| Author: Shokahle R. Dlamini (PhD), University of Eswatini, Department of History |
The UKAHN Bulletin |
| Volume 9 (1) 2021 | |
Introduction
In many parts of Southern Africa colonialism impoverished indigenous societies by creating labour reserves to generate conditions which encouraged labour migration. This led to epidemiological landscapes characterised by infectious diseases which had a profound bearing on post-colonial nursing education. In Swaziland (present day Eswatini), which this article focuses on, colonial dispossession and the resultant labour migration introduced challenges such as acute communicable diseases which made the provision of western biomedicine inevitable. At independence, such challenges were transposed to post-colonial Swaziland leading to a dire need to improve nurse education to mitigate resulting health problems. Hence, although colonialism is a major category of analysis in this article, it goes beyond the colonial period to unravel legacies of colonialism which nursing education and public health policy had to mitigate. It analyzes the contribution of colonialism and race to the birth of nursing education; examines the evolution of health challenges, demonstrating in the process, a connection between disease and labour migration in Swaziland; and explains how nursing education was used as a response to these health challenges in post-colonial Swaziland.
Healthcare provision developed in colonial Southern Africa in response to acute communicable diseases. The spread of these diseases was facilitated by labour migration and crowded conditions produced by colonial dispossession.[1] In British colonies in Southern Africa and in the Union of South Africa, for instance, colonialism meant that local populations were dispossessed of their land which was redistributed to white businesses and settlers. Local communities ended up in overcrowded conditions in so-called ‘labour reserves’ on a much smaller amount of land than had been available to them before colonialism.
The term ‘labour reserves’, mostly used by anthropologist Colin Murray, refers to the small, impoverished and overcrowded areas designed by colonisers for ‘native’ residence.[2] Reserves were characterised by inadequate arable and pasture-land to ensure that those who lived in them could not make a living without seeking employment in mines and white-owned farms thus meeting labour demands of the colonial economy. The imposition of colonial taxes in ‘native’ reserves created further pressure on the male population in this region to leave the rural areas en masse to find waged employment in the growing urban formal economies controlled by colonial capital. The urban areas, to which black workers were moved, also resulted in crowded conditions, with little respect for the health and wellbeing of the employees. These urban areas became breeding grounds for communicable diseases which migrants took back to the reserves, and Swazi migrants were no exception to this.
Swaziland, one of the High Commission Territories (HCTs), was one of the countries which supplied neighbouring South Africa with a significant number of migrants from the 1940s.[3] By the time of independence, in 1968, Swaziland was battling with communicable diseases such as tuberculosis (TB) and sexually transmitted infections (STIs) introduced during the colonial period as a result of this colonial dispossession and resulting labour migration.
This article aims to illuminate numerous shifts in the history of disease, health and healing in Swaziland. First and foremost, it examines how racism became an impetus to nurse training and how Swaziland used nurse training as a response to the prevalence of communicable diseases. It explains how capitalist penetration and the supposed superiority of the white race in` Swaziland transformed both her agricultural production and her epidemiological landscapes, inducing numerous deleterious socio-economic shifts. Furthermore, it demonstrates how, through resulting labour migration, Swaziland was deliberately impoverished, leading to epidemics of numerous diseases, which in turn provided a second impetus for developments in nurse education and training.
In weaving the story of colonialism and race in nurse education in colonial and postcolonial Swaziland, I integrated archival material with selected oral sources. At the University of the Witwatersrand Library Archives, I was fortunate enough to come across a file that provided insight into the reasons why, in a British colony such as Swaziland, a missionary society from the United States was responsible for the inception of medical services in 1925. In tracing the history of nursing and the reforms of the nurse programmes, I relied on archival material deposited at the Swaziland National Archives currently known as Eswatini National Archives. The most significant body of evidence that exposed the steps taken to racialize nurse training in labour reserves in South Africa and in HCTs was a file which directly dealt with proceedings of a conference held in 1932 in Bloemfontein regarding the training of ‘native’ nurses.
Most archival materials at the Swaziland National Archives comprise of documents up to the late 1960s yet this article goes beyond this period. To counterbalance the problem of evidence, I used archives from the Nazarene Nurse Training and the University of Swaziland along with newspapers and oral interviews. Oral interviews which I conducted with former students of ADNT School were extensively utilized for the purpose of validating information acquired from archival sources. Of the twelve nurses interviewed during my PhD research, only five were selected for this article because this number allowed me to build a comprehensive picture of the development of nursing training at ADNT School. These were Dr Maggie Makhubu, Dr Winnie Nhlengethwa, Mrs Mary Ndlela, Mrs Eva Lukhele, and Mrs Margaret Tembe. These nurses trained at different times at ADNT School from the 1940s to the 1970s. Oral sources, as we all know, are significant for providing information the subject’s personal perspective. Likewise, the nurses interviewed here were significant for the insights they provided on their everyday experiences while training at this school and their perception of the training they received.
