25 years of training doctors at WSU: how - Walter Sisulu University

Walter Sisulu University
PROFESSORIAL INAUGURAL LECTURE
20 April 2010
25 years of training doctors at WSU:
how have we responded to the
1983 UNITRA Council Guidelines?
Professor E. N. Kwizera
Department of Pharmacology
School of Medicine
Faculty of Health Sciences
Walter Sisulu University
Eastern Cape
South Africa
Auditorium, Nelson Mandela Drive Campus, Mthatha, Eastern Cape

WALTER SISULU UNIvERSITy (WSU)
DEPARTmENT OF PhARmACOLOGy
SChOOL OF mEDICINE
FACULTy OF hEALTh SCIENCES
TOPIC
25 yEARS OF TRAINING DOCTORS AT WSU: hOW
hAvE WE RESPONDED TO ThE 1983 UNITRA COUNCIL
GUIDELINES?
By
ENOCh NShAkIRA kWIzERA
DATE: 20 APRIL 2010
vENUE: WSU AUDITORIUm
3

The Vice-Chancellor of Walter Sisulu University, Professor Balintulo;
The Deputy Vice-Chancellor, Academic and Research, Professor Obi;
The Deputy Vice-Chancellor, Planning, Quality Assurance and Development, Professor Buijs;
the Registrar, Professor Tau-Mzamane;
Executive Deans of Faculties;
the Director, Research Development, Professor Ekosse;
Directors of Schools;
Heads of Departments;
University Teaching and Administrative Staff;
Students; Distinguished Guests;
Friends and Family;
Ladies and Gentlemen
As I stand before you this autumn afternoon, I cannot think of a single adjective to describe
how I feel. For starters I am anxious and nervous about delivering this once in a life time
Lecture. I have given classroom lectures and read papers at conferences for thirty years or
so, and I am pretty much used to that. Not a Professorial Inaugural Lecture though, and I thus
hope that my anxiety and nervousness are understandable. But then again, as my colleague,
Professor Iputo observed when delivering his Professorial Inaugural Lecture just over 10 years
ago, I am also relieved that these occasions do not provide for ‘question time’. My anxiety is
also at least partly countered by the excitement of finally delivering this Lecture, which should
have been delivered 6 years ago, and which over the last 2 years has been postponed so many
times. I am proud that my University is, today, formally recognising my lifetime academic
achievements; but I am at the same time humbled by the awareness that this is actually being
done while I am still alive, and not posthumously; and I am thankful to the Almighty God for
that and for everything else.
Over the past 20 years my career path has been dichotomous. My primary and principal speciality
is Clinical Pharmacology, but I also consider myself a Health Professions Educationalist. As
far back as 2004, I had intended to give my Inaugural Lecture on a clinical pharmacological
topic, the fortuitous discovery of medicines, which has interested me since my early medical
school days 40 years ago. Towards the end of 2009, however, I decided to change to a medical
education topic, partly because 2010 would be the 100 th Anniversary of the Flexner Report
which revolutionized and standardized medical education in North America, and by extension,
in the rest of the world; but mainly because the WSU Faculty of Health Sciences would be
celebrating its Silver Jubilee this year. I therefore thought (and hopefully rightly so) that a
medical education topic would be a more appropriate and, indeed, a more interesting one.
OVERVIEW OF THIS LECTURE
Mr VC, Sir, I propose to deliver this, hopefully relatively brief Lecture, under the following
six themes:
1. Dedication
2. Brief history of medical training in South Africa and in Transkei
5

3. UNITRA Council Guidelines
4. Our response to UNITRA Council Guidelines 1985 - 2010
5. Concluding remarks and the road ahead
6 Acknowledgements
DEDICaTIOn
In the first of his 3-volume Autobiography series, “Unreliable Memoirs”, Clive James, the
Australian / British writer, begins: “I was born in 1939. The only other big event of that year was the outbreak of
the Second World War” 1 . When I first read this opening 30 years ago, I was so impressed that even
before I had really read the book, I started telling my mates: “I was born in 1950, and the only two other
significant events of that year were the outbreak of the Korean War, and the imprisonment of Kwame Nkrumah”. I certainly
said that in jest and in mere emulation of Clive James, whose satire as TV critic for “The
Observer” I also admired at the time. For Clive James, however, the outbreak of the Second
World War was indeed a big event, because his father enlisted and was killed in war. By
contrast, neither the Korean War nor Nkrumah’s imprisonment was of any direct consequence
for me, so to speak. For my parents, however, my birth was remarkable in more ways than one.
When I was born, they had been married for just over 8 years, and already had three children,
all of them daughters. And by then my father was at the receiving end of ridicule from his
male peers who, in their ignorance of the genetic basis for the determination of an offspring’s
gender, would taunt him: “Your wife is stronger than you and that’s why you are producing girls only”. But my
father took it all on the chin and told them repeatedly and with confidence: “I have faith that God will
give me sons”. That is how, when I was born that Tuesday night in the second week of June 1950,
I came to be named Kwizera, because the word ‘kwizera’ in my mother tongue means ‘faith’.
But there is even more to this. Those of you familiar with the Bible (and if I may beg the
indulgence of those who are not), might recall that Hebrews 11.1, in the King James Version,
reads: “Now faith is the substance of things hoped for, the evidence of things not seen.” Thus, by naming me ‘Kwizera’,
my father was in a way foretelling, among other milestones in my life, this special day when
I would stand before you to deliver my Inaugural Lecture as Professor of Pharmacology at
Walter Sisulu University. Indeed, had this Lecture been scheduled as soon as I was belatedly
promoted to Full Professor effective January 2004, and in any case for a date before 11 October
2004, the day when my father was called to rest, he would have been there to witness further
fulfilment of his Faith in God, and his faith in me. I, however, have faith that right now he
is looking down at what is happening in this auditorium, and that he is warmly smiling, and
nodding proudly at his first of 3 sons in whom he had faith; and whom he fondly gave the
nickname: ‘Successor’.
I dedicate this Lecture, first and foremost, and with my eternal gratitude, to my parents: to my
father, the late Rev. Canon Ernest Mizerero Nshakira, and to my 86-year old mother, Edreada
Nshakira, who both imparted to me not only their powerful genes, but also brought me up
with love, sacrifice, leading by example, and ever-present encouragement. Being the dedicated
Church workers that they were, in those days before religion became the lucrative enterprise
6

