FROM THE EDITOR

WSU medical school - a study in innovation and resilience

That the Walter Sisulu University medical school continues to exist and to produce competent health professionals is evidence of extraordinary institutional resilience. The school is located in a university with a troubled history. But even as the university has lurched from crisis to crisis and has periodically been under threat of closure, the medical school has developed and grown to become the university's premier centre of excellence and, it has often been said, its raison d'etre, thanks in large part to sheer grit, commitment and sense of mission on the part of its leaders and academic community.

Founded as a faculty of the University of Transkei in 1985, the medical school began with little or no academic staff or teaching facilities. Its development was like building a passenger airliner in flight. Recruitment of staff, development of teaching facilities and even the writing of the curriculum were always accomplished just one step ahead of the first cohort of seven students. Amazingly, those first students went on to become successful medical practitioners, with two subsequently emigrating to Australia and Canada.

The reasons for starting a medical school in the politically dodgy context of an apartheid homeland in the turbulent years of the 1980s were twofold. Transkei-born students funded by the homeland government to study medicine in the metropolitan medical schools in South Africa rarely returned, and Transkei remained severely short of medical practitioners. It was considered (quite correctly, as it turned out) that there would be greater retention of medical graduates if the doctors were trained locally. The second reason was to increase access to medical training by Transkei high-school graduates. In the words of Iputo,¹ a long-time WSU professor: 'The South African health system has disturbing inequalities, namely few black doctors, a wide divide between urban and rural sectors, and also between private and public services. Most medical training programmes in the country consider only applicants with higher-grade preparation in mathematics and physical science, while most secondary schools in black communities have limited capacity to teach these subjects and offer them at standard grade level. The Faculty of Health Sciences at Walter Sisulu University (WSU) was established in 1985 to help address these inequities and to produce physicians capable of providing quality health care in rural South African communities.'

At its founding, the school adopted a traditional curriculum made up of a pre-clinical phase fashioned around didactic lectures, and a clinical phase made up of classic rotating clerkships. But as Iputo tells it, there was 'lively debate about whether the tertiary hospital-based, technologically-driven, Western-style curriculum would produce doctors [with] the basic attributes deemed essential for doctors working in the rural and impoverished environment of the Transkei. There was consensus that in order for the new institution to fulfil its mission, an innovative pedagogical approach was needed.' There was a strong sense that the medical school should not seek to be a clone of the older sister schools in South Africa or be straight-jacketed into the traditional way of doing things. Exciting innovations were unfolding in medical education elsewhere in the world that had found little traction in the politically isolated South African environment. As a new institution, the Transkei medical school was in the fortunate position of being able to be innovative and to carve its own identity.

A new curriculum combining community-based education (CBE) with problem-based learning (PBL) was adopted in 1992. In the PBL mode, students took responsibility for their own learning based on pre-selected clinical cases reflecting the disease profile of the region. Didactic lectures were drastically reduced. Students accustomed to spoon-fed rote learning and fact memorisation now had to learn to analyse and relate theoretical information to real-life situations, and to acquire knowledge through understanding and critical reasoning. In terms of CBE, much of the clinical training occurred around district hospitals, rural clinics and community centres under the guidance of family practitioners. The University-Community Health Partnership Programme (UCHPP) brought the university, the community and ruling chiefs together to consult on local health needs and design interventions together in a true town-gown-crown partnership. The UCHPP, initially funded by the Kellogg Foundation, saw community health centres established by the university in remote rural sites. Consequently, WSU has had a significant and measurable impact and influence on rural healthcare delivery in the Transkei region.

But it was not all plain sailing at first. According to Iputo, 'establishing a medical school in a South African homeland, using a new and untested curriculum, and run by a predominantly black faculty during the apartheid years in South Africa, was a daunting task. The proposal was met with skepticism from the white establishment, the medical profession, and the student body. Among many blacks, the idea at that time smacked of [yet] another attempt by the South African government to mount a substandard educational program for the black population.' In fact, the South African government had nothing to do with the medical school project, and was hostile to it.

In 2010, the WSU medical school celebrated its 25th anniversary. The celebration took the form of two weeks of conferences and seminars on CBE with participants from the World Health Organization and countries around the globe. But what was there to celebrate? Had the medical school achieved its mission? To date, the school has graduated more than 1 000 doctors (as well as a host of other healthcare professionals). A survey of all medical graduates in the years 1990 - 2008 reveals that a whopping 44% had remained in the Eastern Cape, and 27% had settled in the largely rural KwaZulu-Natal province. Four per cent had emigrated to Canada, New Zealand, the UK, India, the USA and sub-Saharan countries. About 50 graduates had completed specialist training and passed College exams in 13 specialties, and another large group was in training in 18 specialties in various academic centres around the country.

That said, all is not perfect at WSU. Its location in an environment of extreme rural poverty in an underdeveloped city remains a disincentive to potential new staff. Consequently, WSU is grossly understaffed and is highly dependent on expatriate staff including Cuban doctors. The university is chronically underfunded and obliged to operate on a shoestring. After 25 years, the medical school is still without a building of its own. Succession will soon pose a challenge as the senior academics - the founding faculty - approach retirement. As well as the school has performed in near-impossible circumstances, existential threats therefore remain.

Daniel J Ncayiyana
Editor
profdjn@gmail.com

1. Iputo JE. Faculty of Health Sciences, Walter Sisulu University: Training doctors from and for rural South African communities. MEDDIC Review, Fall 2008. http://mediccreview.medicc.org/index. php?issue=l&id=7&a=vahtml (accessed 16 January 2012).