The article is divided into two main parts. The first part provides the colonial history of disease creation, racism and the birth of nurse training. It also examines the nature of public health policy derived from environmental and epidemiological landscapes left by colonial rule. The article then turns to an analysis of post-colonial history of nursing training emanating from the rampant diseases created by colonialism. The analysis finishes in 1980, a time when the Swaziland Institute of Health Sciences (SIHS) was established in Mbabane by the Swaziland government.[4]
Shokahle Dlamini and Dorothy Davies have both written, in earlier work, on nursing education in Swaziland.[5] However, neither attempted to show how racism became an impetus for its birth, how its development was shaped by the legacies of colonialism, or how independence for Swaziland served as a prime-mover of significant shifts in nursing education. This analysis therefore provides a fresh vantage point from which to consider the legacies of racism and colonialism in Swaziland. Analyzing the health needs of Swaziland from a perspective firmly entrenched in the colonial period, where race and ethnic divisions were predominant, reveals that one of the most significant inventions of colonial rule in Swaziland was the impoverishment of the colonised who were racially discriminated against, thus turning them into a disease-burdened society whose health and healing were mainly dependent on western biomedicine. By taking this approach, the article contributes to a very under-researched area in the history of medicine in Southern Africa, specifically the role of nursing education as a response to effects of colonialism such as public health problems.
Colonial Policies and the Evolution of Poverty-related Challenges
Before colonial conquest, Swaziland had already lost control over some parts of her land through concessions granted to South African farmers to graze their livestock and for mining rights.[6] Concession granting ultimately led to a massive reduction of land through the issuing of the 1904 Land Partition Proclamation which marked the commencement of land expropriation and the creation of ‘native’ reserves.[7] It was this land expropriation which induced and further completed the transmutation of Southern African countries into reliable labour reserves ‘for the benefit of capital within the region ….’[8]
Land appropriation and the creation of ‘native’ (or ‘labour’) reserves were followed by the introduction of capitalist relations of agricultural production which undermined pre-colonial relations of production and created a new class of proletariat Swazis, since capitalism was dependent on the working class for its development.[9] In Swaziland proletarianisation was attained through employment in settler farms as well as in mines. The introduction of capitalist forms of production along with the implementation of various administrative and economic policies such as colonial taxation played a major role in inducing deleterious socio-economic developments in post-colonial Swaziland.
Labour reserves have had a protracted impact on the health of Africans both in the colonial and the post-colonial eras leading to inadequate land for farming, food insecurity and poverty. Illuminating the changes caused by the creation of reserves in Southern Africa which led to the relentless prevalence of tuberculosis and syphilis, Helen Sweet has observed:
In rural areas, where the African population was concentrated in … reserves, there was insufficient land to farm and high hut taxes to pay, so that men were forced to leave their families and work as migrant labourers in white-owned mines, industries and farms. … thousands of Africans formed a vast migrant workforce, often living in crowded single-sex hostels near their jobs and separated from their wives … Sexually transmitted diseases and tuberculosis became commonplace among migrant workers, who also transmitted these diseases to their families on their occasional visits home to the rural “reserves”.[10]
A lot has been written to explain how colonial economic policies facilitated the extraction of raw materials and the creation of labour power (or proletarianisation) in Southern Africa, which set the scene for the devastating consequences of the extractive tendencies of the colonial economies beyond their boundaries. This impacted negatively upon the newly independent countries of Southern Africa.[11] As Marks and Anderson argue:
South Africa’s contemporary health pattern is rooted in the social changes that began with the discovery of minerals in the last third of the nineteenth century…The industrial and the agrarian revolution which followed the development of the mining industry, the new concentrations of population in the mines and in the rapidly developing towns and the special hazards of the mining operations as well as growing impoverishment in the countryside were to have swift and devastating implications for the physical well-being of workers …[12]
Swaziland, because of its geographical location, made it an obvious provider of migrant labour to South Africa and as a result, at independence and in the post-colonial period it was battling with particularly high levels of poverty-related illnesses and other communicable diseases, such as TB and STIs, introduced in the colonial period by labour migrants, as discussed above.
The problem was intensified by the practice among the South African mining companies to deport ‘all miners found to have contracted tuberculosis’ back to their homelands, which caused TB to become endemic in the migrants’ home countries.[13] It could be argued that, through labour migration, TB was spread in their home lands by black miners who initially contracted it from white miners since, as historian, Randall Packard has observed, white settlers were a host population of TB.[14] Although in Swaziland, TB had been detected as a medical issue in the 1920s and 1930s, its spread only reached endemic proportions four decades later due, among other factors, to the continuous overcrowding in reserves and an accelerated rate of involvement of both men and women in labour migration in the post-colonial period.
In Swaziland TB was more prevalent in the southern parts of the country where increased agricultural impoverishment led to extensive involvement in labour migration.[15] Writing about the relationship between Botswana and South Africa, which shares many parallels with Swaziland, Packard observed a similar occurrence of more TB infections in the south of Botswana than in the north because of non-involvement of the northern region in labour migration.[16] He emphasized that ‘the introduction of tuberculosis by returning migrant workers into rural areas in which … agricultural impoverishment, and dependence on wage labour had been established among sizable portions of the population, created conditions conducive to the spread of tuberculosis infection.’[17] Considering the level of involvement of Swazis in South African gold mining by the time of independence, it is unsurprising that TB reached more wide-ranging proportions in the country in the 1970s.
