COMMENTARIES

 

The speech that transformed medical education in South Africa, as delivered in September 1985: A dream to be fulfilled

 

 

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

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

Correspondence

 

 

Redacted speech of Prof. Marina Xaba-Mokoena

Your Excellency, The State President of Transkei and Chancellor of this university, The Honourable Prime Minister, Cabinet Ministers, Paramount Chiefs in our midst and their wives, the Vice-Chancellor, the South African Ambassador to Transkei, the Chief Justice, Dignitaries, Ladies and Gentlemen; I am about to address you on: 'Some challenges to Transkeians'.

One of the greatest challenges is health for all by the year 2000. This had been discussed already in 1963, by the medical doctors of Transkei, that considering the population and patient/doctor ratio, we are far below standards acceptable to the World Health Organization. Considering the statistics, we have today in Transkei approximately a 1:44 000 doctor/patient ratio and, if we consider expatriate doctors too, a 1:15 000 doctor/patient ratio. This is far below what is acceptable by World Health Organization standards, which is 1:500. Hence, in October 1983, a joint pilot committee was established in conjunction with the Health Department and the University of Transkei, as the formation of the medical faculty was regarded with great urgency. We need to train, or produce, at least 500 doctors for Transkei and, for every doctor, five paramedicals.

With regard to Std 10 pupils, 2 189 matriculants in 1976 increased at an average rate of 29.3% to 10 251 in 1982. Statistics relating to matriculation examination results were tabled, and it was noted that there would be sufficient candidates with exemption to follow a medical degree or B.Sc degree. It was further noted that 90% of the B.Sc students at UNITRA (about 200 students) intend to follow a degree in medicine. The Department of Health via the Public Service Commission offers bursaries in the form of salaries to students who intend to follow a medical degree. It has long been accepted that training facilities in Southern Africa for doctors are inadequate.

To alleviate this impossible situation, the University of Natal was able to increase its places during 1974. The Department of National Education, which supported and still supports that faculty, made this possible. MEDUNSA was also opened to cater for black students in the whole of Southern Africa and yet, during the years quoted below, Transkeians had the following numbers of students keen to study medicine, with qualifying criteria, and having been awarded bursaries, but with no places for admission: 1982=17; 1983=18; and 1984=15.

The Faculty of Medicine of the University of Natal was established to train nonwhite medical practitioners. Up to 1963, there were few problems, as about half of the applicants who applied and met the requirements for admission were admitted. From about the year 1968, the number of applicants increased out of all proportion to the available facilities, such that so many more probable candidates could not be admitted. This too caused some reaction in African communities. Branford, who was sometime Assistant Registrar for the Faculty of Medicine at the Natal University, developed the statistics of admissions to the medical school during the first decade of its existence, and found that:

(a) matriculation success was an indication of future success in the study of medicine

(b) to progress, a student must be able to communicate adequately, (a minimum of at least 50% in the final matriculation examination in English was and still is regarded as a sine qua non for admission)

(c) adequate marks in the matriculation examination in mathematics and science were definitely also a measure of future success. The main reasons for a large percentage of applicants, who have passed matriculation, failing to gain admission to the faculty have been found to be a low overall aggregate in matriculation.

Candidates who passed matriculation after a second attempt were also eliminated. If a candidate could not pass his examination at the first attempt, he was really wasting his time in applying for admission. Looking at the full statistics for African candidates since the establishment of the Faculty of Medicine in Natal, it became clear that each year the number of candidates who qualified for admission was rapidly increasing. Percentage-wise, in 1951, 81% of the qualified candidates were admitted whereas, in 1974, 19% of the qualified candidates were admitted to the Faculty of Medicine due to limited facilities. (One must remember that African candidates had to compete with Indian and Coloured candidates for admission.)

The Department, being fully aware of the situation, had for many years sought a solution. Even if the facilities were increased to an intake of 160 students per year, very few more African doctors would qualify. Thousands are needed throughout the Republic and the Independent States. There is at present one qualified African doctor to some 44 411 potential patients. It will take many decades to improve the situation, if only some 20 doctors qualify annually.

During a visit to the Medical School in Durban, it was heard that the quality of matriculants had so improved that it had become embarrassing for the Faculty of Medicine. They are limited by a fixed number of places available in the Medical School and have to turn away some very good African, Coloured and Indian candidates. This would mean that in the future, scholars would have to try even harder to gain the best possible matriculation pass if they wish to be considered for admission. Although I have mainly talked about training medical students, we intend to train even pharmacists, health educators and inspectors, and all kinds of paramedicals. This is of such great importance that one wonders how some of our 28 hospitals are run and manned without these. We have coped with dispensary assistants, darkroom attendants - lmostly untrained and unqualified staff.

I have thus far endeavoured to show the reasons for the desirability and motivation which has led to the establishment of our new Faculty of Medicine and Health Sciences. Coming back to 'Health for all by the year 2000', the 36th World Health Assembly held in Geneva in 1983 approved a wide-ranging programme of activities geared to achieving 'Health for all by the year 2000'.

