Chapter 6 of The Nationbuilders
Keywords: Health; Political Economy & History;
Douglas Robb may appear to be among the most privileged of the nationbuilders in this book. His father was a manager of the Kauri Timber Company and the father-in-law from his marriage to Helen Seabrook in 1935 was even better placed. He was too young for the First World War, too old for the Second. The depression of the 1930s did not impact as heavily on the practice of the promising young surgeon as it did for many other occupations. But a year before he was born, Robb’s father came to New Zealand because the climate would be better for his tuberculosis. Two of his sons caught the disease in their infancy. There were no particularly effective therapies in those days, and the eldest died from TB at the age of 21. The second, Douglas, suffered until he was almost 40, when the symptoms suddenly disappeared.
The disease limited Robb’s early life options. Because of intermittent periods of convalescence he missed academic honours that his earlier performance had promised, but even so graduated in medicine at the Otago Medical School. It was probably the reason he gave up his adolescent ambition of being a missionary in China. The time in bed meant he was well read, and it gave him more time to think. Perhaps too, it taught him of the vulnerability of the patient, which gave him an exceptional bedside manner. At his funeral Owen Baragwanath recalled “Visiting patients on the eve of major surgery I would find them radiant and smiling and they would tell that ‘Dr Robb’ had spent half an hour sitting on the end of their bed talking about their family or football or something else. The following morning there would be no fear. Their life would be in the hands of a friend.” [1]
Yet this does not explain the origins of Robb’s reputation as someone who was a ready dissenter from the conventional wisdom, and in public. The personae may have come from the Presbyterianism of his Scottish parents, especially his mother to whom he dedicated his first book, but the story is as much about New Zealand. His differences were largely with a narrow and backward looking medical establishment. For them for some, even after he died he was an upstart challenging current practices and acting outside the conventions of the college of professionals. With hindsight he may simply appear progressive sometimes wrong for good reasons, but usually right and often farsighted.
Although rebellious at university and he represented junior medical staff in a dispute with a hospital secretary in Norwich, Robb’s adult reputation as a maverick began when he returned from his England in 1928 after five years surgical training. Back to Auckland he immediately became a private consultant, rather than working his way up through general practice. His confidence was the result of the advanced knowledge of minor surgery he brought back with him, together with the injection method for haemorrhoids and varicose veins, which he introduced (no doubt generating envy among the older surgeons). He was elected an honorary surgeon to the Auckland Hospital Board in 1929, but was not reappointed in 1935. To add to his list of sins he attempted to introduce medical auditing of surgeons, offered to train the house surgeons in new surgical techniques (an innovation much resisted by the surgeons in private practice), wrote anonymous articles in the New Zealand Herald criticising the Board, and on occasions took in patients directly rather than having been referred through a GP.
If he remained in trouble with much of the medical profession for some time and some of the medical profession for all time in 1938 he was elected as a graduate representative on what is now the University of Auckland Council, a position he held for 33 years. Within the wider Auckland establishment he was already building a respected reputation. He even looked it: tall, imposing and distinguished. If there was a wilderness at this time it was the frequent rests and an overseas trip that treatment of his tuberculosis required.
To see his nationbuilding role we scroll back to 1935 and shift the location from Auckland to Wellington, where the first Labour Government had been elected on, among other things, a promise to introduce free health care. The story of what happened is both tortuous in itself, and complicated by some strong personalities, while its accounts are often partisan and thus far incomplete.
The conflict between the BMA and the Labour Government is sometimes portrayed as the government pursuing the wishes of the vast majority of the population for ‘free’ medical services with the majority of the doctors resisting in their own self interests. The underlying political philosophy here is majoritarianism – that the majority may impose on the minority. In a hollow society the minority are only individuals, but in a liberal democracy there are social institutions not wholly dependent on the state which arise organically out of the individuals, or some section of them. This, of course, does not resolve a particular case where there is a conflict between the desires of the majority (a liberal democracy does not equate this as a right) and the rights of a minority. But it does offer a framework by which the dispute can be organised, pursued and, hopefully, resolved. A key feature is that it is rare for either the majority or the minority social institution to be wholly united internally, so there is a possibility of some compromise arising between factions from the two sides.
Initially the Labour Government’s health sector policies were driven by David McMillan, a doctor who had worked with Presbyterian minister Arnold Nordmeyer in the Waitaki Basin. Both became MPs in 1935. (A local union official, Jerry Skinner, joined them in 1938, to become a successful cabinet minister under Fraser – handling postwar rehabilitation – and after Fraser’s death in 1950, deputy-leader of the Labour Party.) McMillan and, probably, all the Labour Caucus were extremely antagonistic to a class-based system of health care supported by the doctors’ professional association in which the state provided medical care would be means tested: free for the poor, subsidised for those on middle incomes, and at full cost for the rich. Walter Nash was not alone in being distressed by the ‘two door’ practice of some British doctors – one for those who paid and one for the indigent.