it is for some today, my parents did not have much materially. However, when they utilized
whatever little they had, my siblings and I were always given priority. More importantly, what
they did not have materially was more than compensated for by their many virtues, including
spirituality, hard work with their own hands, honesty, modesty, and humility; all of which they
instilled into me, and which were instrumental in shaping the man I am today.
One great lesson I learned from my parents while growing up in those materially skinny (but
spiritually and morally very rich) surroundings was to make do and to be contented with
whatever I had, and not to waste any energies, thoughts or emotions being consumed with envy.
For example, when I first went to High School in January 1965, I was barefoot (one of the 3 or
4 ‘barefooters’ in my class of ca. 30 boys) and I remained so for the First Term. I did not even
have ‘slippers’, and after taking a shower I would walk back to the dormitory barefoot! In fact,
I was so different in appearance from the mainstream, that a common question about me, was:
“Ogu nawe n’omwana w’eishomero?” (i.e. “Is this one also a schoolboy here?”).
But all that did not deter me from working hard and finishing Second Term 5 th in my class. And
this was notwithstanding the fact that besides two or three Americans, nearly all of our teachers
were from the UK, and they had such confusing accents (e.g. Yorkshire, Irish, Scottish, Welsh,
Geordie, and of course Cockney) that for the first few weeks we (the village boys who were
being taught by ‘Wazungu’ for the first time) would sit through lesson after lesson and get out
of them all with no understanding whatsoever of what the teacher had been talking about! For
my very promising start High School (and against all those odds), my father rewarded me with
my first pair of shoes (the make was, I recall ‘Manhattan’ -of course they do not make them
anymore…), and I will leave for another day the description of how so difficult and painfully
uncomfortable it felt walking in shoes for the first time, at the grand age of 15! Needless to
say, I did not have any long trousers either -my first pair of trousers was in 1966 (in grade 10),
and I still recall the uncomfortable scratchy feeling I had around my legs when I put on and
walked in those brand new long trousers also for the first time -and to make matters worse,
on an evening school visit to Bweranyangi Girls High School! I will not digress going into
the ‘Ntare-Bwera’ story at this stage; and nor will I reveal today when I adorned my first real
underpants (and not the PE shorts that the school provided as part of our uniform)!
Perhaps -and more importantly, growing up in those materially lean surroundings taught me to
be innovative, an attribute which has served me very well in diverse aspects of my dichotomous
career. For example, before commencing my research studies at the University of Bradford
(UK) in the late 1970s, I had to build apparatuses from a scratch so I could isolate and incubate
rat liver cells for my experiments. Besides the usual laboratory glassware, the only ‘standard’
equipment my University gave me (besides the tiny laboratory space) were: a water bath, a
Watson-Morley pump, oxygen-carbon dioxide gas cylinders, and the routine consumables. For
everything else, I simply had to improvise 2, 3 .
7

8
(Kwizera, 1977,1980)
More importantly, Mr VC, Sir, some relatively more recent improvisations have been in
the roles I have played in the development, implementation, and evaluation of the Problembased,
and Community-based MB ChB curriculum at the then UNITRA (and now WSU) from
1989 to date 4-33 ; particularly my successful introduction of ‘one tutor per tutorial group’ in
our programme 8,10,12,14 . As I will elaborate in due course, one of the secrets of our success as a
medical school has been the adaptation of ideas and practices from diverse parts of the world
to make them fit in our settings; and needless to say, this has involved a lot of improvisation.
Today we live in a different world to the one I grew up in, and the one in which I made the
laboratory improvisations in the late 1970s. But like my parents, I have made every effort to
pass to my children the same virtues that I acquired from my parents, and it is my hope -or
rather my FAITH- that they, and their children, and grandchildren -ad infinitum, will keep the
Nshakira ‘Torch of Faith’ burning.
There are of course other people who have made and left big and positive imprints on my life
and career, and I think it proper to include them early in this Dedication, rather than merely
acknowledging their input at the end of this presentation. Which this reminds me of a colleague
in medical education circles, the late Miriam Ben David (RIP) who famously used to say: “Life
is unpredictable. Eat your dessert first”. But I digress.
The first such group is, naturally, my teachers, going way back to the mid 1950s when I used
to follow my older sisters to school and got ‘free’ education from the likes of the late John
Murwani (RIP) who taught me my first rudimentary English vocabulary long before I could,
write, read, or spell anything. Needless to stress here, I did not have any privilege of ‘preschool;
or the nursery rhymes that go with that; but thanks to my children, I learned all of them
rhymes in my middle age when the same kids would come home and recite them endlessly

every evening! Then there were my ‘formal’ teachers at primary, junior secondary, and High
School, my undergraduate and postgraduate teachers and supervisors; and particularly my latter
day and very recent teachers: Faculty at the Foundation for the Advancement of International
Medical Education and Research (FAIMER) Institute in Philadelphia, USA. Needless to say,
this dedication would be incomplete if I did not include my past and present colleagues and my
past and present students from both of whom I have always learned a lot, and who I continue
to learn something from everyday.
One teacher who taught me Biology in my Grade 10 at Ntare School in the first half of 1966
(and pending his enrolment to Makerere University medical school), was none other than
Alex Nganwa-Bagumah, who is and has been Professor and HOD of Anatomy at UNITRA/
WSU since 1985. When Alex taught me Biology at Ntare School, he had just written his
A-levels at the end of 1965, and when the results came in early 1966, he had scored the first
A-level Biology ‘A-symbol’ in our school’s modest 10-year history. The excellent teacher
that he was then –and indeed still is now, he effectively transferred to me the basics of High
School Biology, and I did not disappoint. When I wrote my A-levels four years later, at the end
of 1969, I, following in his footsteps, recorded the second A-level Biology ‘A-symbol’ in our
school’s history! I believe there has since been a deluge of ‘A-symbols’ in Biology from Ntare
school, but I know that Prof Bagumah and myself still have our special places in Ntare School’s
archives in this regard. Professor Nganwa-Bagumah remains my close friend, teacher, mentor,
academic colleague, and confidant. I am indeed lucky and proud to have such a person as
Professor Nganwa-Bagumah in my professional and personal life, and I deliberately pinpoint
him today, while co-dedicating this Lecture to various people besides my parents.
Much as I would have loved to include all of my teachers here, I am torn between ‘eating
my dessert first’ and turning the bulk of this into ‘an Inaugural Lecture of Dedications’. As
a compromise, therefore, I will have to settle for mention of many deserving individuals
under ‘Acknowledgments’. However, I also wish to deliberately highlight two other special
individuals: Andrew Walubo, Chief Clinical Pharmacologist, and Professor and HOD, Clinical
Pharmacology, UOFS, Bloemfontein; and Yoswa Dambisya, Senior Professor of Pharmacology,
ULIMP, Polokwane. In the very early 1980s, I taught undergraduate pharmacology to these
two gentlemen when they were 3 rd year medical students at Makerere University, Kampala;
and they did me proud not only by choosing pharmacology as a speciality, but also by excelling
at it and becoming among the most prominent professors of pharmacology in South Africa
today. Andrew and Yoswa, wherever you are as I speak, I salute you! Mr VC Sir, allow me also
to salute and recognise the presence here of a few of the more than 2600 doctors that I have
helped train in Uganda and South Africa; and who are in this gathering this afternoon.
The Dedication of this Lecture would surely be incomplete without including my extended,
and particularly my immediate family. I therefore wish to, at this juncture, also dedicate it to
my siblings: Ana (RIP), Blandina, Eleanor, Rusi (RIP), Eriya (RIP), Lydia, and Nathan, who
individually and / or collectively profoundly contributed to making me what I am today. To
you, ‘bana ba mama’, I say: We had the best parents, we had the best moulding and upbringing
9