Thus, as a result of the massive reduction of land available for indigents and the forced migration, and return, of workers, Swaziland suffered from a range of poverty-related illnesses, communicable and non-communicable diseases, high rates of maternal death and malnutrition especially among children ages 5 and under, leading to high infant mortality. It was under these circumstances that ideas about developing nurse education began to emerge.
Race as impetus for nurse education in Swaziland
According to Nhlanhla Dlamini, ‘When the British took over the administration of Swaziland … the white immigrants constituted a community of their own, set apart from the Swazis’.[18] So the inception of British rule in Swaziland added another ethnic group in the kingdom to those already in existence, which were divided along racial lines. It was to this distinct British community that Dr David Hynd, a Scottish-born medical missionary, was commissioned by the Church of the Nazarene (CON) to provide medical services. This commission was initiated in 1925 by an agreement between the CON and the colonial state whereby:
…the British government offered a grant of 35 acres of land in Bremersdorp to the CON; on condition a well-equipped hospital was going to be erected on the site and a qualified British physician was going to be stationed there; with qualified nurses who would attend to the medical needs of the whites while conducting missionary work among the natives.[19]
The driving force for this agreement was both medical and racial. It intentionally introduced a white dominant racial hierarchy in the medical mission compelling Dr Hynd to provide medical services to the white community while providing only a spiritual service to Swazis. This agreement epitomized racial attitudes which became more pronounced when the Raleigh Fitkin Memorial (RFM) Hospital became operational from 1927.
Reflecting the racism inherent within the colonial power, this agreement required the CON medical missionaries not to heal the Swazi bodies, but only to save their souls. This was a complete denial of healthcare services to the majority of the ‘native’ population. The racialized provision of medical services was common practice by British colonial officers in Africa. Writing about a similar experience in Bechuanaland, Mogobe and Ncube said, ‘western medicine was initially meant for the Europeans, but as time went on – and in exchange for some favours including the acceptance of Christianity – it was provided for the few Batswana with whom the missionaries came into contact’.[20] In Southern Rhodesia, Waite boldly states that the health service ‘practiced apartheid’.[21] In most cases in Southern Africa, where people of colour were provided with medical care, it was simply to prevent their diseases from affecting the whites.
Although the colonial state had donated land to the CON to make it possible to meet the health needs of its British officers in Bremersdorp (present day Manzini), Swazis were able to obtain medical attention from Dr Hynd as early as 1925. The poor health of the Swazis in the 1920s, evident in a high disease burden and relentless human suffering, forced the missionary doctor to ‘save their souls by tending their flesh.’[22]
As a result, during the opening of the RFM Hospital on 16 July 1927 there were already a number of ‘native’ patients, attended by only three white nurses who worked tirelessly to provide nursing services to all ethnic groups. It was the prevalence of racial attitudes combined with the scarcity of white nurses in this hospital which stimulated the training of Swazi nurses to relieve white nurses from nursing black patients. In his speech on the day of opening, David Hynd stated that they would need considerable ‘native’ assistance, a need that would be met through the training of ‘native’ nurses.[23] By stating the need for ‘native’ assistance, Hynd was able to add a critical aspect to the aims of the Bremersdorp mission: that of nursing training. With such an aim, RFM could be comfortably compared with other early nurse training schools in Southern Africa, which also claimed nurse training as one of their aims from inception, such as the Victoria Hospital in Lovedale, South Africa.[24] As a result, before the end of July 1927, Dr Hynd had initiated the training of Swazi women as nurses by enrolling three Swazi women for training on the job. Their names were Khelinah Shongwe, Minah Dlamini and Kheziah Maphalala.[25] These pioneers of the nursing programme graduated in 1931 with hospital certificates.
The agreement between the colonial state and CON exposes a unique occurrence in mission history in Southern Africa; the collaboration of CON missionaries with colonial administrators. Although scholars such as Sweet and Masakure have argued that colonial governments supported missions, especially in healthcare provision, they dispute any close alignment between the two.[26] In Swaziland the CON missionaries’ relations with colonial administrators improved in the 1930s with the appointment of a new Resident Commissioner (RC) from 1928-1935, Mr Ainsworth Dickson, who actively supported nurse education. Both the RC and Dr Hynd shared the same sentiments towards healing; both strongly believed that strengthening the medical sector was most important in winning Swazis to western civilization. Expressing this, Mr Dickson once said:
In a civilized community the prevention of diseases is more important than the cure of the individual. But with a native people, like the Swazis, who attribute every physical ill to the agency of some malevolent spirit, every individual cure is an effective weapon in attacking the forces of witchcraft.[27]
His strong conviction of the efficacy of curative medicine in ‘civilizing’ the ‘natives’ caused him to emerge as a critical supporter of the CON medical mission.