The New Zealand doctors’ professional association was one of the exceptions to the hollow society, for it was largely independent of the state, being based on the support of the doctors it represented. Oddly or perhaps consistently with the colonial nature of the hollow society it was called the ‘New Zealand branch of the British Medical Association,’ and known as the BMA. It did not change its name to the New Zealand Medical Association until the 1970s, and then it did so only when a ginger group, led by Austrian immigrant Erich Geiringer, adopted the name first, underlining the colonial demeanor of the older body.
The profession about 70 percent general practitioners in the 1940s was understandably anxious to maintain that independence of the state, arguing that being put on a state salary compromised the relationship between doctor and patient. The opponents accused them of wanting to maximise their income by charging what the market would bear, and being subsidised by the state where they would be insufficiently remunerated. The BMA was led in its negotiations by a crusty Scots doctor, James Jamieson, who was particularly concerned about the independence issue – moreso, it would prove, than the profession as a whole.
Labour was initially over-dependent on McMillan, who had even less following in the profession. Peter Fraser was Minister of Health from 1935, where he had introduced a number of changes: extended health camps, improved working conditions for the health profession, established the Medical Research Council, increased the numbers of school medical officers, district nurses, and health inspectors, and so on. But when he formally gave up the portfolio, a month after becoming Prime Minister in April 1940, he had not addressed the structural issues, and the funding provisions of the 1938 Social Security Act had still to be implemented. Initially he passed the portfolio onto Tim Armstrong, previously Minister of Labour, perhaps indicating that the four years negotiations between government and the BMA had the characteristics of an industrial dispute. However Armstrong proved lost in the complexities of the health portfolio, and in January 1941, Nordmeyer became Minister. (Ironically, he joined the cabinet when McMillan, who had been Minister of Marine since June 1940, left to go on leave from parliament and back into general practice.)
By 1940 Labour had introduced the sickness and invalids benefit, had taken over responsibility for mental hospitals, introduced a maternity benefit as a doctor’s full payment, and begun state funding of hospitals. The overt major issue it faced was the funding of general practice, but the covert (and related one) was the structure of the provision of medical care at both primary and secondary levels.
The Labour Government tried a number of schemes to fund general practice so that patients did not have to pay. Some succeeded in that some doctors adopt them, weakening the claim that the BMA represented a united front. Even so the majority of doctors resisted. The crucial meeting between the BMA and the government may have been in September 1941. Perhaps an even more important meeting had taken place immediately before. Jamieson recalled “The atmosphere [of the meeting between the BMA and Fraser, Nash and Nordmeyer] was electric. There had obviously been a row and they had barely composed themselves. Fraser could assert himself when he wanted to. Messrs Nash and Nordmeyer looked as black as thunder. [2]
The BMA record of the meeting relates that Fraser said “He had studied the proposed legislation on the ‘plane on his way back, and he had debated with himself [and probably the officials accompanying him] what should be done to avoid the impasse that was developing. It occurred to him, continued Fraser, that the objections of the doctor or at any rate, most of the objections, might be eliminated in this way: Suppose medical practice was to continue in the ordinary way, but when the doctor’s bill was presented and the patient paid it, the patient should be able to present his receipted account to the Social Security Department and obtain a portion of his costs.” [3]
The key word in this passage is ‘portion’. Fraser was agreeing to the doctors’ demand for the possibility of a co-payment by the patient, allowing that the system of primary care need not be wholly publicly funded. And that where arrangements broadly settled over the next fifty years. The state paid a part of the cost, and the patient paid a top up if the doctor thought it justified.
Bill Sutch, who was advising Nash at the time although there were no officials at the meeting, broadly confirms the story, adding he thought a key element was a friendship between Fraser and James Eliott, a former president of the BMA, and Fraser’s personal physician. Sutch concluded bitterly that ‘the financially beneficial arrangements for doctors resulting from the Elliot-Fraser friendship and from Fraser’s own predilections made the work of Robb, McMillan, and Nash a nullity. The health service concept had disappeared.’ [4]
Yes and no. Sutch is right that paying general practitioners on a fee-for-service basis with a government subsidy undermined the notion of a ‘free’ health service. Whether it undermined a general ‘health service concept’ or just that particular one can be debated, and in any case it had little impact on secondary care arrangements.