as children, and we are the best! And more importantly, thank you for always being ‘your
brother’s keeper’ and keep it up! I will do likewise.
Last, but most certainly not least, this Lecture is lovingly and emotionally dedicated to my
children: Olivia, Walter, Fiona, Timothy, and Clara –for I live only for you guys, and as
intimated already, I have FAITH in you carrying that ‘Nshakira torch of Faith’. I also must
mention here Ruth and Stella, the mothers my children for the vacuums you individually filled
in the respective phases of my life; and for lovingly being part of the propagation of our genes;
and Maggie, my source of love, companionship, solace, and all, for the past 5 years.
BaCKGROUnD TO MEDICaL TRaInInG In SOUTH aFRICa
Prior to the establishment of the Faculty of Medicine and Health Sciences at the then University
of Transkei (UNITRA) in 1985, there were seven medical schools in South Africa, five (or 71%)
of which catered for the Whites who constituted less than 15% of the country’s population 34 .
10
70
60
50
40
30
20
10
0
Black Coloured Indian White
First year
Final year
South African first and final year medical students by race (1994) (de Vries and Reid, 2003)
Indeed, nearly 10 years later in 1994, whites accounted for nearly 50% of first year and more
than 60% of final year medical students in the country The said five medical schools were at:
University of Cape Town (est. 1900), University of the Witwatersrand (1921), University of
Pretoria (1943), Stellenbosch University (1956), and the University of the Free State (1969).
University of Natal (1951) catered for Indians, Africans, and a sprinkling of Whites, while
the Medical University of Southern Africa (MEDUNSA) (1978) trained mainly Africans and
Indians, and had the largest undergraduate enrolment of any medical school in the country. In
a summary of the Council Guidelines for the Medical School at UNITRA, Kriel and Coles 35
noted:
“It is clear from international experience that medical schools in developed countries do not produce doctors who are
equipped with the relevant skills, knowledge and attitudes to deal with the health care problems of …. communities in
….. developing countries. ….. The reasons for this phenomenon have been elucidated by curriculum research which
has shown that the curricular process has a very fundamental impact on the manner in which students perceive their
academic and professional tasks.

“It is therefore unreasonable to expect the Republic of Transkei to send its students to medical schools in the RSA to be
trained as doctors, because they will either not return to practise in Transkei, or, if they do, they will not find (personal
and) professional fulfilment in their work.
“For this reason, the medical school at UNITRA has been established in order to relate its medical education to the health
care needs of the country. It is therefore clear that this medical school should not follow the traditional medical education
patterns of the RSA or western countries, but should study relevant models elsewhere in the world that have sought to
address a similar situation to that pertaining in Transkei.”
The Guidelines authors 35 were also quick to clarify upfront:
“This does not mean a difference in the standard of education and training, but a difference in orientation. The challenge
is to present the same basic science and clinical knowledge in such a manner that the graduate will be both motivated and
able to work in urban and rural communities in Transkei.”
As I and my colleagues30 recalled in an article published 5 years ago, the establishment of this
Faculty had its vehement opponents, like Saunders36 with his (infamous) question: “where will
the staff of sufficient academic standing be found?”, his prophecy of doom: “there is a danger of their obtaining fifth
rate, First-World medical education”, and his unsolicited suggestion: “surely a school of public health to educate
professionals to work in rural areas constitutes a greater need”. In spite of these, and the memorable but highly
educative teething pains we experienced at the end of 1989, this faculty has now been in
existence for a quarter of a century, has a multinational, highly qualified, efficient and effective
academic staff, and with 925 doctors (and still counting) has probably produced more African
doctors per year of existence than any other South African medical school, with the obvious
exception of MEDUNSA and probably Natal.
So, how have we made it? More importantly, how have we responded to the UNITRA
Council Guidelines over the past quarter Century, and how have our responses contributed to
our successes (or in rare instances, to our shortcomings)? First though, a look at those eight
Guidelines:
11

UnITRa COUnCIL GUIDELInES
a)
b)
c)
d)
e)
f)
g)
h)
12
“The goals of medical education at UNITRA (is / should be) to produce doctors and other health personnel who:
are equipped with the necessary scientific and professional knowledge, skills and attitudes to deal with the health
care problems of urban and rural communities, families and individuals in Transkei;
are motivated to work in both urban and rural primary health care settings in Transkei, and who can find
professional and personal satisfaction in such work;
are able and motivated to work in health care teams to the benefit of the people of the country;
are able to educate and motivate communities, families and individuals to take personal responsibility for their
health and their own health care;
can think critically and creatively to deal with the health care problems of communities, families and individuals
and have the necessary knowledge and skills to do research appropriate to the needs of Transkei within the various
health care settings un the country;
are equally committed to the prevention as to the management of illness and are capable of understanding health
care problems in their biological, psychological and socio-economic context;
are self-directed and life-long learners who will be able to adapt to changing circumstances in Transkei, keep up
with developments in their professions and have the necessary motivation and background to acquire relevant
specialised qualifications to fulfil the needs of the country and to advance their own careers;
exhibit high levels of ethical and administrative insight, skills and integrity.”
In the first instance, it was clear from the outset (and indeed, from the Council Guidelines)
that new this medical school would, unlike the majority of the then existing medical schools,
not go into the business of training doctors for export to the US or to the UK and the old
Commonwealth (of Australia, Canada, and New Zealand).
4000
3500
3000
2500
2000
1500
1000
500
0
australia Canada new
Zealand
UK USa
South African-born practitioners in OECD countries (2001) (Breier and Wildschut, 2006)
Nor were we, indeed, even going to train doctors for export from the Transkei to Cape Town,
Johannesburg or similar. The prevailing political, market, labour, and other forces at the time
were already taking good care of that aspect of the South African labour export market. So,
Mr Vice-Chancellor, Sir, allow me now to make a ‘blow by blow’ report back as to whether
and how we, as the WSU the Faculty of Health Sciences, have, over the years, responded to
each of the above Guidelines, and the impact of those responses to our successes. This being
a sort of introspective exercise, however, I will also mention areas where we perhaps have

fallen short of those Guidelines / expectations; and propose strategies for remediation and / or
improvement.
a). Equipped with the necessary scientific and professional knowledge, skills and attitudes
to deal with the health care problems of urban and rural communities, families and
individuals in Transkei
Let me begin by observing that this was a ‘double-barrelled’ Guideline (as were most of
the others). Council expected us not only to impart the requisite tools (knowledge, skills,
and attitudes) to the nascent doctors under our care, but to also ensure that they would use
these said tools “to deal with the health care problems of urban and rural communities, families and individuals in
Transkei”
The Eastern Cape Province (ECP) is basically a rural, and with an urban : rural population
distribution of 35 : 65%, it is the third most rural province in the country after Limpopo
(11 : 89) and KZN (39 : 61) 37 ;
100
90
80
70
60
50
40
30
20
10
0
GP FS NC EC LP
Urban
Rural
Urban-rural ratios in South African Provinces (de Vries and Reid, 2003)
with relatively poor (even by South African standards) healthcare services, particularly
the doctor population ratios. For example, of the 9 Provinces, the ECP has the third lowest
number of doctors per 100 000 population (27) after Limpopo (18) and North West (23) 38,
39 . And if that is the case today, one can confidently say that the ratio was eve lower in the
Transkei of 25 years ago under apartheid and homeland rule.
13