It was due to Dickson’s influence that the state gave the RFM Hospital £600 for the construction of what was to become the Ainsworth Dickson Nurses’ Home, which opened in February 1940. At its official opening Hynd said:
In view of the great interest which the late Mr Ainsworth Thomas Dickson took in the initiation of the Scheme of Native Nurses’ training for the benefit of the territory, we have always wished to commemorate in a visible way at the hospital his great interest in health matters; and we are glad to be able to perpetuate his memory by naming this building Ainsworth Dickson Nurses Home.[28]
This name was instantly extended to Ainsworth Dickson Nurse Training School (ADNT), referring to the whole school up to the 1980s.
A Step towards the Recognition of a Racialized Nursing Provision
As Swazi men were forced to seek work in South African mines, the women were left behind to do agricultural production alone.[29] Although women shouldered this burden, they also experienced serious culturally-based constraints due to their perceived subordination within a patriarchal society which restricted control of resources in the homestead and hindered women from realizing their full potential in agriculture. According to Simelane, in Swaziland women ‘have little scope to take initiative in certain critical instances such as obtaining more land or credit facilities … without their husbands’ permission’.[30]
The migration of able-bodied men, and the disempowerment of Swazi women, thus led to famine in Swaziland which in turn resulted in malnutrition and other health problems such as starvation, and the augmentation of the prevalence of TB.[31] Starvation was so bad in the 1940s that school-going children went to school without breakfast, carried no midday meal with them and went until five in the afternoon without food.[32] Unsurprisingly then, in the 1930s and 1940s, there was an increased rate of morbidity, due to poverty-related diseases such as kwashiorkor, pellagra and scurvy. It was deleterious conditions such as these that necessitated the service of ‘native’ nurses in reserves.
On Friday, 17 June 1932, a very significant conference was held in Bloemfontein, attended by all those concerned with non-European medical and health services especially Principal Medical Officers.[33] The conference had been convened by John David Rheinallt Jones, an advisor to the South African Institute of Race Relations to examine the possibility of training Africans for medical work in reserves, especially as black nurses.[34] The conference noted that due to the deteriorating health conditions of the ‘natives’, there was an urgent need for African nurses in the reserves.
Dr Bruce Bays of the East London municipality in the Eastern Cape was also a delegate at the conference. Dr Bays, who had been an examiner in the non-European nursing programmes offered in mines and municipality hospitals in South Africa, used the conference to reveal his insight on the training of non-Europeans as nurses. He had realised it would be some considerable time before an adequate supply of fully trained African nurses would be available due to the low levels of education of ‘native’ women combined with what Shula Marks refers to as the ‘centrality of marriage in African society’ which militated against their education.[35] While Bays supported a scheme for training large numbers of women in practical healthcare to help in reserves, reservations were expressed in other quarters. Miss B G Alexander of the South African Trained Nurses Association raised the point that while her Association supported some training to deal with the special needs of the reserves, such training should not compromise the standards of the certificates granted by the South African Medical Council.[36]
The conference agreed that the need among Africans in rural areas was so urgent that it could only be met by providing nurse training, which by necessity would have to be of a simpler kind than that required for a certificate of the South African Medical Council. It resolved that the requirements of reserves would be better met by African nurses with a qualification of a lower standard than that of the full certificate. A sub-committee was appointed to draw up a scheme for training on a lower grade curriculum than that offered by the South African Medical Council. This inferior certificate would be granted to non-Europeans, who, on qualifying, would only be permitted to practice in defined areas and as officers under the control of a recognised body.[37]
The 17 June Conference was intended to encourage the production and recognition of African nurses by colonial governments in Southern Africa; but Swaziland had already achieved this goal, on a limited scale, in 1930 when the colonial government ‘began to provide financial assistance to the CON’ to fund some ‘native’ nurse training.[38] From 1930 to 1934, it gave the RFM Hospital £100 per year to recruit and train four Swazi women as nurses.[39] It is interesting to observe that the very same colonial state which did not promote the physical ‘healing of Swazis’ in 1925 was willing to support their training as nurses in the 1930s. This sudden change of attitude was due to the influence and advocacy of Ainsworth Dickson and the recommendations Sir Alan Pim, a consultant engaged to investigate the socio-economic conditions in several colonies in the region between 1932 and 1938. The Pim Report on Swaziland, completed in 1932, recommended that the colonial state in Swaziland should train Swazis as nurses to carry out minor medical duties in reserves.[40]
It was also agreed at this conference that ‘nursing schools with facilities for training non-Europeans for the full nursing and midwifery certificates of the Union [South African] Medical Council should be urged to do so’.[41] Up to 1949, the ADNT School did not qualify as a provider of training for the full nursing and midwifery certificates of the Union because it lacked both the human and physical resources essential for full nurse and midwifery training. Furthermore, the educational level of the Swazi youth in this period was considered too low to allow admission for full nurse training; so its nurse training was restricted to the ‘inferior’ programmes designed for ‘native’ nurses. Attesting to this, Mrs Eva Lukhele, one of the graduates of this programme in the 1940s, said that her training took place in ‘native’ wards at RFM Hospital.[42] Her area of jurisdiction as a Swazi nurse was demarcated by the hospital certificate she received which had these inscriptions: ‘This is to certify that Eva Mabuza has completed a course of four years training in general nursing at the non-European section of the RFM Hospital and is competent to undertake the medical, surgical and obstetrical nursing of non-European patients.’[43] It was only on 2 November 1948 that the ADNT School was approved as a school of nursing, by the High Commission Territories Nursing Council (HCTNC), offering the full nursing and midwifery certificates. [44] The first candidates to be accepted onto the full nursing and midwifery programmes, all black women from the region, enrolled at the ADNT School in 1949.