Robb was never directly involved in the negotiations. His was the role of ideas man and polemicist. He corresponded and talked to Sutch, and with someone in the Minister of Health’s office (probably Martyn Finlay). Following a meeting at National Park Minister Nordmeyer wrote to him: “Thank you for your letter on hospital finance and control. I am taking the opportunity, whenever I have a spare moment which is not often these days of dipping into your book and re-reading the long chapter on the hospital system. Undoubtedly something will have to be done before long, and I am giving a good deal of consideration both to your suggestions and to others that have been made to me.” [5]
John Lovell-Smith says that Robb’s writings may have been influenced by the 1943 proposals for the organisation of medical care in Northland, but other structural reforms reflect his approach too. [6]
Altogether he authored, or co-authored, four books or booklets in the 1940s. The first, Medicine and Health the one mentioned by Nordmeyer was self-published in 1940, arguing for more preventative medicine and more medical education before discussing general practice and hospitals. It proposed the reform of primary care with:
1. Reconsideration of undergraduate training for men and women destined for general practice.
2. Provision for regular periods of post-graduate study.
3 Library and journal service.
4. Mutual relief amongst doctors, regarding night work and weekends.
5. The attachment of every general practitioner to some large institution or organisation …
6. A salaried service, with the usual accompaniments such as retiring allowance, regular leave, etc., …
7. Once the people have decided the form the service is to take, medical men should be placed in charge of its management. [7]
Except perhaps the sixth point, there would be few doctors who would bridle at these proposals today. Yet he obviously considered these as radical proposals in the 1940s, and even went to the extent of covering himself by quoting an article in an overseas journal at the end of the first chapter, with the apparent intention of emphasising he was none of the last epithets. “Any medical man who strays outside his speciality is apt to be regarded askance. If you are a bacteriologist and you make your life work the thirty two types of pneumococci you will be honoured by all your colleagues: but try to limit the spread of pnueumococci infection by clearing the slums and you will be called an advertiser, or an adventurer, or perhaps, the final insult, a Communist!” [8]
The three chapters on the public hospital system are more devoted to the problems facing the institutions than presenting solutions. That would come in the later books.
Reading the book more than sixty years later, one is struck that Robb is aware of an upheaval going on in the medical profession in terms of the amount of knowledge that doctors were increasingly requiring, with implications for new education, post-experience training, specialisation, and new ways of organising professional arrangements. If one wanted to distinguish his views from those of many other advocates of major health reform, Robb was as concerned with the ‘production side’ of the supply of health services than the equity one. Of course he cared about patient access, but his focus includes the changing conditions of providing healthcare.
But we may be seeing here the devastation to the profession of the world war he just missed out on. Other young doctors would have died in it, and the profession was depleted of the generation who should have been offering leadership with Robb, while the older generation whose skills and outlooks were becoming obsolete were left entrenched.
Robb’s thoughts about hospitals are developed in his next three books. Perhaps the appointment to a position in the Auckland Hospital in 1942, in part the result of the doctor shortage induced by the war, gave him new insights. In 1943, A National Health Service was published by eight authors, although it is said that Robb wrote 90 percent of it. Aside from the funding and payments issues, the publication is concerned with two key matters: the structure of the hospital sector it being argued that there were too many hospital boards and the internal management. Neither would be considered particularly revolutionary today, although later he advocates 11 boards instead of the 42 at the time, which he described as an ‘absurd anachronism’. [9] Given the current 21, in the fifty years we have got half way there.
The 1943 booklet provides the most detailed account of the organisation of medical care in Northland, where six hospital boards served a population of less than 70,000. There was to be a base hospital at Whangarei and five district hospitals which would do simple surgery, perhaps with a general practice also on site. Robb’s interest in the Far North had been stimulated by ‘Rawene’ (G.M.) Smith, a larger-than-life doctor who ran a practice in the Hokianga, after fleeing a promising career in Glasgow on account of a matrimonial indiscretion. Robb had first met him when he was in the district for rest in 1933. It was at Smith’s he probably first met Rex Fairburn, the Auckland based poet, and the social credit theories, which Smith and Fairburn and, less publicly, Robb held. Fairburn was a frequent visitor to the Robb household.