14
16
14
12
10
8
6
4
2
0
WC GP FS KZn nC MP EC nW LP
Number of medical practitioners per 10 000 population by region (2004) (Breier and Wildschut, 2006)
Our first strategy to address the need for serving rural communities was to deliberately select
majority of our medical students from rural areas, mainly from the Transkei, but also from
‘Border’ and KZN.
WSU medical graduate demographics (Kwizera and Iputo, 2010)
% at W SU % 2001 census
Black 71.67 79.00
Asian 26.06 2.50
Coloured 1.48 8.90
W hite 0.81 9.60
Female 51.14 52.18
Male 48.86 47.82
This policy was based on the belief and expectation that medical students with rural origin
were more likely to serve rural communities after qualification 40-42 . International studies have
since demonstrated strong rural origin-rural practice correlation 43-46 , and a similar trend was
reported from South Africa a few years ago by de Vries and Reid 47 . At WSU, we are still
analysing the relevant graduate data, but preliminary findings indicate that our strategy of
rural recruitment has worked very well. For example, out of the 571 WSU-trained doctors

who, as of 2009 were in independent practice (i.e. were neither in Community Service nor in
Internship) 242 (42.38%) were practicing in the Eastern Cape. At least a third of these were
in rural areas and the majority of those in or near large urban areas had their practices in the
townships 48 . This preliminary finding not only shows that we are meeting a cardinal UNITRA
Council Guideline, but it also vindicates us on our policy of deliberate rural recruitment. More
excitingly, I am almost certain that once the data has been fully analysed, we are going to
report one the highest provincial and national graduate retention rates by medical schools in
this country.
Another curriculum factor that has been propounded as promoting medical graduates’ choice
of rural careers is their rural exposure during undergraduate training 49-53 . In our settings, we are
a rural institution, and our training is therefore, intrinsically a continuous rural exposure 28 . We
however, did not want to complacently make this assumption, and we deliberately incorporated
a significant (rural) community-based component into our undergraduate curriculum; which
has been amply described in various publications from this institution 54-58 . Unlike the strong
correlation between rural origin-rural career choices, however, the impact of rural placement
or exposure per se is less prominent and more variable, partly because the practice is relatively
recent and there is no standardised implementation among different institutions 59 , and partly
due to the presence many confounding variables, some of which can not be easily controlled
for 53, 59 . Nonetheless our experience from Exit Surveys of final year students in 2001, 2002 and
in 2005, 2006 (6 and 5 year programmes, respectively), is that 37.7% reported that communitybased
clinical training was better than in other settings (e.g. tertiary teaching hospitals), 18.4%
thought it was somewhat better, 30.6% felt it was about the same as other settings, and 4.1%
and 2.0% said it was somewhat worse, and worse, respectively 24 .
Regarding the equipping our medical undergraduates with “the necessary scientific and professional
knowledge, skills and attitudes”, we were the first medical school in sub-Saharan Africa to implement
an innovative curriculum based on the ‘SPICES’ model 60 –i.e. Student-centred, using Problembased
learning (PBL), Integrated, Community-based, with provision for Electives and planned
so as to be Systematic. When developing this curriculum, we drew different aspects from
different medical schools in Australia, Middle East, Europe, and North America which were
already practitioners of innovative curricula, and we adapted these aspects to suit and serve our
settings and needs, respectively. In the process, we also forged useful and lasting partnerships
with some of these institutions, e.g. the University of Newcastle in Australia and Bowman
Grey University in USA.
Our PBL curriculum has been extensively described 4, 7, 61-64 , monitored 8, 10-12, 65 , reviewed 66
and evaluated 9, 11, 24, 29, 65, 67-71 ; the latter including rigorous accreditation visits by the Health
Professions Council of South Africa (HPCSA) 71, 72 . In addition, we have followed-up all our
graduates meticulously 9, 48 , and the clear picture that has emerged from these processes is
that, notwithstanding our considerable constraints, we have produced, and we are producing
well-trained, holistic, competent, and confident doctors, who have made a big contribution to
healthcare in this region, province, and country at large.
15

16
6
5
4
3
2
1
confidence
p < 0.05
collaboration
management
UNITRA cf Other SA doctors (1998) (Rolfe et al 2000)
More importantly, our graduates are comparable to graduates from any other medical school
locally and internationally, as attested, at least in part, by the fact that as of 2009, 5% (n = 28)
of our 1990-2005 graduates were practising overseas in North America, Europe, Australia and
New Zealand. It is also heartening to note that whereas for 15 years we were the lone travellers
on the PBL road in this country, we have since been joined by at least three other medical
schools 38, 73 which are older and more well-established, but which have directly or indirectly
benefited from our experience as PBL pioneers in the country.
Besides successful accreditation visits by the HPCSA 71, 72 , one exciting finding from programme
evaluation of our PBL curriculum was that it improved student performance and throughput
rates 48 . For example, comparing our ‘traditional’ and our PBL curricula, the latter significantly
brought down the attrition rate from 23% to 10.3%, while the mean throughput rate fell from
6.7 years to 6.4 years 48 . On the other hand, exit surveys of final year students 24 and some
External Evaluator reports 69 have helped us to identify and attend to areas of the curriculum
where students needed further exposure (e.g. family dynamics, family violence, medicine and
the law, and practice management).
b). Motivated to work in both urban and rural primary health care settings in Transkei,
and who can find professional and personal satisfaction in such work
We have compiled a complete Alumni Database, and among the entries are particulars of
where each graduate attended High School and where they are practising currently. As noted
earlier, 242 (42.4%) of the 571 WSU medical graduates over the 1990-2005 period were, in
2009, practising in the Eastern Cape, which is largely rural. Another 24.5% (n = 140) were in
Kwa Zulu-Natal, and this figure tallies with the percentage of our graduates that are Indian
(26%) and who are recruited mainly from KZN. Gauteng had 11.7%, and the Western Cape

had 5.8% of our graduates, while Free State had 2.4%. These three provinces are, in that
order, the most highly urbanised in the country (with urban : rural ratios of 95:5%, 87:13%,
and 71:29%, respectively), and the numbers of our graduates practising in these provinces are
disproportionate to the very few students we recruit from there. It can therefore be concluded
that as per above Council Guideline b), our programme is also producing doctors who are
attracted to work in urban settings! What is more gratifying, however, is the apparent absence
of an exodus of our graduates of rural origin to the cities, with all their bright lights and other
tempting attractions.
Three years ago, I was privileged to host and co-supervise a medical student from the UK who
had taken a gap year to study for an intercalated degree in International Health. He interviewed
our medical graduates about their motivation for, and experience of studying medicine, their
reasons for practising in the Eastern Cape, and their views on doctor migration 74 . Our graduates
had been equally motivated to study medicine by role models (38.5%), and by guaranteed
job security (38.5%), but mainly by altruistic values (to help people) (84.6%). Although
monetary gains were admittedly considered to be important, they were not high on the list
of the graduates’ motivating factors (30.8%). Most graduates (61.5%) had chosen the then
UNITRA mainly for its comparatively lower, and more affordable training costs, and partly
because of the PBL curriculum (38.5%) and “good preparation for practice” (30.8%). A few (7.7%)
came to UNITRA because other medical schools had either kept them waiting too long for a
response, or had turned down their application; while some graduates’ choice was also because
they “would be working with and around people of my own culture and language”, a statement that says a lot.
As to the quality of their medical schooling, the report’s author says, and I quote: “ ….. all
… were unequivocal in stating that they had received equal, if not better training than their counterparts” 74 . The main
reasons for working in the Eastern Cape were: because it was home (100%); to help fulfil the
community’s health needs (61.5%); or the moral obligation to plough back into the province
that had financed their education and training (46.1%); while just under a quarter (23.1%) had
been lured by the ‘Rural Allowance’ (which surely is one of the worthier legacies of the late
Dr Manto Tshabalala-Msimang (RIP). Even those in private practice emphasized they were
not in it primarily for financial gain, but rather to provide better services than what obtained
in the shortages-riddled public sector, and to find job satisfaction instead of frustration arising
from the aforementioned shortages. The majority (61.5%) were working in the public sector,
30.8% were in the private sector, and 7.7% provided services in both sectors 74 . Interestingly
(and thankfully) only 23.1% of the UNITRA/WSU graduates interviewed had considered
temporary or permanent emigration from South Africa, although they were unanimous in
observing that emigration was a right to which doctors, like any other professionals, were
individually entitled.
Mr Vice-Chancellor, Sir, from the above Student Project research findings, and from the data
generated from analysing our Alumni Database, it is abundantly clear that we have successfully
fulfilled the requirements of UNITRA Council Guideline number two.
17