According to a report in I.S.I.S. News, monthly newsletter of Health and Social Security, published in Rome, the World Health Assembly discussed the difficulties being experienced in organising the control of tuberculosis in developing countries. The great hope for an early victory over tuberculosis was hampered by the lack of adequate technology in developing countries. The Assembly decided that experts should be made available to promote health and sociological research, particularly in the field of epidemiological and immunological study. The introduction of technology as a result of such research, and its adaptation to the primary healthcare and collaboration between the action programme for essential medicine and the pharmaceutical industries, would render preventative healthcare operation effective at developing country level (ISIS News 29-31, 1983).

A basic philosophy on undergraduate education is of prime importance in defining the task of the faculty. The faculty should derive its objectives from healthcare, giving due emphasis on the needs of the communities, families and patients.

The faculty must aim to raise the standards of the healthcare system, of which it is part, making the most efficient use of the available human and physical resources. This should be done with recognition of the views of the students and faculty itself. The faculty must exert influence on the education and health system by contributing, in the form of research and experimentation, to the acquisition of the best possible structure for, and procedures in, healthcare. Research is necessary in relation to the supply and demand of healthcare delivery and in connection with such matters as the definition and co-ordination of tasks, and education and training of doctors and other healthcare workers.

Hence, medical education must be relevant to the needs of the student on qualification, and what will be regarded as meeting the needs of the community he will serve. Therefore, we think it is a realistic and unique situation to train doctors for Transkei in Transkei. Admittedly, though not altogether identical, conditions in the Transkei are not very much different from those in Ciskei, Venda and Zululand or South Africa. Of the total population of South Africa, 70% are black and many of them live in developing rural areas. Yet 80% of the doctors are in cities and large towns. Approximately only 5.5% of South African doctors practise in villages and rural areas.

Developing rural and urban communities largely suffer from diseases which are, in the long term, related to socio-economic predicaments, and which are paradoxically preventable and curable at relatively low cost. It is still easier, and more profitable for a physician, to write a drug prescription than to tell an average hypertension patient to lose excess weight, stop smoking, quit worrying, exercise more, and reduce intake of salt, cholesterol and highly refined foods.

To illustrate these points, the most common causes of human manpower resource waste, or health hazards crippling manpower, or simply absence from work, are secondary to, and intertwined with, preventable conditions like:

(a) tobacco smoking and air pollution

(b) alcohol abuse and its consequences

(c) accidents - in particular, motor vehicle accidents.

Do we want to be swamped by an increasing flood of preventable diseases, or wait until the symptoms develop before heeding the arguments? Health seems to come a poor second to wealth where smoking is concerned in so far as governments are concerned throughout the world. The smoke ring is the ring of defences which has kept the power of the tobacco industry intact for the past 20 years, despite its lethal products.

In his inaugural speech at Wits in 1984, Prof. Gear slated South Africa's medical curriculum and accused graduates of abrogating their responsibility. He stated that the present curriculum is irrelevant, because it does not encourage our graduates to work where the need is greatest. Calling for a radical reform to the present curriculum he said, 'Our present system of a western model of excellence is discriminatory and essentially leads to the production of doctors whose training is irrelevant for much of South Africa's needs.' He continued, 'Our medical school is modelled on the fine traditions of British Medicine and is orientated to a highly sophisticated technical setting. It emphasises curative medicine at the expense of preventative.'

Whilst I agree perfectly with all he has said, I feel we should strive for excellence but not, or instead of, perfection. It is better to get more things done well, that one thing perfectly. Various opinions can challenge that statement, but whatever is worthwhile doing, is worth doing well.

Here it is to be noted that the three universities in the Western Cape do not accept blacks, and those which do, accept only a minimal gesture number. There are in fact, at present in the Republic of South Africa, six medical schools for whites, whilst blacks have access to only three for the whole of Southern Africa.

We have also had some criticisms in the South African Press in September 1984, to which I replied. It reminds me of the day the University of Natal was to be inaugurated by a Natal Administrator - Mr J G Shepstone - and the South African Press came out the day after with cartoons of black witchdoctors being graduated! This was in April 1955. Do the doctors who graduated regard themselves as 'witchdoctors' today, or are they regarded as such? No. Incidentally, one of them is lecturing in the UK today (Dr O Jolobe).

In summing up, I would like to express that I undertook, on behalf of my community and people, an important and difficult task which had to be done; and in this connection, I would like to relate this story about 'People named Everybody.

This is a story about people named Everybody, Somebody, Anybody and Nobody.

There was an important job to be done, and Everybody was sure that Somebody would do it.

Anybody could have done it, but Nobody did it.

Somebody got angry about that because it was Everybody's job.

Everybody thought Anybody could do it, but Nobody realised that Everybody would not do it.

It ended up that Everybody blamed Somebody, when Nobody did what Anybody could have done!

Prof. Moshe Prywes of Ben Gurion University of Beer Sheva in Israel, in his paper on Community Medicine, said the 'first born' of a marriage between Medical Education and Medical Care describes the Dean of the Faculty as playing a crucial role in mobilising academic resources of the university, to aid in the planning and evaluation of changes in the healthcare system.