Reorganization of the Nursing Programme
In the run-up to independence in the period 1966-1968, the HCTNC was dissolved and a new regulatory board for nurses, the Nursing Examination Board of Botswana, Lesotho and Swaziland (NEBBLS) was formed. Its membership consisted of African citizens, appointed by ministers of health.[45] NEBBLS guaranteed partnership and mutual assistance between the former HCTs and further enabled them to exploit scanty funds in order to help each other improve their human resources.[46]
NEBBLS would be responsible for nurse education curriculum development, approving nursing programmes, conducting nurse registration and issuing licenses for nurse competence.[47] It designed the curriculum, conducted examinations, appointed examiners, granted certificates, approved schools of nursing, kept a register of names of student nurses and midwives and prescribed the nature and period of training required and the tests and examinations to be passed.[48] Mrs Ndlela, a nurse trained at ADNT School from 1971 to 1974, recalled that during the 1970s, nursing tutors would constantly remind students that they would fail if they did not meet NEBBLS requirements because NEBBLS was the institution responsible for setting their examinations and granting certificates.[49]
Since NEBBLS was formed to continue registered nurse training:
One of its first tasks … was to prepare and have gazetted the rules and regulations for the training of general nurses and midwives in each of the new independent countries … For this purpose, a subcommittee met in Pretoria in May 1968 to draft rules and regulations and the new syllabus. These …were prepared with the help and guidance of Professor C. Searle from the South African Nursing Council.[50]
The inclusion of Charlotte Searle in this committee indicates that NEBBLS also involved the South African Nursing Council (SANC) to a large extent in nursing regulatory issues.[51] The ADNT School perceived Searle’s involvement to have been helpful and supportive in the progress of nursing education development, a reason she was invited to serve on several boards of nursing training and to facilitate numerous nursing training workshops.
The ADNT School’s administrators trusted Searle to provide professional and expert advice in the field of nursing. Evident to their trust in her she was, several times, appointed as consultant to the school and as advisor to the nursing school principal throughout the 1980s.[52] In this position she advised the principal to move nursing education programmes to the University of Swaziland in order to prepare for the provision of degree programmes in nursing, something the school implemented towards the end of the 1980s.[53] This advice, which reflected international changes in emphasis from apprenticeship-based to university-based nurse training, obviously facilitated development in nurse education at ADNT School.
After 1968, and funded by foreign aid from the USA, Swazi nurse educators from ADNT School began to receive the necessary training to equip them for the health challenges the country was facing at the time. Kiereini points out that, ‘With independence and the signing of basic agreements, the African governments and United Nations Agencies gradually entered into partnership to improve health services for Africa’s populations’.[54] As Swazi nurses went to further their education abroad, the country welcomed back nurse educators who were equipped and prepared to design and develop nurse education curricula that would meet the post-colonial health needs of the nation. As a result, Swazi nurse educators with basic nursing degrees became responsible for major innovations which overhauled the nurse education curriculum of the early independence period at ADNT School.
Winnie Nhlengethwa, Vice Chancellor of the Southern African Nazarene University, was one who benefitted from such a scheme:
At Ainsworth Dickson most of the nursing educators received funding from USAID to further their education in other African countries and abroad…This followed a realization that the time for missionary service at RFM Hospital and at the nursing school was over… I was one of those who received the USAID scholarship to study at Howard University in the USA… In fact four of us went to study abroad while others went to African universities.[55]
Transformations in the Nurse Education Programme
As the profession evolved, nursing education had to develop to meet the changing needs of both the students and the nation at large and the curriculum was revised immediately after independence. TB in the labour reserves had continued to be a major challenge in the 1970s, partly intensified by lack of knowledge of TB prevention and control but mainly exacerbated by the fact that in the 1970s, due to lack of health education programmes, half of TB patients defaulted treatment.[56] Nurses were blamed for not informing patients enough about TB.[57] There was a need to reduce the pool of infectious patients and thereby prevent the spread of infections, and to achieve this, in addition to treatment of patients a programme of health education was developed for both the sick and their relatives.
This measure was only possible if enough nurses were available with sufficient training in disease prevention and control and in health promotion. As a result, the ADNT School had to review its course offerings. Up to independence, the nursing programme did not offer courses in health education and health promotion, but due to an immeasurable need for such knowledge, the School began to offer courses in years two and three of the programme to empower nurses in rural clinics to educate the population.