c). Able and motivated to work in health care teams to the benefit of the people of the
country
The inculcation of teamwork into our graduates starts right early in their undergraduate training
where the primary setting for learning is in small group PBL tutorials 62 , and where students are
also required to undertake group work on community-based health research projects 58 . Thus,
our students are imbued with a cooperative rather than a competitive spirit very early in their
training, and this is expected to endure. During their early and subsequent clinical exposure,
students experience team work, vicariously initially, but directly subsequently 64 ; and they, in
particular learn from their experience in clinics and district hospitals that this teamwork is more
symbiotic than hierarchical. Thus, by the time they graduate, our students are capable of being
effective and efficient members of healthcare teams. Ability to work in teams is, however not
a characteristic unique to our graduates, but one that is expected of, and is actually acquired
by all medical undergraduates. Unless one is practising traditional medicine deep in some rural
village, healthcare is, by its very nature, a teamwork effort, irrespective of whether it is in the
public or in the private sector. Thus, this was probably the least demanding of the UNITRA
Council Guidelines, and yes, we have fulfilled it too.
d). Able to educate and motivate communities, families and individuals to take personal
responsibility for their health and their own health care
Nearly 20 years ago, the UNITRA Faculty of Medicine and Health Sciences pioneered
community engagement and empowerment as an arm of health professions education by
the formation of the UNITRA Community Health Partnership Project (UHCPP) with the
Department of Health, and with the Communities of: Ngangelizwe, Baziya, Mbekweni, and
Mhlakulo 54 . One immediate offshoot of this project was the building of four Health Centres for
the partnering communities, which also became the epicentres of education (for both students
and communities) and community empowerment, e.g. by establishment of demonstration
vegetable gardens (Mbekweni) or as rallying points for a self-help water supply project
(Baziya).
Students also use these Health Centres for facilitation of their group community-based health
research projects and for home as well as school visits, all of which activities involve ingrained
community health education 55, 58 . In addition to the foregoing specific instances, this Council
Guideline is fulfilled on a daily basis, irrespective of the student’s level of study, or their
study settings. In the PBL tutorials, students are required to identify and discuss non-medicinal
management of patient problems including education and counselling 61, 62 , while in the clinical
setting they get to learn that a consultation is incomplete if patient education and provision of
information are omitted 64 .
We have plans, now in advanced stages, to implement multi-professional learning in the
Faculty 66 , and it is envisaged that the presence of the School of Allied Health Professions
in our midst, incorporating, inter alia, the Departments of Health Promotion, and of Social
Work, will not only boost this approach to our education programmes but that it will also help
18

us refine our fulfilment of the above Council Guideline. Two other developments expected to
be even bigger boosters for the community health outcome-based fulfilment of this Guideline
are the recent introduction the Master of Public Health programme, and more significantly the
“Adopt a Community” project by the Department of Community Medicine 75 .
e). Can think critically and creatively to deal with the health care problems of communities,
families and individuals and have the necessary knowledge and skills to do research
appropriate to the needs of Transkei within the various health care settings in the
country
Mr VC Sir, we introduced our first and ill-fated version of PBL in 1989 30 , ill-fated because for
various reasons which I won’t go into here, the students toyi-toyed against it at the end of that
year and we had to re-design the version that was subsequently implemented successfully in
1992. In one of the weekly Tutors meetings 76 we held early in 1989, I remember a colleague
(who will be familiar with those colleagues involved at the time, but who this afternoon
will remain anonymous) asking: “How can I tell if a student is thinking critically in a tutorial, when I cannot
read his or her thoughts?” This particular colleague was not terribly fond of the innovative PBL
curriculum, and he never concealed his very conservative ideas about this, nor did he conceal
his determination to make the innovation fail –reportedly going to the extent of advising some
students to spearhead the rebellion, with promises of helping them get admitted to other South
African Medical Schools! By asking the above rhetorical question, our dissenting colleague
was perhaps using it to highlight what he considered to be unclear or unrealistic items on the
checklist we were using for continuous student assessment, and he remained unimpressed
when someone gave him the dictionary meaning of ‘critical thinking’ in our context, viz.
“containing careful or analytical evaluations” 77 .
Mr VC, Sir, given the above dictionary definition, allow me to submit that clearly, anybody
whose work includes making decisions -and that is perhaps everybody- has got to be a critical
thinker. I thus consider critical thinking to be a generic skill, and not one that is confined to
doctors or to WSU medical graduates for that matter. However, this skill has to be learned, and
as with all skills, the best way to learn it is through repeated practice 78 .
In the training of our undergraduates, students acquire critical thinking skills in nearly all their
learning settings. In the small group PBL tutorial 62-64 , a real world, real life problem is presented
to the students by sequential revelation of information, in a bid to trigger learning by helping
them identify what they do not know, and therefore need to learn; before they can understand
the problem, let alone attempt to solve it. They formulate hypotheses, and suggest ways to
test them. Then, as they are given further information, they continually revise and and/or rerank
their hypotheses until they come to a likely diagnosis, suggest management strategies,
and reach closure. In other words, they learn and constantly practise: analysing components
and relationships in a system; comparing and contrasting options; making inferences and
interpretations from data; and evaluating the relative worth of options 79 . Thus, in our context,
PBL not only enables students to formatively acquire critical reasoning skills, but they also
19

