group and sex
Coloured
Female
I 1
I 7 10
% of total
Total 2----2 5 10 5 5 13 42
*
18.7 30 27.2 25.4
(iii) Sexual stratification within the medical profession Within the medical profession in South Africa there is a well-defined hierarchy based on specialist qualification and income levels. The two are usually linked, and as much of South African medicine is practised at a private entrepreneurial level, private practice gives doctors access to the greatest financial rewards. Prestige in the South African medical system is also accorded to doctors in positions in the teaching hospitals who attain eminence in their specialities. Many South African specialists combine hospital practice in the large teaching hospitals with private practice so that they are able to ‘rate’ in the profession in terms of occupational prestige and income. General practitioners in this country rank below specialists in status and within speciality training there is a hierarchy too with the ‘high-powered’ specialities like surgery and internal medicine in the top rank. A count from the register of the South African Medical and Dental Council on the basis of doctor’s names, showed that of the 4082 specialists listed for 1981 only 259 (6.35%) were female. One or two errors are possible where first names could not be easily classified but the trend is unmistakable. Some reasons for this overwhelming difference were obtained from the interviews with the 15 women doctors. It seems that today many young doctors who wish to specialize, extend their statutory 1 year period as house officer or houseman* for a further year. They then proceed to the required further 3 years of full-time hospital training combined with further academic study in their chosen speciality. According to our informants, most young women doctors embark on marriage and child-bearing in the years immediately after graduation. The requirements for specialist training are in direct conflict with their child-bearing Table 3. First year intake of women compared with number graduating as doctors 6 years later at UWMS Graduates N
Year
First year intake N
1971 1972 1973 I974 1975 1916 1977
36 33 46 45 38 54 56
35 42 30 32 43 47 51
Total
308
280
(1977) (1978) (1979) (1980) (1981) (1982) (1983)
Discrimination against women in the South African medical profession Table 4. %Women
graduates
in medicine
at the UWMS
1975-1981
No. of female No. Year 1975 1976 1977 1978 1979 1980 1981 1982 1983
graduates 27 24 35 42 30 32 43 47 51
of male graduates
Total
% Female
122 129 130 163 150 157 144 142 134
149 153 165 205 180 189 187 189 185
18.0 15.6 21.2 20.4 16.6 16.9 22.9 24.8 27.5
and child-rearing roles so that specialist training is postponed. Once her children are old enough to become relatively independent, the woman doctor often finds she cannot confront full-time specialist training in the hospital and often fears the return to academic medicine, as many fields of medicine change rapidly over a 2 or 3 year period. Many of the women doctors interviewed considered that young women would undertake specialist training more readily, if the regulations were altered to make parttime specialist training possible. There seemed to be no doubt that the lack of specialist status relegates women doctors to the lower ranks of the profession. Women doctors have little influence in the powerful medical profession itself and cannot exert pressure to change the regulations governing specialization. In a recent article Barlow [1 1] comments on the fact that only 2 women had been branch presidents of the South African Medical Association and 1 woman doctor had sat on its Federal Council. This situation could well change as young women doctors graduating today develop a greater feminist consciousness (there is a growing women’s movement at the University of the Witwatersrand). What of the choices of speciality by those South African women doctors who complete specialist courses? From the register of the Medical and Dental Council they are to be found in dermatology where they are 16% of specialists, pediatrics (15x), psychiatry (12%), anaesthetics (lo%), pathology (10%) and radiology (9%). In gynacology and obstetrics they are only 5% of the specialists, in internal medicine 3% and in surgery and neurology less than 1.6%. The point of view expressed by the women doctors interviewed, was that women choose specialities because of regular hours and freedom from night calls. It is possible too that women doctors experience resistance from patients and that some of the specialities chosen (e.g. pathology, radiology and anaesthetics), involve less patient contact. This is a subject which requires further investigation, but more importantly the restricted number of women specialists results in few women filling the most important teaching roles in the clinical departments of the medical school. This reinforces among medical students the stereotype of women as ‘second class’ doctors. A few of the women doctors interviewed *Women doctors in South Africa have formed the South African Association of Medical Women. With the projected growth in the number of women practitioners in the next decade, this organisation could become increasingly members.
