Military surgeon Jiang Yanyong, the doctor who defied the government and spoke the truth of SARS in 2003, talks at a forum on the 10th anniversary of SARS held in Beijing. He died this past week at age 91. Simon Song/South China Morning Post via Getty Images hide caption
China's health minister, Zhang Wenkang, himself a former military doctor, issued a statement on April 3 with the reassuring news that the capital had seen only 12 cases of SARS all of whom had contracted it outside of Beijing. On April 6, China's premier, Wen Jiabao, followed up to "warmly welcome friends worldwide to come to our country for tourism, visits or to engage in commercial activities" and asserted that "the Chinese government [was] fully capable of controlling the spread" of the illness.
Jiang watched these statements in disbelief. He knew that doctors and nurses in Beijing were contracting SARS while treating patients, who occupied hospital beds by the dozens. After talking to colleagues at his own hospital that he would describe as "furious" at Zhang and Wen's lies, he decided to sound the alarm. On April 4, he faxed a statement on the true spread of the disease to China's main state broadcaster and to a TV station in Hong Kong. He received no response.
I was a correspondent for Time in Beijing and was having a hard time reaching doctors who would speak to me. On April 8, I called a well-connected friend who'd grown up in Beijing and who I hoped might know some doctors. He was breathless when he answered. Apparently, he had been just about to call me. He asked me to call him back from a "safe" phone outside of the Time bureau. Once I did, he told me about Jiang's statement and said he'd send it right away.
I returned to my office to read the statement more closely. It was just five paragraphs long. Jiang described how appalled he'd felt when he'd heard the health minister's statement and then detailed why the official number of cases was an undercount. His own hospital moved a SARS patient to an infectious disease hospital, where 10 doctors and nurses fell ill. At another hospital, there were 60 cases and seven deaths. The official number of cases for all of Beijing that day was 19 with one death. Perhaps the most damning of his revelations was that medical personnel in Beijing knew in early March that SARS was spreading locally but had been forbidden to make that information public to "ensure stability" at two upcoming annual government meetings that would bring officials from all over the country to the capital to set China's policy agenda for the year ahead.
Perhaps this was the trick of an experienced doctor, a good bedside manner, or maybe we somehow managed to put each other at ease. From there the conversation flowed smoothly. Jiang explained how he knew what he knew, his voice rising as he described how angry and frightened his colleagues were and the risk SARS posed to the general population. "If I were an ordinary person and started to run a fever," he said, "I wouldn't know to go to a hospital. I could be severely ill before I realized it was more than a cold." This was the fear that had impelled him to act.
We published that night. By the end of the next day, after Jiang fielded calls from dozens of reporters, the military instructed him to stop talking to foreigners. He called me to tell me this. But the following week, when a World Health Organization SARS inspection team visited Beijing hospitals, he still found a way to pass me information. Both military and civilian hospitals in Beijing had hidden SARS patients from the inspectors. One hospital moved the sick out of their ward to a hotel; another piled them into ambulances and drove them around the city until inspectors left. By that time, Jiang's courage had inspired other doctors and officials to speak out. Though most did so anonymously, they did so in numbers great enough to confirm the hidden patients. On April 20, Beijing bumped up its official SARS case count nearly tenfold and fired both the health minister and Beijing's mayor. The SARS outbreak spread to four continents before it was stopped in July 2003.
We last met in December of 2015 at what by that point was "our hotel." As usual, he'd ridden his bike to our meeting. He brought along a small laptop and spent much of our time together showing me, with evident pride, pictures of recent surgeries he had performed. At the age of 84, he still loved being a doctor.
Two decades since SARS and three long years into COVID, with the walls of secrecy and silence Jiang pierced now rebuilt, his funeral on March 15 was small and closed to the public. I have seen no mention of his death in China's official media. During the height of his celebrity in 2003 when people around China called him a hero, Jiang was fond of saying he'd be content to be remembered as a doctor who told the truth. We'll have to try.