use PBL to learn how to make evidence-based diagnostic and / or therapeutic decisions80 .
That our students are, as early as their second or third year of study, able to critically analyse
a patient problem scenario to the extent of suggesting diagnoses and management strategies
is one aspect of our curriculum that never ceases to impress External Examiners from sister
institutions in South Africa, and from as far north as Uganda4, 81 . Typical comments by the
External Examiners have been: “My 3rd year students would not be able to tackle the patient problem the way yours
do”; or “If your pre-clinical students and my pre-clinical students were to encounter this scenario in real life, your students
would be able to do something about it whereas my students probably wouldn’t” 81
Mr VC, Sir, the second requirement of Council Guideline e) was for us to train graduates with
skills and knowledge to conduct health research relevant to local community needs. We have
fulfilled this Guideline by introducing our students to basic health research methodology as
early as year 1 when they learn statistics and statistical methods. In year 2, when they go for a
month-long Community-based Experience and Service (COBES) exposure at selected District
Hospitals in the Eastern Cape, they learn and practice such skills as gathering and recording of
vital statistics (birth rates, neonatal mortality rates, maternal mortality rates, infant mortality
rates, child mortality rates, morbidity and mortality rates, disease burden, crude death rates,
cause-specific death rates, etc.), as well as taking anthropometric measurements in school
children 55 . More focused community-based research training and practice takes place in year
3, wherein students spend each term time Wednesday in communities where they learn clinical
skills in the mornings and research methodology in the afternoons. The latter, which involves
early ‘know your clinic’ and ‘know your community’ themes, culminates in student group
community-based health research projects, the results of which are presented by the students,
on a dedicated day, to (besides their year 3 peers) a diverse audience that includes: University
Management, Health Sciences Faculty; fellow WSU students, staff from the Health Centres,
representatives from all the involved communities, and from local and provincial service
providers 58 . The lasting impact of this exercise has been not only the acquisition of research
competences by our students 82 , but also the use by the communities of the data generated from
these researches to convince government and local municipalities to deliver services identified
as critically lacking by the student-conducted research 69 . I thus wish to observe at this juncture
that by training in the communities, our programme and our students have, through relevant
community-based research, had a positive impact on the health of these communities. We,
however, still need to rationally and scientifically evaluate this impact, in view of some obvious
and some not so obvious confounders. Having thus said, though, Mr VC, I wish to observe that
we have pretty well fulfilled this Council Guideline, and that we are on our way to doing so
even better, as I will illustrate shortly.
f). Equally committed to the prevention as to the management of illness and are capable
of understanding health care problems in their biological, psychological and socioeconomic
context
Allow me to observe, Mr VC, Sir, that fulfilment of this Guideline is again inherent in any
medical undergraduate curriculum anywhere in the world, and that differences (if any) are in
20

how this is done. I am sure that every Health Professions practitioner (and hopefully, every
Health Professions student) will by now be aware that in 1978, an International Conference
on Primary Health Care was held under the auspices of the World Health Organization (WHO)
in Alma-Ata in the then USSR; and that this Conference adopted the 10-point Declaration of
Alma-Ata83 . This Declaration was, for the next 22 years known by the slogan ‘Health for all
by the year 2000’, although the careful wording of the Declaration in this regard was simply
that: “A main social target of governments, international organisations and the whole world community in the coming decades
should be the attainment by all peoples of the world by the year 2000 of a level of health that will permit them to lead a socially
and economically productive life”. Incidentally, the WHO definition of health84 was (and is): “a state of
complete physical, mental, and social wellbeing, and not merely the absence of disease or infirmity”; a definition that has
not only attracted interesting debate85, 86 , but also one which perhaps was not in the minds of
those (me included) who were, over those 22 years, bombarded with the “Health for all by the year
2000” slogan, and who instinctively thought of health simply as the absence of disease and/or
infirmity! Additionally, I daresay that the architects of the Alma-Ata Declaration must have
been a bunch of optimists who not only thought that 22 years was a long time, but who also
implicitly expected ‘plain sailing’ over the said period of time. In the words of a Dean of a
medical school in a Central African country, which he uttered, rather cynically (I must add) in
1995 at an All Africa Conference on Medical Education in Cape Town: “….. they might as well have
declared: ‘AIDS for all by the year 2000!’ ”.
Mr VC, I am perhaps now digressing a bit, and to come back to how we have responded to
Council Guideline e), let me put it in a nutshell and say that it is all in our Faculty Prospectus 87 .
More specifically, our PBL curriculum is integrated both horizontally and vertically, to ensure
that nothing is learned by our students in isolation, or in a vacuum; and to make sure that their
learning and assessment takes place in a real life, rather than a theoretical context. And when
it comes to diseases, the training for fighting which is one of our main core businesses, we
emphasize not only cure, prolongation of life, or palliation, but also primary and secondary
prevention. One way of ensuring the latter two, has been the deliberate inclusion of Population
Medicine in all the three phases of our curriculum (viz. Phase 1: Normal Structure and Function,
Phase 2: Abnormal Structure and Function, and Phase 3: Clinical Practice), wherein, as COBES
and / or as Community-based Clinical Clerkships (COMCC), this vital theme (together with
Clinical Skills training) provides the ‘golden threads’ that link the different phases of our
curriculum. We also emphasize holistic care in the training of our undergraduates, by priming
them to address the wellness of the patients’ body, mind and spirit –or the physical, emotional
and spiritual aspects of an individual. And by ‘spiritual’ I do not mean any religious aspects
of a doctor-patient interaction, but rather the ‘essence of who one is’, or the ‘core of self’. To
address the latter, we have, over the years, sought support from the UNITRA/WSU departments
of Anthropology, Psychology, and Sociology in the module of ‘Human Behavioural Sciences’;
but we believe we could be of better service to our students if we had our own department of
Human Behavioural Sciences (may be under the watchful eye of the Department of Psychiatry).
This department would also provide a more efficient and effective service to our sister (no pun
intended) Schools of Nursing Sciences, and of Allied Health Professions. Mr VC Sir, I am thus
calling for the incorporation of the other Human Behavioural Sciences (i.e. Anthropology,
Sociology & Population Studies, Psychology) into the WSU Faculty of Health Sciences, so
21

that we can exploit the resources available therein for the common good of our students, our
academic staff, and (most obviously) our communities.
Mr VC, Sir, before I digress even further, let me reassure you that we are fulfilling this Council
Guideline, although there is still room for improvement.
g). Self-directed and life-long learners who will be able to adapt to changing circumstances
in Transkei, keep up with developments in their professions and have the necessary
motivation and background to acquire relevant specialised qualifications to fulfil the
needs of the country and to advance their own careers
Mr VC, Sir, I am sure you will agree that of all the UNITRA Council Guidelines that I have
referred to thus far, this is probably the most ‘loaded’, in that it is a composite of at least
5 ‘sub-guidelines’: self-directed learning, life-long learning, adaptation to local changing
circumstances (no specifics), keeping up with developments in the profession, and specializing
to fulfil national needs and to advance own careers. At the same time, however, I believe that
this is one UNITRA Council Guideline where we have excelled, thanks to our innovative PBL
and CBE SPICES-model curriculum 11, 29, 65, 88 .
The PBL aspect of our curriculum implies that our students’ learning is not only self-directed 89,
90, 91 but that it is also stimulated by their encounter with real life problems. Because their future
professional life is expected to be full of patient problems, we want to believe that the curriculum
turns them into life-long learners. It may be argued that every individual is a life-long learner
in one way or another, and I have no problem with this sentiment. I however wish to submit
that the life-long learning which we believe PBL promotes is purposive and that the life-long
learning which every individual goes through is by default or accidental. In this regard, it is
interesting to note a close relationship between our PBL curriculum and the features of lifelong
learners, viz. they plan their own learning; they assess their own learning; they learn in
informal settings; the learning is active; there is peer learning; they integrate knowledge from
different disciplines; and different learning strategies are used in different situstions 92 . There
are compelling reasons for imparting life-long leaning skills to our graduates, and examples
are: explosion of knowledge and of technology; economic restructuring, organisational reform,
and changes in the workplace and career patterns; need to find more cost-effective ways of
teaching and learning within constrained resources; shift to an information society; emergence
of new occupations and careers, and rapid transformation of others; and the need to meet
expanding educational needs and expectations of larger numbers of students from increasingly
diverse backgrounds 92 .
Our students’ career intentions have been researched 93 and preliminary findings suggest that
these are matched by the actual career paths followed by the graduates 94, 95 . More excitingly,
although medical postgraduate training in South Africa is, like many other prominent
professional and/or managerial positions, still dominated by white males 96 , we at WSU have
not done badly motivating our students to specialise as per the above Council Guideline; and
22