During the 1970s, and compounding the problems caused by the rising incidence of TB, incidence of STIs (syphilis and gonorrhoea were most common) also grew to epidemic proportions.[58] In 1973-1974, incidence of STIs in Swaziland stood at three to five per cent, but three years later in 1977, it was estimated to be eight to nine per cent.[59] According to a report in The Times of Swaziland:
Syphilis may result [in] still births, congenital deformities and blindness of the baby. It is also known to cause rapid spread of morbidity which puts a lot of strain on the patient and on medical services as hospitalization and medication begins to be required. In 1977, for instance, 4,000 cases of VDs [venereal diseases] were treated in government hospital and clinics in Swaziland.[60]
Swaziland’s immediate response to this epidemic was to mount a refresher course for nurses in rural clinics, offered by nurses at ADNT School.
In the 1970s, in response to the mounting public health crisis, including the re-emergence of malaria as threat to the nation’s health,[61] a national health policy was drawn up which aimed at enhancing the quality of life of Swazis through the improvement of overall standards of public health and reduction in the incidence of diseases caused by lack of sanitation. This policy also aimed to improve curative services, raising treatment standards and enhancing distribution where possible.[62]
With independence and the signing of basic agreements, African governments and European countries gradually entered into partnerships to improve health services for Africans. In Swaziland, Germany and the Netherlands provided donations to improve health services at the RFM hospital, including the introduction of a programme to produce community nurses at the ADNT School in 1977. Part of the agreement in obtaining funds for this programme was an undertaking to train health personnel who would be more involved with promotive and preventive health, especially in rural communities.
This programme, the first to emphasise preventive rather than curative medicine, was intended to promote health and prevent illness among the more deprived communities in rural Swaziland.[63] It led to a rapid expansion of government-built rural clinics and urban health centres, a development which exerted pressure on the ADNT School to produce even more nurses to staff these government health facilities.[64] As a result, forty-two new candidates were accepted into the general nursing and midwifery programmes in 1977; thirty were accepted into the general nursing programme and twelve into the midwifery programme.[65]
Furthermore, in the 1970s, NEBBLS conducted a major reworking of the nursing curriculum. Changes included the addition to the curriculum of social sciences, physics, chemistry, microbiology, ward management and teaching, disaster nursing, and the introduction and extension of the course in preventive and promotive health to all levels of the basic nursing curriculum. The old curriculum had included 15 hours of ‘health education’ in the final year, whereas the new curriculum replaced health education with 101 hours on preventive and promotive health, spread across all three years.[66] The increase in the number of hours allocated to preventive health aimed to shift training from a highly curative-based curriculum to one that also incorporated elements of disease prevention and promotion of health. The extended focus on preventive and promotive health reflected national and international changes of emphasis towards preventive and social medicine. In addition, another major shift in the syllabus was the increased time allocated to courses such as Anatomy and Physiology, Nursing Theory, and Nursing Practice. Sociology replaced ethics and scripture, while hygiene gave way to courses on microbiology with physics, chemistry and materia medica. All these changes suggest a greater emphasis on nursing as a science. The midwifery syllabus was also revised to include family planning and maternal child health education.
With the inception of NEBBLS, candidates aged 18 years and above now needed five ‘O’ level credit passes including English, Mathematics and Biology to be accepted for training regardless of sex, religion and marital status. This was another new departure from the old HCTNC requirements which only required an ‘O’ level certificate without specific subjects. The candidates still had to apply for admission to the school of nursing through the matron, but NEBBLS also required candidates to undergo individual interviews and they had to pass a pre-admission mathematics test. Mrs Margaret Tembe, tutor (and former student) at ADNT School, described the process succinctly: ‘At the end of every academic year we knew we had to receive applications, shortlist from a long list of applicants, those who were going to be interviewed and conduct interviews…’[67]
These changes in admission and in the curriculum offered at ADNT School were of paramount significance in the preparation of competent nurses to deal with the challenges of post-colonial Swaziland. Curricular-related shifts empowered nurses and further facilitated the delivery of quality nursing services especially in rural clinics. This was essential in Primary Healthcare delivery. As Searle observed, the number of nurses available and the quality of service they provide became two related factors in that, ‘Even though a numerically adequate nursing force is available, if the nurses are unable to effectively perform the functions required of them through lack of knowledge or if they provide a slip-shod service through lack of sound personal and professional philosophy, community needs are not met’.[68]
Conclusion
According to the 1925 colonial administration’s agreement with the Church of the Nazarene (CON), colonial Swaziland was supposed to have a two-tier healthcare system in which the few fully trained white nurses cared for the colonisers, while similar services were denied to the majority of the ‘native’ population. However, as early as 1925, due to the poor health of the Swazis, evident in a high disease burden, Dr David Hynd, originally brought in to establish a health service for the colonisers, also commenced the provision of health services by the CON to ‘native’ Swazis. By the late 1920s, as a result of increasing health problems especially within the ‘native’ labour communities, the colonial government relented and a form of nurse education developed to train ‘native’ nurses to take care of their own people.
