Balancing act: Transformation is complicated by the scarcity of black doctors in higher education willing to teach, says Jonathan Jansen. (Photos: Gustav Butlex)

Analysis: Why doesn't medicine measure up to SA's transformation ideal?

Amy Green
Student demographics are shifting, but academic staff remain predominantly white

March 2015 saw a wave of student protests at universities across the country, starting with the University of Cape Town, where the flinging of faeces symbolised failed transformation – including at medical faculties and training hospitals.

Although the #RhodesMustFall campaign has been opposed by some, ongoing activism emphasises that a significant number of students and academics are concerned that institutionalised racism persists.

Transformation at medical faculties and training hospitals has been an ongoing struggle. The Free State’s public health system is not only controversial for its perceived inefficient and cash-strapped circumstances: the slow transformation at the province’s only medical school and attached training hospitals has also drawn criticism.

In March, University of the Free State (UFS) rector Jonathan Jansen met the staff of the health sciences faculty to address, among other concerns, the issue of transformation.

“I spoke very clearly about our transformational challenges and the need to deal with these things upfront rather than have politicians stuff it down your throat,” he says.

Universitas Hospital
At Universitas Hospital, the main teaching institution for the UFS’s medical school, tensions ran high last year after a string of what some call racially motivated disputes.

An altercation between Hendrik Theron, a white UFS cardiologist, and a black car guard, at whom Theron allegedly threw a cloth, led to Theron facing internal charges of racism and assault.

According to a letter released to the media in February by concerned Free State doctors, Theron was found not guilty of racism but decided to resign after the “witch-hunt” against him.

Theron was head of cardiology at the hospital and his departure preceded a total shutdown of cardiology services in the department when the only remaining specialist also resigned.

Doctors working at the hospital told the Mail & Guardian that the then chief executive officer of Universitas, Sehularo Gaelejwe, was to blame for the “mass haemorrhage” of doctors at the hospital last year when he embarked on a “firing spree” described by one doctor as “forced transformation”.

One registrar, a specialist in training, alleged that nurses were instructed by Gaelejwe to look out for any mistakes made by white doctors and to report them immediately to management. Gaelejwe was suspended in October for reasons that have not been made public.

Universitas, the University of the Free State’s training hospital, has drug shortages and is understaffed.

Rainbow nation
But after 21 years of democracy, the demographics at UFS’s medical school aren’t mirroring Nelson Mandela’s “rainbow nation” vision.

Although the school notably improved its proportion of black, coloured and Indian students over the past few years – in 2012 70% of students were white and by 2015 this had dropped to 49% – the majority of the teaching staff remain white (84%).

Jansen admits that the faculty’s staff demographics are skewed but says it is no different to other higher education institutions that also actively push for transformation. For example, UCT’s medical faculty has only slightly fewer white teaching staff (64%) than the UFS.

According to Jansen, staff transformation at universities is complicated by the scarcity of black doctors in higher education willing to teach.

“We’ve made some wonderful appointments of black professors but we need 10 times more to be able to shift the needle,” he says.

Poaching
He says the UFS actively looks for black professors to fill academic posts but warns that this process can quickly turn into “poaching” staff from other universities.

“We need to be careful to not circulate the same black professor amongst multiple universities – it might look good for us as UFS but that’s not progress on a national level.”

But the medical school’s dean, Gert van Zyl, argues that the faculty’s leadership demographics are good for the decision-making positions: 86% of the heads of department are either black, coloured or Indian.

“We have a backlog in addressing these issues. They are challenging, but that’s not to say we aren’t actively doing anything,” Van Zyl says.

Jansen says attracting more disadvantaged and black students to study medicine has been difficult.

“The challenge is not only to get more disadvantaged students into the programme but also making sure they get out and complete their studies,” he says.

Financially and academically equipped 
Part of the problem, says Jansen, is that disadvantaged students are often not financially or academically equipped when they leave high school to cope with the demands of a degree in medicine.

The medical staff at UFS have set up a loan scheme for students to try to ameliorate this situation. According to UFS spokesperson Lacea Loader, a number of senior medical staff contribute to a fund from which students can borrow money without interest.

“The majority of students who benefit from this scheme are black; over a quarter of a million rand is provided through the loan scheme per year,” she says.

Two projects in the pipeline are to provide all medical school students with laptops and notes in electronic format, as well as cellphones at a subsidised rate.

To help disadvantaged students academically, a mentor system pairs senior students with first years to “guide them with academic and social needs”, says Loader.

But even if students are supported financially and academically, will the delapidated and understaffed Universitas Hospital affect the quality of medical students’ training and prospective doctors’ ability to pass?

Both Jansen and Van Zyl are adamant that it won’t.

Universitas won't affect training
“We’ve recently signed a memorandum of understanding with the department pertaining to Universitas and we also have a state-of-the-art simulation unit to aid teaching and mitigate any disruptions,” says Jansen.

He argues that medical students at UFS get “the best of both worlds”.

“You can learn to be innovative in an under-resourced environment like a public hospital but also still get experience in the ideal environment of our simulation unit.”

He says the only area “where it may affect us is the impact it might have on a professor or the staff who also happen to do clinical work for the hospital”.

“When our professional colleagues stand with their feet in those two holes, that is where we pick up quite a lot of negativity and despondency.”

A doctor working at both UFS and Universitas, with a foot in each hole, confirms that Jansen’s concerns are well founded.

“It’s inevitable that something’s going to crack. I’m just glad I’m not a medical student now. There are so few people running the show and you should see how demotivated people are.”