in this regard the two gender groups appear to be fairly equally represented.
80
70
60
50
40
30
20
10
0
1999 2000 2001 2002 2003 2004 2005
Male M Med enrolment by race at UCT (1999-2005) (Breier and Wildschut, 2006)
70
60
50
40
30
20
10
0
1997 1998 1999 2000 2001 2002 2003 2004
UNITRA PBL PGs: Gender (Kwizera, 2009)
As of 2009, there were just over 570 WSU medical graduates that were post-Community
Service, and of these, 43.5% had either obtained a postgraduate qualification or they were
undergoing postgraduate training for one 48 . The clinical disciplines preferred by our graduates
for specialisation are: Paediatrics (14.1% of the 43.5%), Obstetrics & Gynaecology (11.7%),
Anaesthesiology (7.3%), Internal Medicine (5.7%), General Surgery (5.2%), Family Medicine
(4.4%), Psychiatry (4.0%), Ophthalmology (3.6%) and Orthopaedics (3.6%). Interestingly
in exit surveys 31 , final year students consistently identified Obstetrics & Gynaecology and
Paediatrics clinical clerkships as the top two with which they were most satisfied, a perception
B
C
I
W
M
F
23

that is also reflected in their postgraduate training preferences. Gender preferences for the
different specialities are similar to what one sees elsewhere, both nationally and abroad, with
females going for Paediatrics and Family Medicine, and males dominating General Surgery as
well as the surgical sub-specialties of Ophthalmology and Orthopaedics. The two genders are
equally represented in Obstetrics & Gynaecology and in Internal Medicine 95 .
There are, however, two aspects of postgraduate training by our students which give rise to
major cause for concern. The first is that, whereas we are retaining in rural Eastern Cape those
of our graduates who are generalists, the same is not the case with those who have specialised.
Either they stay in the big Metropolises where they specialised (Durban, Cape Town, Pretoria,
Johannesburg), or if they return to the Eastern Cape at all, then they prefer the bigger cities of
Port Elizabeth and East London. While it is true that hospitals in these two cities are part of
our teaching platform, the bulk of clinical teaching still takes place in the Mthatha Hospital
Complex, and we need to attract our graduates who have specialised to come back to Mthatha
and play an active and much needed role in the medical education and training of their younger
brothers and sisters. With the relatively recent introduction of Registrar training in the Mthatha
Hospital Complex, we are, hopefully, going to use this opportunity to ‘grow our own timber’;
although this is more of an intermediate-to-long term solution than an immediate one. The
immediate solution is the return of our graduates who have specialised to their alma mater. If
one looks at other medical schools in South Africa and elsewhere, or indeed at other Faculties in
WSU, it becomes abundantly clear that Universities and their Faculties are built and sustained
by their own graduates; and there is a limit as to how much or how long the WSU School of
Medicine can rely on an expatriate academic staff component of more than 95%. And these
are not words of a turkey voting for Christmas (or Thanksgiving). I, God willing, will reach
retirement age 5 years from now, and the outlook for succession in my department remains dim.
I am sure the same could be said of many other departments in the School of Medicine, and
we need to urgently find ways of attracting some of our soon to be 1000+ medical graduates
to return to us.
The second area of major concern is that hardly any of our graduates have, or are specialising in
the basic biomedical sciences. We have recently tried to address this by introducing a Bachelor
of Medical Sciences degree in a bid to, again, ‘grow our own timber’ but we have to be very
careful to ensure that majority of the graduates from this programme do not end up studying
medicine (which seems to be the strategy of most), because then we will simply be ‘scoring
own goals’ More importantly, there is need for reflection and introspection on our part in a bid
to answer some important questions: Why are WSU medical graduates not pursuing careers
in the basic biomedical sciences? Is it lack of mentoring and / or motivation? Have basic
medical sciences been misrepresented in our curriculum so they have become unattractive to
our graduates as careers? Or do they (probably rightly so) equate being a medical graduate with
clinical practice, and not teaching and researching basic biomedical sciences in a laboratory?
As the FASEB Journal Editor wrote recently, may be it is time for another Flexner Report “and
the return of medical education to the basic biomedical sciences” 97 .
24

My grumbling aside, Mr VC Sir, I think we have executed this Council Guideline superbly,
and since the ‘Transkei’ referred to in the UNITRA Council Guidelines has since again become
part of the Republic of South Africa, then we derive satisfaction in knowing that our medical
graduates who have specialised are providing sterling service to their country, even if they
are not in rural Eastern Cape, and / or even if they have not specialised in the basic medical
sciences. In addition, we have a Radiologist in Australia, a Psychiatrist in New Zealand, a
Gastroenterologist in Canada, a Paediatrician in New Zealand, a Surgeon in the UK, to cite but
a few of our ‘ambassadors’ abroad, of whom we can be truly proud!
h). Exhibit high levels of ethical and administrative insight, skills and integrity
On perusal of the 157-page WSU Faculty of Health Sciences Prospectus 2010 87 , the discerning
reader will notice that it begins on page 2 with a ‘Student Declaration’ which is ‘sworn’ by new
students at the start of their training in our Faculty. Then, towards its end on page 155, there is
an adaptation of the Hippocratic Oath which is ‘sworn’ by successful final year medical students
in December, before they commence Internship in January, pending their graduation in May.
Both these documents emphasize ethical behaviour of our students and graduates, respectively.
However, we have not stopped at ‘declarations’ and ‘oaths’, but have deliberately taught our
students Ethics and Professionalism from year one, and by means of different approaches
including lectures 98 , as well as hands on training in research ethics 58, 99 . One could also submit,
anecdotally, that the requirements of this Guideline have been fulfilled through mentoring and
role modelling. In my 21 years at UNITRA/WSU, I have not come across or heard of a single
instance where any one of us was found guilty of unethical behaviour, negligence or misconduct
by their employers, the HPCSA, or any Court of Law. By the same token, I am not aware of
any of our more than 925 (and still counting) medical graduates who has fallen foul of the law,
or the HPCSA, as a result of unethical or criminal behaviour. In addition, though again I say
this anecdotally, some of our graduates currently occupy positions of responsibility and high
accountability as Medical Superintendents in various government hospitals, and in government
Departments of Health (both provincial and national) countrywide. Many are highly respected
members of their communities wherein they are providing ‘generalist’ services, some have
joined the country’s Defence Forces and are proudly wearing their uniforms both at home
or in AU Peace-keeping Missions (e.g. in Darfur and the DRC); and others –albeit few, have
joined us in Academia. The bottom line, Mr VC, is that we have, unequivocally, fulfilled this
UNITRA Council Guideline to the core; and if anyone in this gathering has any information to
the contrary, I am very keen to be brought in the know. And, in any event, if there have been
any mishaps that I am not aware of, let us remember that our graduates are, like the rest of us,
only human!
In summary, Mr Vice-Chancellor, Sir, I wish to submit that the Faculty of Health Sciences
at WSU has, by and large, positively and successfully responded to the Council Guidelines
outlined by the then UNITRA Council just before this Faculty was established 25 years ago;
and that those positive and successful responses have borne results of which we as WSU can
collectively be proud.
25

