COMMENTARIES

 

Origins of South Africa's eight and oldest rural medical school: Pioneering a new approach to medical education

 

 

S A Mabunda^{I, II, III, IV}; M N Xaba-Mokoena^V

^IPhD, MMed PHM, FCPHM, MB ChB; School of Public Health, Walter Sisulu University, Mthatha, South Africa
^IIPhD, MMed PHM, FCPHM, MB ChB; Global Centre for Human Resources for Health Intelligence, Walter Sisulu University, East London, South Africa
^IIIPhD, MMed PHM, FCPHM, MB ChB; School of Population Health, University of New South Wales, Sydney, Australia
^IVPhD, MMed PHM, FCPHM, MB ChB; George Institute for Global Health, University of New South Wales, Sydney, Australia
^VMD, MMed Pulmonol; Faculty of Medicine and Health Sciences, Walter Sisulu University, Mthatha, South Africa

Correspondence

 

 

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ABSTRACT

With seven medical schools and only two (University of Natal and the Medical University of Southern Africa (MEDUNSA)) freely admitting black South Africans in the early 1980s, South Africa still had notable shortages of medical doctors, especially in rural areas such as the Transkei independent homeland. Of the few doctors in the Transkei, only 5% or less were in rural areas, the rest in bigger towns. At the time, further observations were that most rural doctors were not South African, and they often found it difficult to communicate with patients directly. Owing to the paucity of medical doctors in the rural Transkei and elsewhere in South Africa, the University of Transkei - which had already helped many rural graduates from other fields - desired to remedy the situation. This was further noted by the then President of the Transkei, Dr Kaiser Matanzima, who approached a female pulmonologist in 1984, Dr (later Professor) Marina Nolwandle Xaba-Mokoena, who was the medical superintendent of Mthatha General Hospital, that a medical school or faculty of medicine and health sciences was direly needed for the area. This faculty would be affiliated with the University of Transkei (UNITRA), renamed Walter Sisulu University in 2005. So, when the highest office in the homeland approached her, stating that this idea had been canvassed for many years previously without success (rumoured to have been conceived as early as 1963), she considered and agreed on condition that she would be granted all support needed. The government further gave an instruction for only individuals from the Transkei to be enrolled in the soon-to-be new medical school.

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Who is Prof. Xaba-Mokoena?

It would be incomplete to describe Prof. Xaba-Mokoena without mentioning her father's legacy. Her father (Dr Rotoli Xaba) from the Transkei (Willowvale) where Prof. Xaba-Mokoena was born, was the 23rd non-white South African doctor who had graduated from Edinburgh, Scotland, in 1936 and returned to practice in South Africa. ^[1] No university could accept him for medical studies in South Africa (only the University of the Witwatersrand and the University of Cape Town had medical training at the time).^[2-4] Prof. Xaba-Mokoena's first and middle names (Marina (from marine) and Nolwandle (from overseas)) relate to the fact that she was born in 1938 immediately after her father returned from overseas.^[3] She matriculated at 15, initially trained as a nurse then later moved to Sweden (Stockholm University) on a scholarship from the Swedish International Development Authority (SIDA) where she graduated as a medical doctor in 1973.^[3/ She then trained as a pulmonologist but, as per her initial undertaking to return to serve in developing countries, she then returned to Africa (first Lesotho, then South Africa). ^[3] When she arrived in South Africa, she was an accomplished clinician who had published extensively on tuberculosis (TB) and tobacco-related illnesses, which were major burdens in the Transkei at the time. ^[3] She went on to be vice-president of the South African National TB Association (SANTA) and founded the Transkei National TB Association.^[3]

 

The opening of WSU Medical School: Challenges and enablers

On 31 May 1985 (atypical as the academic year had already commenced in February), 12 enthusiastic students descended to Prof. Xaba-Mokoena's office to respond to a call for willing students to be enrolled as the first cohort of the University of Transkei's Bachelor of Medicine and Surgery class. Going against initial instruction from the homeland president, only five of the candidates were from the Transkei, with one being a refugee from Sri-Lanka. To qualify for the programme, students needed to have had at least their first year of training in either chemistry, physics or biology and at Bachelor level. The intention was to start with 12 enrolments and increase gradually annually thereafter to meet the projected demand for over 140 student intakes.

 

 

On the opening of the faculty, Prof. Xaba-Mokoena was told that she had approximately R10 - 12 million to start with and, in the future, funds could be sought from all the other departments out of the money that had been budgeted for and not used in that financial year - instead of the funds being returned to treasury. She, however, never concerned herself much about finances as the people who had recruited her (i.e., the Government of the Transkei and the University) had promised to support her when approached to start this project.

The greatest challenge was to get suitably qualified staff as there were not many doctors who had post-graduate training in the Transkei and only a few could qualify to be lecturers or academics. So she had to advertise and look for staff outside the region and, in turn, find accommodation for these doctors and their families and schools for their children, and jobs for their partners, where the partners had a suitable qualification, regardless of the field. With every member of staff who was appointed, she had to help in setting up laboratories and obtaining equipment and further ensure that staff got in touch and co-ordinated with each other and also relevant and equivalent members of staff in those departments of universities that were willing to assist.