Teaching is integrated horizontally, among subject areas within a particular phase of the curriculum, and vertically among subject areas over successive phases. The curriculum structure is suggestive of a spiral form, rather than the conventional form of layers. But the programme of integration among subject areas must be the responsibility of the faculty itself, from within, and not from without. The Medical Faculty will be inaugurated as a means to that end at least.

The basic change is the education of future doctors, built on integrated and community-oriented physicians who are ready to serve people, instead of being hospital- or disease-oriented. This would mean a very important step forward in the history of health personnel education.

Prof. Moletsane in his inaugural speech at this very university a month ago, spoke beautifully about curriculum development and changes. Towards his conclusion, he said, 'The potential is great; the country has people, Transkei has people, it has wonderful land and access to the sea with a conducive climate for prepared people and personnel.'

I have had to mention some of these ideas in order to make the world aware of the fact that there are people who are prepared to do things for themselves and their people. Even we in the medical field have some community orientation. Since I have returned home, many people have regarded me as the TB doctor rather than the specialist in lung diseases or chest physician that I am. The reason is simple: most of my patients here suffer from tuberculosis. I am sure it would not have interested many if I had spent this hour talking about lung physiology or various respiratory or lung diseases. On the other hand, community medicine and health for all are of common interest to all of us.

Before I finish, I should like to thank all of those who have assisted in seeing the taking off of this project. In particular, I would like to start off with His Excellency, The State President of Transkei, Dr K D Matanzima, who had a vision. In the ancient Book of Proverbs, Chapter 29, Verse 18, it reads, 'Where there is no vision, the people perish.' I am sure that UNITRA Top Administration and the former Pilot Committee all understand what I mean when I say that His Excellency had a vision and insisted on this Faculty being started.

Shakespeare wrote in his play, Julius Caesar, 'The evil that men do lives after them. The good is often interred with their bones.' I trust it will not be so with our State President. I am reminded that it was in the same strain and way that His Excellency started this university, first at what is now the Technical High School and later on here to this monument. I again remember occasions when even I also had my doubts and posed questions, but His Excellency related to me and others, about the first B.Sc students at Fort Hare - none other than our Honourable Minister of Health, Dr Bikitsha, and the late attorney, Mr Tshiki - receiving four days of lectures at Fort Hare, and doing three practical days at Rhodes University. Those narrations encouraged me and made me feel His Excellency knew what he was desiring and how he would achieve it, and I decided to fully support him and the Transkeian Government to the bitter end.

Again, I thank the Rector of the University, Prof. van der Merwe, who if he did not put down his foot, many things might have gone haywire. I thank the various professors and administrators of this university who were ever willing to give a helping hand or word; the then Pilot Committee Members, the Dean of Wits Medical School -Prof. M McGregor - and his former Rector - Professor D J du Plessis; the various Ministers and Secretaries of some departments who have been concerned, together with their staff, in particular Health, Education, Works and Energy, Finance; the architects and builders of the dissection room and laboratories, the former Chief Medical Superintendent of Umtata Hospital, Dr A B L Pupuma, Mr Gwiliza for fetching and storing cadavers for us, the Anatomy Department of the University of Natal, and many other people I could not enumerate in order to save time.

I feel I should like to emphasise that all of us in administration, and as technicians or civil servants, we are here to translate the aspirations of politicians, and thus our government, into reality with loyalty. There is a good old saying, 'There cannot be two bulls in one kraal.'. Last but not least, I cannot forget to mention my own family; my husband, son, relatives and close friends, who have not ceased to give me moral support during all this difficult time. They did not call me names, when I personally felt at times like an irresponsible wife and parent, by having to be absent from home at various times, and always dashing in and out in a hurry, and neglecting partly my domestic duties. For their patience with me, and understanding, a very special word of thanks. All those I have not mentioned should forgive me!

Finally, I should like to say we have a unique mix of challenges, which offer us the opportunity to become both excellent and relevant. A 27-year-old man was playing with the son of a friend. The boy was building a toy crane with some plastic blocks. 'Don't you need a steering wheel in the crane?', the young man asked the boy. 'No,' the boy quickly replied, almost in a disdainful tone. 'The crane will be run by a computer.' We live in such a world, but then, even so, someone must switch on the computer or programme and set it on. And I hope, the day I have to hand over to someone else when my time is up, that there will be a TRANSKEIAN to take over. Otherwise, I will have failed dismally, if I have not trained or will not be followed by a national.

I have to end up in Prof. Gear's tone saying, 'I have a dream one day that we shall have a national health service, which is both excellent and which is accessible to all the people of Transkei,' and to that I add, I further have a dream, that primary healthcare shall be provided for rural and urban areas, for both public and private use, in schools and at home, and for the poor and the rich. And in conclusion, I have a dream that responsibility and HEALTH FOR ALL shall be provided one day for every Transkeian by, or even if after, the year 2000.

 

 

Correspondence:
S A Mabunda
drskhumba@gmail.com

Received 11 May 2025
Accepted 11 August 2025