important
in promoting
the interests
of its
1257
commented on the ‘lack of ambition’ shown by women doctors in general. They said that married women doctors are frequently prepared to work for low salaries because they can depend on their husbands’ incomes. They were also critical of women in the profession for not ‘doing more’ to better their situation. These comments indicate an awareness of women’s collusion in their own oppression and it is to be hoped that this awareness will be one of the factors which could improve the status of the woman practitioner within the medical profession*. In South Africa women doctors are underrepresented not only in the specialities, but also in private practice. They tend to concentrate in full-time salaried posts or in part-time salaried posts. The solution of part-time work combines work with family responsibilities, but as Hillier [12, 1601 points out in writing of British women doctors, part-time work carries a degree of stigma. The part-time practitioner is seen as less committed to work and is usually disqualified from promotion. Table 5 shows that 44% of male doctors are in private practice-25% in full-time private practice and 18% combining private and public practice. Only 12% of women are in full-time or part-time private practice. Most women doctors are in full-time salaried or part-time salaried appointments. There can be no doubt that they are doing work which is essential in their communities. It is the women doctors who staff Black clinics, run immunization and blood transfusion services and work in the crowded out-patient departments of hospitals, but the work they do is in many cases of lower status in the medical profession, and is frequently rejected by their male colleagues because of low salaries or its routine nature. Maykovich [8, p. 1951commenting on a very similar situation in the American medical profession, suggests that women doctors avoid competition with men by keeping out of entrepreneurial private practice. This author also quotes a number of American studies which show that women concentrate in certain ‘reserved’ specialities like psychiatry, public health and paediatrics. CONCLUSIONS
This paper has examined some of the ways in which women are discriminated against in the medical profession. An attempt has been made to show that even when liberal values assert themselves and a medical school tries to promote equality in the admission of women to the medical school, the structure of the wider society restricts the role of the woman doctor. This does not mean that it is not laudable to try to redress perceived inequalities (medical schools which restrict the admission of women, are to be censured), but ameliorative action is limited when the mechanisms of subordination continue both within the medical profession and in society as a whole. In the South African context, the subordination of women in medicine can be seen in their low status in the profession itself, their ‘failure’ to enter specialist ranks in substantial numbers, and their concentration in traditional women’s fields of public medicine rather than private practice. Their lack of power
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BERYL UNTWIALTER Table 5. Fields of practice of male and female doctors calculated from information from the Census of Health Services 1979’
Private practice Part-time private practice Salaried part-time Salaried full-time Awaiting employment Age retired Retired (other reasons) Total
Males
Females No. %
No.
“/.
125 74 297 895 31 72 181
834 2020 334 5065 98 358 254
25.9 18.4 3.0 46.2 0.9 3.3 2.3
1675
7.5 4.4 17.7 53.4 1.9 4.3 10.8 100
10.963
100
*This census was based on information from 12,638 questionnaires returned by practising doctors to the Department of Statistics Health Services 1979: Medical Practitioners: Department of Statistics: July 1981: pl (13).
within the profession is further demonstrated by their inability to achieve even minor organisational changes which would enable them to specialise on a part-time basis. The medical profession can be seen as a microcosm of the society it serves. In all countries (and South Africa is one) where medicine is practised largely on a private entrepreneurial basis, the profession is largely a male preserve. It is of interest to note that in socialist countries where fee-for-service medical practice has been abolished, women take their rightful place in the medical profession. For example, in Poland 46% of women are doctors and in Russia 74% [7, p. 461. What makes any profession male or female is not the nature of the work itself but the power relations which exist in that society. In South Africa as in many other Western societies, the medical profession reflects the all-pervasive patriarchal relations of the wider society which continue to subordinate women. Doyal [14, pp. 21-301 has recently pointed out that one of the major areas of struggle for the women’s movement has been in the field of health and that action on health issues has often provided a unifying link for feminists. The main focus of the struggle has been the oppression experienced by the woman patient particularly with regard to the control of women’s reproductive functions. While this struggle must continue, there is a further facet to sexism in medicine-the inferior status of the woman health worker in a profession in which women predominate numerically. Within the profession, the woman doctor has a higher status than that of other health professionals such as the nurse, physiotherapist or occupational therapist, but her role is generally inferior to that of the male doctor. Women doctors have fought for the right of entry into the medical profession, but their gains will be illusory if they do not attain equal opportunities within that profession.
REFERENCES
1. Zola I. K. Medicine as an institution of social control: the medicalizing of society. Am. social. Rev. 20, 487-504, 1972. 2. Oakley A. Wisewoman and medicine-man: changes in the management of childbirth. In The Rights and Wrongs of Women (Edited by Mitchell J. and Oakley A.), pp. 17-58. Penguin, London, 1976. 3. Thomas K. Religion and the Decline of Magic. Weidenfield & Nicholson, London, 1971. 4. Walsh M. R. Doctors Wanted: No Women Need Apply. Yale University Press, New Haven, CT, 1977. 5. L’Esperance J. Doctors and women in the 19th century society: sexuality and role. In Health Care and Popular Medicine in the 19th Century England (Edited by Woodward J. and Richards D.), pp. 105-127. Croom Helm, London, 1977. 6. Gamamikow E. Sexual division of labour: the case of nursing. In Feminism and Materialism (Edited by Kuhn A. and Wolpe A. M.), pp. 96123. Routlcdge & Kegan Paul, London, 1978. 7. Leeson J. and Gray J. Women and Medicine. Tavistock, London, 1978. 8. Maykovich M. K. Medical Sociology. Alfred, Sherman Oaks, 1980. 9. S. A. Institute of Race Relations. Survey of Race Relations in South Africa 1982. Tbe Natal Witness, Pietermaritzburg, 1983. IO. Denartment of Statistics. Census of Health Services 1979. Medical Practioners: Statistical News Release. Central Statistical Services, Pretoria, 1981. II. Barlow M. R. Women doctors. S. Afr. med. J. 63, 29-32, 1983. 12. Hillier S. M. Women as patients and providers. In Sociology as Applied to Medicine (Edited by Patrick D. L. and Scrambler G.). Cassel, London, 1982. 13. Department of Statistics. South African Statistics 1982. Government Printer, Pretoria, 1982. 14. Doyal L. Women, health and the sexual division of labour: a case study of the women’s health movement in Britain. Crir. Sot. Polic. 7. 21-33, 1983.