He adds: “It sounds silly but if you walk around the hospital you don’t hear laughter anymore. When I first arrived four years ago the sisters used to always sing in the morning and you’d hear bursts of laughter during the day. I miss that.”

Students have ‘state-of-the-art’ simulation amenities, such as high-tech dolls, that aid teaching.


The challenge of becoming a doctor without resources

Outside the health sciences faculty at the UFS, two fourth-year medical students sit chatting at a wooden table.

They are discussing the problems in the building next door, the main academic teaching hospital for the university and the only tertiary facility in the province, Universitas Hospital.  

“Our lecturers have told us not to worry but they mention the word ‘crisis’ a couple of times in that same sentence,” says Donald, a fresh-faced, blond-haired medical student hailing from Cape Town. “But it hasn’t really affected our training.” 

Donald’s brunette friend Danika, also clad in a white coat, is quick to say: “Well, sometimes it does, with shortages of medicine and equipment. 

“Remember when I was on rotation in the trauma ward last year and there was no morphine?” Morphine, a “highly used agent”, is often the first-line option for severe pain and is also the only injectable opioid listed on the standard treatment guidelines for the public sector, according to Andy Gray from the University of KwaZulu-Natal's pharmacy faculty. He says the injectable version “is simply vital and should never be out of stock”. 

Drip sets
Donald looks across the table at Danika for confirmation. “Ja, like sometimes there are no drip sets and if you ask another ward they won’t give you any because they are also trying to guard their stock. 

“So our lecturers would hoard their own stock and bring it out so that when they ask us to put in a drip we actually can,” she says. 

“At the same time,” responds Donald, “I got to speak to my friends at Stellenbosch and the University of Cape Town over the holidays and their experience of public hospitals is completely different to ours. 

“The Western Cape teaching hospitals don’t run out of bulldog needles and they don’t have to resort to using syringes to draw blood. [What we are learning here] is like bush medicine, compared.” 

Over the past year, Universitas Hospital has made headlines with top staff resigning en masse – this has been labelled a “crisis” by whistle-blowers in the medical arena. 

Amid fears that these conditions could affect the academic progress of medical students UFS rector Jonathan Jansen says the “quality and depth of training is still beyond reproach”. 

Controversial CEO
After controversial chief executive officer Sehularo Gaelejwe, blamed by several doctors for the loss of staff, was suspended in October, Jansen says the hospital is slowly filling vacant posts and “hope[s] that in the new financial year the hospital will be much more functional than [it is] at the present moment”. 

Jansen adds: “We’ve recently signed a memorandum of understanding with the department, pertaining to Universitas, and we also have a state-of-the-art simulation unit to mitigate any disruptions.” 

Gert van Zyl, the medical school’s dean, explains that the world-class simulation unit allows students to do clinical work on campus with the right equipment but on highly sophisticated dummies. 

The students themselves seem less perturbed. Glancing up from the textbook in front of her, Danika says: “It [‘bush medicine’] does have its advantages though. You can’t only know how to do things with amazing technology in the perfect setting. You need to know how to do things with what you have so you get that experience.” 

Donald nods in agreement but says: “That’s not to say it’s right, though.” 

Danika sighs and after a moment she says: “Still. Our lecturers are amazing. I think we’re being trained really well. “Even if I had a choice I wouldn’t study medicine anywhere else.” 


Universities to bring about change

There must be more than just a shift in demographics to achieve transformation, some experts are increasingly arguing.

University of Cape Town (UCT) sociology professor Xolela Mangcu called for the humanities faculty not to “simply Africanise” but actually “decolonise” the curriculum and introduce “black studies” as a subject, according to a City Press article in April this year. 

Linda Rhoda, who heads communications for the UCT medical school, says the faculty has already transformed its curriculum to be more in line with South Africa’s public health needs – to intensify its focus on primary healthcare. “Learning communicative competence in isiXhosa and Afrikaans has been integrated into this course to improve communication with patients at Western Cape sites,” she adds. 

“We have also introduced a special studies module on languages where students taking this module can live with a family for a few weeks to immerse themselves in the sociocultural-linguistic environment of the community.” 

Most universities have initiatives specifically aimed at ­attracting black medical students. For instance, Stellenbosch University’s [email protected] project gives black pupils the chance to attend a three-day programme “to experience what the faculty of medicine and health sciences has to offer”, according to Ronel Bester, communications officer for the faculty. 

The event takes place in the third-term school holidays. Last year, 55 prospective black medical students participated. 

And many universities have introduced bridging courses to accommodate students from disadvantaged backgrounds where the quality of maths and science education at high school level may not be up to standard. UCT has a programme like this so that “all students may benefit from the outset”, says Rhoda. Computer literacy is taught to first-year medical students as a part of this programme. 

The University of the Free State has a similar programme which offers classes in the holiday period to give struggling students a chance to catch up. 

Stellenbosch University gives disadvantaged students the opportunity to complete their first year of medical studies over two years and also to receive individual mentoring. 

Some universities, such as the University of the Witwatersrand, have embarked on broader transformation efforts that are not confined to race. Wits recently changed its medical student admissions policy to focus on degrees of disadvantage more than race-based policies. Implemented this year, the new policy allocates 20% of its places to the top performing pupils from rural areas, 20% to those from the poorest schools in the country and a further 20% is reserved for African and coloured students. 

The remaining 40% of spaces are offered to pupils based on academic merit regardless of their socioeconomic background. Vice-chancellor Adam Habib says that not all the spots reserved for the rural and poorest schools were filled in 2015 because “students did not make the [application date] cut-off” but he said he is “confident” that all reserved spaces would be filled in the future. 

All doctors and students asked not to be named to ensure the future of their medical careers.

University of the Free State (UFS)

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