By the early 1940s, training was provided for indigenous women at the Ainsworth Dickson Nurse Training School (ADNT), but it was inferior to that offered in South Africa and only permitted its graduates to work in ‘native’ hospitals. As Swaziland moved towards independence and beyond, this early form of nurse training proved incapable of producing nurses who could cope with the demands placed on them by the re-emergence of TB and malaria, and later, the emergence of new diseases such as HIV/AIDS. [69]
Post-colonial Swaziland inherited a healthcare system from colonial missionary medicine, which tended to ‘emphasize costly high-technology and urban-based curative care’, unaffordable to an economically struggling nation such as Swaziland, where the majority of the people were rurally located. This system proved unworkable in post-colonial Swaziland, demonstrated by the declining health of the population, flagged by health indicators such as reduced life-expectancy and high infant mortality rates. It was in response to these public health challenges that full nurse education in Swaziland evolved.
Chief among these developments was the introduction of full nurse training courses in Swaziland by the ADNT School. The courses, as they evolved became increasingly scientific in content and more attuned to the public health needs of the Swazi population. Support from countries such as Germany, the Netherlands and the US enabled Swazi nurses to travel abroad for training and return to the home country, as academically-empowered nurse educators. Of equal importance in the post-colonial period were the bonds which formed between the newly independent nations of Southern Africa which led to the formation of a new inter-territorial nursing board, NEBBLS, which took over responsibility for the quality of nurse training.
Analysis of defining moments in Swaziland’s journey from colony to independent nation has exposed effects on nursing education; particularly the transition from the colonial-missionary based healthcare provision to a more professional and science-based approach, with preventive and social medicine at its core, and which put the health needs of the Swazi population first. The transition from colonial to post-colonial healthcare facilitated the emergence of a Swazi philosophy of health embedded in the health policy and national development plan of the 1970s. By viewing the development of healthcare in Swaziland from a colonial and post-colonial perspective it is possible to argue that the nursing curriculum in the 1970s and 1980s was, to a certain extent, informed and shaped by the country’s health requirements.
A great part of this article comes from my PhD thesis completed at the University of Johannesburg. I am grateful to Professor Natasha Erlank for her contribution towards the completion of such an enormous task.
References
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[3] HCTs in colonial times were the three countries of Southern Africa namely: Bechuanaland, Basotholand and Swaziland. They got this name from the fact that in 1906 their governance was transferred to a British High Commissioner (HC) for South Africa. L. Hailey, Native Administrating in the British African Territories, Part V, The High Commission Territories: Basutoland, the Bechuanaland Protectorate and Swaziland (London: Her Majesty’s Stationary, 1953).
[4] Interview with Dr Maggie Makhubu on 6 March 2014.
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[13] Randall Packard, ‘Industrialization, rural poverty, and tuberculosis in South Africa, 1950-1950’, in Social Basis of Health and Healing in Africa, ed. by S. Feierman and J.M. Janzen (Berkeley, Los Angeles and Oxford: University of California Press, 1992), 104-130: 121.
[14] Ibid., 121.
[15] See SNA, RCS 22/32: Swaziland Annual Medical Report, 1931.
[16] Packard, ‘Industrialization, Rural Poverty and Tuberculosis’.
[17] Ibid., 126.
[18] Nhlanhla Dlamini, ‘Race Relations in Swaziland: The Case of Havelock Asbestos Mine, 1939-1964’, (Unpublished MA thesis, University of Swaziland, 2001), 39.
[19] Wits Library Archives, File, A1441/D: Church of the Nazarene World Missions Work and Missionaries Information.
[20] D. K. Mogobe and E. Ncube, ‘Evolution of formal Midwifery Education in Botswana, 1926-2005’, Notes & Records, 38 (2009), 89-98: 89. Batswana people are a Bantu-speaking ethnic group indigenous to Southern Africa.
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[22] Dlamini, ‘The Introduction of Western Medicine in Southern Africa’, 562. The expression quoted was used by D. Hardiman in D. Hardiman (ed.), Healing Bodies, Saving Souls: Medical Missions in Asia and Africa (Amsterdam: Rodopi, 2006).
[23] SNA, RCS 319/27: Opening Ceremony for the Raleigh Fitkin Memorial Hospital, Bremersdorp, Extract from a speech delivered by Dr Hynd on 16 July 1927.
[24] Martin J. Lunde, ‘An Approach to Medical Missions: Dr Neil Macvicar and the Victoria Hospital, Lovedale, South Africa, circa 1900-1950’, (Unpublished PhD thesis, University of Edinburgh, 2009).
[25] Dlamini, ‘The Introduction of Western Medicine in Southern Africa’, 567.
[26] See Helen Sweet, ‘Expectations, Encounters and Ecclesiastics: Mission Medicine in Zululand, South Africa’, in Western Medicine to Global Medicine: The Hospital Beyond the West, ed. by Mark Harrison, Margaret Jones and Helen Sweet (New Delhi: Orient Black Swan, 2009), 330-359:358; Clement Masakure, African Nurses and Everyday Work in twentieth-century Zimbabwe (Manchester: Manchester University Press, 2020), 352.
[27] SNA, R.S.C.461/34: Grants towards medical and nursing training of natives in High Commission Territories, 1934.
[28] SNA, R.C.S. 418/38: Grant for Construction of Native Nurses’ Hostel at Bremersdorp. Extract from a speech delivered by Dr Hynd during the official opening of the nurses’ home in 1940.