Fairburn wrote a tribute to Robb in 1945 as a part of a series about ‘various people [in fact eleven men] who deserve to better know.’ [10] Writing to Allen Curnow, one of the eleven, he said ‘I am trying to keep clear of the old gang, and give the boys a hand’. [11](Among the others were Owen Jensen, Eric Lee Johnson, Smith, Bill Sparrow and Sutch). Of Robb he wrote ‘there can be very few public men in New Zealand whose motives are more disinterested, and whose intentions are simpler. … In his attitude there is something of the spirit of the mediaeval guilds, in which group responsibility was accepted, and high standards were maintained by internal discipline.’ He concluded, ‘I think I am justified in saying that his book , Medicine and Health in New Zealand, is one of the really significant events in New Zealand medical history.’ [12]
Fairburn dedicated one of his three great poems To a Friend in the Wilderness to Robb. Its final stanza, which begins ‘Old friend, dear friend’ and is sometimes used at funerals, could be Fairburn referring directly to Robb.
“Old friend, dear friend, some day
When I have had my say, and the world in its way,
when all that is left is the gathering in of ends,
and the foregathering of friends,
on some autumn evening when the mullet leap
in a sea of silver-grey,
then, O then I will come again
and stay as long as I may,
still the time sleep;
gaze at the rock that died before me,
the sea that lives for ever and ever;
of air and sunlight, frost wave and cloud,
and all the remembered agony and joy
fashion my shroud.”[13]
But it seems unlikely that the poem as a whole refers solely, or even mainly, to Robb. Fairburn wrote three long poems, each of which is dedicated, and to argue that To a Friend in the Wilderness refers specifically to Robb, would have to mean that Dominion referred specifically to Jocelyn Fairburn and The Voyage to Philip Smithells. (It was Robb who operated on Fairburn for the kidney tumour which killed him in 1957.)
The relevance of the poem left even Robb a little bemused, although he uses the wilderness image in his autobiography, Medical Odyssey. Robb saw himself not so much as a rebel as a prophet, drawing an analogy with Isaiah. He was modest enough not to draw attention to the idea that prophets lack honour in their own country or house, if that be the Auckland medical establishment as late as the 1960s. When the whole BMA had its joint annual meeting with the New Zealand Branch in 1961, a New Zealander needed to be chosen as the president. His Auckland division did not nominate Robb but other divisions did, and so he was elected to the prestigious international position, one of a number at the end of his life, albeit with some resentment from within his ‘house’. [14]
Robb wrote in his autobiography of ‘the art of the dissenter’. “This art is surely necessary in our midst, lest we stagnate, and ‘one good custom should corrupt the world’. It should, by rights, be valued, sought out, taught, and its practitioners encouraged. That in essence is what higher education is about, or should be about. But it will be a long time before this is openly done. I expect the dissenter will continue to be a lone wolf, or to hunt in a small pack. They must not be discouraged by the enmity, or opposition they arouse. …. Then the day comes scarcely heralded, perhaps almost unrecognised by the dissenter himself when … the new ideas begin to be accepted. The dissenter who started it may no longer be there, or he may have long since given up, and gone fishing. But however close he is to the now favourable seat of operations he dare not show his satisfaction, nor allow himself the gratification of saying ‘I told you so.’ He commonly sees others often former opponents climbing up and riding on the now rolling wagon.” [15]
There was in Robb the attitude that Sutch praised Gordon Coates for. You do what is right, and expect others to recognise your integrity. Robb wrote “The truth is I never felt myself to be much of a rebel … I started out with a few fundamental attitudes, for which I suppose I may praise or blame my elders, at least in part, and simply went on applying them. It is true that the conclusions I came to on some occasions proved to be at variance with customary practice though I always seemed to be the last person to appreciate the dire implications of what I was pleased to embrace. At almost every stage I was naive enough to think, for much longer than anyone else did, that I had been a rather helpful fellow, who had at least come up with some good ideas.” [16]
From 1950 Robb was less involved in health reforms, as other matters absorbed his restless physical and mental energy, even if his manner was unhurried. The Auckland Hospital Board appointment had led to his development of the heart unit at Greenlane Hospital. Part of the achievement was bringing on young heart surgeons. He ran the unit as a team, as his writing of the 1940s advocated. He was noted as a surgeon who carried a stethoscope in his medical coat, showing that he was willing to work like a physician where necessary. And he bought on people of great ability, working harmoniously with them in a manner reminiscent of Coates and Fraser.
The pioneering of new surgical procedures was not without difficulties. In order to acquire the skills for the Blalock operation (for ‘blue’ babies), they had to practice vascular surgery on pigs and sheep. Initially it was in the ‘pathology laboratory at Auckland Hospital in dead of night, so as to escape the notice of vigilant anti-vivisectionists.’ Fortunately they were offered facilities as Ruakura, although not without moments of mirth (and team building as they drove down to the Waikato). [17]e was also humorous in the treatment. ‘Hole-in-heart’ children were told after the operation: ‘Roses are red, violets are blue/ Carnations are pink,/ And so are you. [18]
Greenlane became a world leader. Robb relates how returning home he was in Hong Kong he ‘heard the news that William Liley’s pioneer ant-natal transfusion had reached the world and we suddenly realised that we were coming away from Europe towards New Zealand and into the news medically.’ [19] The lesson is not that ‘the kiwi can do it’, but that Robb set and maintained world standards, and so Greenlane joined the innovating frontier of the world.
