International Histories of Medical Manpower 1950-1990

Overview:

This project explores the historical geography of the ‘medical manpower problem’ from 1950 to 1990. As a concept, ‘manpower’ contains a normative judgment and an inherent task: ensuring ‘the right numbers’ of staff are ‘available at the right place, at the right time, and with the requisite skills and motivation to deliver healthcare to the population’ (World Health Organization, 1980, 52). As a research frame, the concept of manpower thus has fascinating temporal (enumerating the present workforce to forecast future needs) and spatial (through measures such as ‘maldistribution’ or ‘medical density’) axes. Manpower was programmatically central to the work of the World Health Organization and UNICEF, and animated multiple studies and conferences at the Commonwealth Fund, Ford Foundation, Josiah Macy Jnr Foundation and the Rockefeller Foundation. Notably, while there is a surfeit of archival material related to international efforts in the medical manpower field, there has not yet been any research synthesising this fascinating, vatic history. This study will thus be the first, of which I am aware, to adopt an expressly global perspective on the historical problem of medical manpower.   

This research is located, empirically and methodically, within two major topographic shifts in health and medicine. First, the massive post-war expansion of the US healthcare ‘industry’ to become the country’s second largest employer by the 1970s, with an insatiable need for staff and increasing political sway (Sorkin, 1977). Second, the establishment of and growth in medical schools and hospitals through the Global South as explicitly decolonial efforts in modernisation and nation-building. This project interrogates the inherent interlinkages between these seemingly disparate shifts through close attention to the key actors, theories and disciplinary perspectives that came to animate the programmatic imperatives of international organisations in the manpower field. In particular, the project traces the links and lineages between increasingly vociferous critiques of the ‘medical industrial complex’ in the West within the field of ‘social medicine’ and efforts to plan more ‘appropriate’ and affordable healthcare provision in developing countries.

Research questions:

1. How was the ‘medical manpower problem’ (and its proposed solutions) conceptualised, defined, enumerated, and communicated at an international scale?
2. Through what ideas, research, actors, and technologies have efforts to confront manpower shortages linked developed and developing countries?
3. What are the continuities and discontinuities between the present-day international ‘health workforce crisis’ and the history of efforts to address the ‘medical manpower problem’? 

Research methods:

This project combines multi-sited archival research with stakeholder interviews in order to trace the complex relationships between past and present medical manpower planning efforts and challenges. The key archival sources reflect and interrogate the geographies of these efforts. As such, the project draws on the rich archives of international organisations (World Health Organization, International Labour Organization, United Nations; UNICEF, UNESCO, Commonwealth), US-based philanthropies (Commonwealth Fund, Rockefeller, Josiah Macy, Ford, Kellogg), national archives (US, UK, Sri Lanka, Tanzania, Kenya, Singapore), the personal papers of key actors in this history (located at, along others, Harvard, Yale, Columbia, LSE, Sussex) and professional medical associations (e.g. BMA, AMA, Commonwealth Medical Association, World Medical Association). As well as these archives, the project also makes use of existing oral history repositories and draws on contemporary documentary and policy analysis to identify key experts in the field for interview. One of the key aspirations and challenges of the research is the need to move beyond the expert, international field to interrogate national and local responses to these efforts across a variety of case study countries. Identification and interrogation of the points of friction between key actors is therefore a core methodological goal.

Significance and contribution:

While the language of ‘medical manpower’ remained ascendant until the 1990s, the term has since been replaced by concepts such as ‘health systems strengthening’ and ‘human resources for health’.  Yet, whatever you call it, the ‘problem’ of staffing healthcare systems has not gone away. If anything, it has amplified as trained healthcare workers have become ever more mobile, medical tourism has boomed and the rise of private healthcare across the world has asset-stripped public systems. And yet despite this global ‘health workforce crisis’ (Sidibé and Campbell, 2015), the methods and parameters used to forecast future manpower needs have barely changed. Efforts to quantify present staffing levels remain patchy and inaccurate and, globally, there still are not enough doctors, nurses and para-medical personnel despite huge investment in medical training and facilities across the world. In disciplinary terms, the project represents a significant contribution to several fields: (global) histories of medicine and development, historical geography and global health. Most importantly perhaps, its novel excavations of the past also hold crucial lessons for the present.