Why are so many doctors from the Indian subcontinent practising in the UK? Why do they come here and what has been their experience of working in the NHS? Although they are such a significant and visible part of the NHS, it is surprising how little we know about this group.
Initially only open to Europeans, Indians were allowed to enter the IMS in 1855, although the requisite was that they still had to sit exams based in London and had to be registered with the GMC. At the time there were many schools training Indian doctors, but only as licentiates.
In relation to medical education, the Anglicist viewpoint prevailed and, through pressure applied by the IMS, indigenous courses for the training of Indian doctors were abolished. Within a short space of time, several medical colleges, modelled along western pedagogic styles, were established. The staff of all these colleges were appointed from the IMS and their methods of instruction were virtually indistinguishable from those practised in England and Scotland.
The best historical record of the early pioneers is contained in Rosina Visram's excellent book on Asians in Britain.8 Visram documents how many doctors, some who came as already qualified from India and some who trained here, were active in the anti-colonial movement. Repeating a pattern which is still present today, they ended up working in the poor areas of Britain. Perhaps it is a bias of historical records that has highlighted contributions of doctors who worked in deprived areas and made a significant contribution through their involvement in local politics? However, it is also likely that many avenues were closed to these doctors because posts in the financially-lucrative areas were almost certainly taken up by white doctors. This is a pattern that still exists today.9 It is also true that many doctors were also probably influenced by the Ghandian philosophy of service to the benefit of humanity without personal rewards. This is perhaps why many doctors also ended up in deprived areas and became involved in local politics.
There is little information on the number of overseas qualified doctors working in the NHS at its inception but there is a consensus that there were about 3000 doctors working in the NHS in the 1950s. Many historians of the NHS have described its creation as a compromise between the demands for a universal system of health coverage counterbalanced against the demands of a relatively autonomous medical profession, which was keen to preserve its elite status. So although the relationship between consultants and GPs may seem natural now, the hierarchy of consultants within the hospital service, and crucially its dependence on junior staff, came about as a result of this compromise. This, more than anything else, created the dependency on migrant labour that has become a feature of the NHS.
Although it was clear from the outset that the NHS could not be entirely staffed by British qualified doctors, the views of the medical establishment can be summarised as one of antagonism to migrant doctors. The British Medical Association (BMA) was keen to pursue a policy that would severely restrict the rights of foreign medical students to practise in Britain, but it was clear that the needs of the NHS had to take precedence. Throughout the 1960s the Ministry of Health worked very closely with the Ministry of Labour to maintain the flow of overseas doctors at a level necessary to ensure the smooth running of the NHS.
Ironically, it was Enoch Powell as Minister of Health in 1963 who oversaw the first expansion of the NHS and was an architect of the policy of recruiting doctors from the Indian subcontinent. It was probably his own spell in the army in India that influenced his views about the roles that Indian doctors could play in fulfilling the dire labour shortages in the NHS. The modern parallel is very interesting in that the huge investment in the NHS following the publication of the NHS Plan in 2000 required a significant increase in the recruitment of overseas doctors.3
Work by David Smith published in 1987, in the first major study of overseas doctors, showed very clearly that about one-third of doctors arriving in the UK during the 1970s achieved their ambitions and went back to the Indian subcontinent but the vast majority did not. The reasons for this are complex but they include doctors not achieving their educational, training, or career objectives, some because they liked it here, and some because they got married or their family circumstances changed. In my view these doctors became the indentured labourers of the NHS.
The concept of indentured labourer has never been applied to such highly-skilled professionals as doctors but it has been a significant part of emigration from India for over 100 years. With the end of slavery it was clear that there was still a need for labour in the Colonies of Britain and hundreds of thousands of Indian workers were recruited to work in the sugar plantations of the West Indies and on the railways in the African Colonies. The reason that there are so many Indians in the West Indies, in South East Asia, and in East and Southern Africa is because of this indentured labour. Workers were willingly recruited in India with the offer of work, accommodation, food, safe passage, and yet when they arrived they found they were paid such poor wages that they could never afford to pay back the money they borrowed to get there in the first place. 041b061a72