There were numerous minor activities, of course, for the energy meant that friends could readily co-opt him into worthy projects, including attempting to develop a local art gallery less dependent upon the philistines of the Auckland. However the second major theme of his later years was the University of Auckland (as it became in 1962) where he was on the Council from 1938, the Pro-chancellor from 1952, and the Chancellor in 1961 to 1968, retiring in 1971. That combined with the pursuit of medical education, which had been a priority from the 1930s, led to the establishment of the Auckland School of Medicine.
On the other hand he was somewhat sceptical of the academic pretensions of the business-oriented faculties arguing ‘it was a matter for debate as to how suitable subjects like law and accountancy are for University studies.’ [20] Perhaps he was referring to that most law and commerce students were taught largely part-time, but he might well have thought his doubts were fully justified with the attempt to commercialise the health system in the early 1990s, especially in the way it downgraded the roles of the health professionals. If he had been alive then he would have been in his nineties Robb would have been the patron of the organisations which resisted the reforms.
Robb’s nationbuilding was by polemic and example, contributing to the health services framework largely adopted today, even if his specific contribution is not directly remembered. Adjusting for the effects of technological and social change, what he advocated has been largely implemented, the exception being the co-payment (and sometimes full-payment) for primary care. Today we largely accept the Robb vision, which seemed so radical in the 1930s: a health service based on professional excellence and ongoing education, that gave weight to preventative medicine, that recognised specialisation and medical teams (including high quality nursing which he devoted some of his writing to), and which had an organisational structure which reflected these goals, and so would be largely publicly funded and publicly provided. The health system is at the heart of the welfare state: in more ways than one, Robb contributed to its development.
Biographical Sources
Baragwanath, O.T., (1974) Address given in St David’s Church, 30 April 1974. (Robb papers, 17/1).
Bush, A., et al (1943) A National Health Service, Wellington.
Cole, D.S. (1974) ‘Obituary’, New Zealand Medical Journal 80, No 251 (Aug. 1974), p.128-132.
Dow, D. (2000) ‘Robb, George Douglas’, DNZB, Vol 5, p.440-441.
McEldowney, D. (undated) draft chapters for a biography, four completed, in the possession of the author.
Morris, S. & D. Robb (1949) Hospital Reform in New Zealand, Auckland.
Robb, D. (1940) Medicine and Health in New Zealand: A Retrospect and a Prospect, Auckland.
Robb, D. (1947) Health Reform in New Zealand, Christchurch.
Robb, D. (1957) University Development in Auckland, Auckland.
Robb, D. (1967) Medical Odyssey, Auckland.
The Robb papers, including a number of interviews by Denis McEldowney of those who knew him, are held in the Auckland University Library
Endnotes
1. Baragwanath (1974) p. 2.
2. J.B. Lovell-Smith (1966) The New Zealand Doctor and the Welfare State, Auckland, p.142.
3. Ibid, p.142-3.
4. W.B. Sutch (1979) The Responsible Society in New Zealand, Christchurch, p.69.
5. A. H. Nordmeyer, letter to Robb, 26 June 1941, in Robb Papers (5/3).
6. Lovell-Smith (1966) p.188.
7. Robb (1940) p.70-1. (Note his awareness of the women in the profession.)
8. W.R.F. Collins (1940) Irish Journal of Medical Science, May 1940, p.199, quoted in Robb (1940) p.8
9. Robb (1947) p.58.
10. Robb (1966) p.108.
11. A.R.D. Fairburn (1944) ‘T.W.M. Ashby’, Action – The Thinker’s Digest, December 1944, p.16.
12. Fairburn to A. Curnow 4.10.1944, in L. Edmond (ed) (1981) The Letters of A.R.D. Fairburn, Auckland, p.134.
13. A.R.D. Fairburn, (1966) Collected Poems, Auckland, p.57.
14. A.R.D. Fairburn (1945) ‘Douglas Robb’, Action – The Thinker’s Digest, April 1945, p.32-34.
15. Robb (1966) p.110-111.
16. Robb (1966) p.108-109.
17. R. Nicks (1984) Surgeons All: The Story of Cardiothoracic Surgery in Australia and New Zealand, Sydney, p.162.
18. Robb (1966) p. 100.
19. Cole (1975), p. 130.
20. Robb (1957).