The year 1985 was a challenging year, in general owing to a volatile political climate. One of the issues was the brutal murder of Bathandwa Ndondo, a former UNITRA student leader who was murdered by security forces on 24 September 1985.^[5] Protests associated with this murder almost brought the academic programme to a halt.

There were many sceptics, some of whom were integral to the university, who even joked whether the graduates would become witchdoctors and also predicted that the programme would die a natural death. Some of the sceptics questioned the tribal and ethnic origins of the founding Dean, others referred to her as 'an ambitious woman who had great or high ideas of her capabilities'. Once they knew that she was also born in the Transkei, they accused her of favouring foreigners as educators in the medical school. These were the very colleagues whom she had hoped would encourage and assist her. Some would go to the extent of asking students who were pioneers why they wasted their time with something that was going to die a natural death. Five candidates in the first cohort were discouraged so much that they dropped out of the programme owing to uncertainties about the future.

Barely a month after enrolment of the first cohort, a commentary article was published by the then Vice Chancellor of the University of Cape Town^[6] who asserted that

'... it is very difficult to develop a university in the RSA [Republic of South Africa] far away from a highly developed urban community.^[6] Unless we have some way of stopping the unnecessary proliferation of universities, tertiary education in this country is going, in certain respects, to become somewhat of a laughing stock.^[6] The University of Transkei is to have a medical school as, according to some reports, is the University of Lebowa.^[6] One can fairly ask what sort of medical schools these will become. Where will the staff of sufficient academic standard be found? What will be the nature of the teaching hospitals? There is a danger of their obtaining a fifth-rate, far-from-first-world medical education. Perhaps these proposed new medical schools are to train an entirely different type of "doctor"? Surely a school of public health to educate health professionals to work in rural areas constitutes a greater need.' ^[6]

Upon graduation in 1990, the first seven students had difficulties registering with the South African Medical and Dental Council to do their internship. They were eventually allowed to do their internship in Mthatha. They completed their internship but were again denied registration by the Council until August 1992 (eight months later than peers from elsewhere). Notably, to proactively dispel stereotypes, the programme had external examiners from the second year to show that the students were at the same level as any other medical student in the country. The seven graduates from the first cohort include Sanjayan Jeganathan (first in cohort to specialise), Mkuseli Kenneth Mashiyi (late), Percy Buti Ndlovu (late), Doreen Noah, Ganasagrie Pillay, Iah Bongiwe Sipamla and Mvula Tshabalala. Their ages at graduation ranged from 24 to 50 years.

Not all was gloom, though, as there was support from the University of the Witwatersrand (Wits) and also pledged support from MEDUNSA. Prof. du Plessis who was a Vice Chancellor of Wits and a surgeon also served on UNITRA's council. He connected Prof. Xaba-Mokoena with Prof. McGregor who was the Dean of Medicine at Wits. Thus, the MB ChB cohort could be supported with external examiners from their second year of study, and they also supported with resources and content. Prof. Simpson from the University of Natal assisted with the first sets of cadavers, after successfully navigating through legislative hurdles with the introduction of dissections for medical teaching. Other motivators both inside and outside the university include Prof. Nompumelelo Jafta and Dr Mthethwa.

 

Contextually relevant curriculum

The founders of the WSU Medical School had a vision of a medical school that would be of the same standard as existing ones, but this one's emphasis would be community-based, community-oriented and problem -based. When planning for the opening of the medical school, Prof. Xaba-Mokoena visited Ben Gurion University in the Negev in Israel and John Hopkins University in the United States of America, to mention but a few. She decided on a model of teaching which uses the primary health care approach (PHC), with an emphasis on a preventive model of care more than a curative approach. The medical school was launched barely seven years after the Alma-Ata manifesto for PHC which had declared health for all by the year 2000.^[7] It was therefore an aspiration of the founding dean for this new medical school to contribute to that objective. However, other established scholars publicly claimed that these medical doctors would be trained as glorified social workers.^[6] They continued to assert that there was no need to have a community-based or community-oriented 6-year medical curriculum; the same result could be achieved through the upskilling of nurses.^[6]

 

References

1. Digby A. Black doctors and discrimination under South Africa's apartheid regime. Medical History 2013;57(2):269-290.         [ Links ]

2. Digby A. The last cohort of early black doctors who studied abroad, 1931-1940. S Afr Med J 2007;97(7):508-509.         [ Links ]

3. Xaba-Mokoena MVN. Dream fulfilled: Memoirs on MVN Xaba-Mokwena. Publisher not identified. 2006.         [ Links ]

4. Phillips H. The University of Cape Town 1918-1948: The formative years. Cape Town: University of Cape Town; 1993.         [ Links ]

5. South African history online. Bathandwa Ndondo. https://www.sahistory.org.za/people/bathandwa-ndondo (accessed 4 May 2025).         [ Links ]

6. Saunders SJ. Some challenges to South African universities. S Afr Med J 1985;67(23):932-933.         [ Links ]

7. Fendall NR. Declaration of Alma-Ata. Lancet 1978;2(8103):1308. https://doi.org/10.1016/s0140-6736(78)92066-4.         [ Links ]

 

 

Correspondence:
S A Mabunda
drskhumba@gmail.com

Received 4 May 2025
Accepted 11 August 2025