[29] Miranda Miles, ‘Missing Women: A study of Female Migration to the Witwatersrand, 1920-1970’, (Unpublished MA thesis, Queen’s University, 1991).
[30] Nomthetho G. Simelane, ‘A Historical discussion of migrant labour in Swaziland’, in Transformation: The Case of Swaziland, ed. By N. G. Simelane, (Darker: CODESRIA, 1995), 15-37: 33.
[31] Dlamini, ‘The Introduction of Western Medicine in Southern Africa’.
[32] Davies, Nursing in Swaziland, 45.
[33] SNA, RCS 940/32: Report by Principal Medical Officer Bechuanaland on conference held at Bloemfontein regarding the training of native nurses, 1932.
[34] Ibid.
[35] SNA, RCS 940/32: Report by Principal Medical Officer Bechuanaland on conference held at Bloemfontein regarding the training of native nurses, 1932; Shula Marks, Divided Sisterhood: Race, Class and Gender in the South African Nursing Profession (Johannesburg: Witwatersrand University Press, 1994), 88.
[36] SNA, RCS 940/32: Report by Principal Medical Officer Bechuanaland on conference held at Bloemfontein regarding the training of native nurses, 1932.
[37] Ibid.
[38] SNA, RCS 938/ 32: Application for Assistance under Colonial Development Fund for Medical outpost, 1932.
[39] Ibid.
[40] SNA, RCS 777/32: Medical Comments on the Pim Report, 1932.
[41] SNA, RCS 940/32: Report by Principal Medical Officer Bechuanaland on conference held at Bloemfontein regarding the training of native nurses, 1932.
[42] Interview with Mrs Eva Lukhele of Croydon in the Lubombo region on 14 September 2013.
[43] Ibid.
[44] The new programmes were established under the auspices of the newly formed High Commission Territories Nursing Council (HCTNC), an inter-territorial nurse regulatory organization established under the South African Act of 1944, with the aim of producing competent black nurses whose certificates were internationally, recognized instead of producing nurses only fit for service in African reserves. SNA, File 1829: The High Commission Territories’ Nursing Council, 1944.
[45] Ibid.
[46] D. K. Mogobe and E. Ncube, ‘Evolution of formal Midwifery Education in Botswana, 1926-2005’, Notes & Records 38 (2009), 89-98:90.
[47] See Serara Selelo-Kupe, An Uneasy Walk to Quality: A History of the Evolution of Black Nursing Education in the Republic of Botswana, 1920-1980 (Michigan: Walsworth, 1993), 121.
[48] Davies, Nursing in Swaziland, 28-29.
[49] Interview with Mrs Marry Ndlela at Limkokwin University in Mbabane on 11 March 2014.
[50] Davies, Nursing in Swaziland, 28.
[51] Charlotte Searle was the first South African nurse to attain a doctoral degree in nursing and became the first South African nurse to be appointed professor of nursing. She was an early supporter of the training of black nurses in South Africa. Selelo-Kupe, An Uneasy Walk to Quality, 125.
[52] Nazarene College of Nursing Archives (NCN), a letter written by Charlotte Searle as advisor to the Principal of the time on 18 May 1989.
[53] University of Swaziland Archives, Board of Affiliated Institutions: Agenda, 1988-1990.
[54] E. M. Kiereini, ‘WHOs Role in the Development of Nursing in the African Region’, International Nursing Review, 35, 3 (1988), 65-66: 65.
[55] Interview with Winnie Nhlengethwa at Southern Africa Nazarene University in Manzini on 17 May 2014.
[56] Anonymous, ‘TB: The most problematic disease’, Times of Swaziland, 25 September 1970, 7.
[57] Ibid.
[58] Anonymous, ‘The Diseases that Kill our Future’, Times of Swaziland, 6 July 1977, 11.
[59] Ibid.
[60] Ibid.
[61] After 25 years of successful malaria control, in July 1977 Swaziland had witnessed only 87 malaria deaths. A year later the disease was rampant: 1473 malaria cases were treated. Swaziland Government, Economic Planning Office, Second National Development Plan, 1973-1977, Mbabane, 196
[62] Ibid.
[63] Nazarene College of Nursing Archives hereafter referred to as NCN Archives, Nazarene Health Services, Annual Report of 1977, 15.
[64] Swaziland Government, Economic Planning Office, 196.
[65] NCN Archives, Nazarene Health Services, Annual Report of 1977, 15.
[66] NCN Archives, Nazarene College of Nursing Transcripts.
[67] Interview with Mrs Margaret Tembe at SAFAIDS Offices in Manzini on 8 March 2014.
[68] Charlotte Searle, The History of the Development of Nursing in South Africa, 1652-1960 (Cape Town: Struik, 1965), 283.
[69] The onset of HIV/AIDS and its relentless spread in the 1990s almost shattered all hopes of the country’s sustainability, but with the commencement of anti-retroviral treatments at the turn of the twentieth century, the numbers of people succumbing to death from HIV/AIDS began to fall. Muhle Dlamini, ‘The Impact of Antiretroviral Therapy scale-up in Swaziland’, UNISWA Research Journal, 27 (2014), 59-69:66.