COnCLUDInG REMaRKS anD THE ROaD aHEaD
Mr VC, Sir, as I near the end of my Inaugural Lecture, allow me to make the following
observations, conclusions and recommendations:
-the WSU Faculty of Health Sciences has really come a long way from 1985 and a total
enrolment of 12 in the MB ChB programme, to today, 25 years on, when the enrolment is more
than 600 (i.e. more than a 50-fold increase in 25 years). This has happened against all odds,
and with appropriate support from the University, I hope it is not unreasonable –especially if
our Faculty is considered to be the WSU Flagship- to expect at least a similar increase over
the next 25 years.
-we (again against all odds) pioneered medical PBL and CBME in the country, not unlike
‘Star Wars’: ‘Boldly going where no other South African medical school had gone before’;
and not only did we survive the venture, but we also proved to the country and to the medical
education community worldwide, that in so-doing, “Yes We Can!” Furthermore, changes in the
Medical Education scene, and in government health policies in South Africa after 1994 have
demonstrated that we were way ahead of our time, and that the antagonism we encountered
at the beginning was perhaps another example of what is written in The Bible (King James
Version), in Luke, 4:24: “ …..Verily I say unto you, No prophet is accepted in his own country”. And interestingly,
none of the local sister institutions which have adapted a similar approach to the training of
their medical undergraduates came to us directly for assistance, preferring instead to ‘import’
bigger chunks of curricula from Australia or The Netherlands, and behaving as if we were
‘invisible’. In the words of one Pathologist from one such medical school, “A myocardial infarction
in Sydney is no different from a myocardial infarction in Johannesburg!” –another statement that says a lot. And
although they give us anecdotal reports of how good our students / graduates are, they seem to
consciously make it a point not to want to learn from our rich experience. Of course this might
partly be due to important distinctions regarding our different historical perspectives, but I
also see an effort on the part of these ‘Johnny come lately” medical education ‘innovators’ to
hijack our pioneer legacy, and to claim their latter day clones as ‘the first in South Africa’ –or
similar. We have to be vigilant and jealously protect our pioneer status as the medical education
innovators in this country and on this sub-continent.
Mr VC Sir, I wish to further strongly suggest that our University’s response to this putative
development, or rather to the potential (or may be real) threat to our legacy as pioneers of
innovative medical education in this country should be your unequivocal support for our
programmes, our plans and our strategies; so we can retain our vanguard position. I need not
overemphasize this, and not simply because of the emerging ‘competition’ on an apparently
still uneven playing field, but mainly for the sake of our heritage as pioneers in innovative
medical education in this country.
Mr VC Sir, in the February 2010 Issue of Academic Medicine, the Editor, Steven L Kanter,
writes a virtual ‘capsule’ message for the Journal’s readers in 2110. And he concludes his
message thus: “And so, as you prepare to celebrate the 200 th anniversary of the Flexner Report, I wish you a rational, ethical,
and satisfying equipoise in dealing with the most important challenges of your time.” Mr VC Sir, without appearing
to be plagiarising, allow me to borrow from Steven Kanter, Editor in Chief of Academic
26

Medicine, and say: “To those of you who will be celebrating the 50 th Anniversary (Golden
Jubilee) of the WSU Faculty of Health Sciences in 2035: I hope that you will add richly to this
Inaugural Lecture or should I say ‘self report’, and that you will have found lasting solutions
to the two problems bugging us now: specialising graduates who do not return, and the paucity
of specialisation in the basic biomedical sciences among our graduates.”
And at this juncture, Mr VC, Sir, allow me to observe -and to express the hope- that I have
delivered this Inaugural Professorial Lecture to your standards and expectations, that I have
answered the questions I set for myself for this Lecture, and that, -God forbid-! I will not be
required to sit for a Supplementary for the first time in my life.
27

aCKnOWLEDGEMEnTS
I wish to express my gratitude to WSU (and to UNITRA, before it) for providing me with
uninterrupted employment for the past 23 years and for giving me the honour to serve as
Associate Professor for the first 17 years and as Professor and HOD for the past 6 years;
and contribute to the training of the nearly 950 doctors produced by this institution thus far.
I particularly wish to thank the Executive Management: Prof Balintulo for steering with a
such a steady hand this, often times ‘tricky’, ship that is WSU; Prof Obi for his supportive,
enthusiastic, and hands-on approach to academic and research affairs at this institution; Prof
Buijs for uncompromisingly attending to institutional development and Quality Assurance;
and Prof Tau-Mzamane for monitoring the institution’s pulse and other vital signs. Prof Ekosse
has been highly supportive, not only in my preparation for this occasion, but also whenever
I have approached the Research Development Directorate for sponsorship to national and
international conferences; and for this and more, I am grateful to him and to all the staff in the
Research Development Directorate.
I must make special mention of the Executive Dean, Faculty of Health Sciences, Prof Mfenyana
–and with him all the past Deans in the Faculty: Prof. Xaba-Mokoena, Prof Ncayiyana, Prof
Kakaza (RIP), and Prof Mazwai, together with the present and past Vice-Deans: Prof Sokhela,
Prof Knight, Prof Nganwa-Bagumah, Prof Lategan, Prof Gibbs, Prof Mkhize, and Prof Surka-
for their visionary leadership and their belief in innovation, which qualities have immensely
contributed to the successes of this Faculty over the past 25 years. Thank you for all your
foresight, and for telling us “Yes We Can” long before the advent of Barack Obama!
Without those who were or have been my formal and peer teachers over the past 53 years, I
would not be standing here today. I therefore wish to acknowledge a few of my many teachers
whose collective roles in my education and training made me who I am today. Among these
are: Yudesi Ndanguza, Yonasani Rwakabingo, Frederick Mugenga, David Rwihandagaza,
William Rukara, Paulo Komunda, Cosma Munyarugerero, and John Bitunguramye (different
primary schools); William Chrichton, Maurice Reeve, Colin Gregory, Brian Remmer, Francis
Kasiragi, Jeb Bangizi, and Ian Tilling (Ntare School); Sultan Karim, Willy Annokbongo, Ian
McIntosh, Raphael Owor, John Luwuliza-Kirunda, James Rwanyarare, John Kakitaahi, John
Ssali, and Sam Sebikari (Makerere University), David Leach, Roger Hicks, Peter Hulbert,
Roger Ash, Robert Naylor, Brenda Costall, Ian Naylor, Diana Woods (University of Bradford);
Jeff Bridges, Peter Bach, Martin Wilks, Patricia Ijomah and Neil Gregg (University of Surrey);
and William Burdick, Page Morahan, John Norcini, James Hallock, Debby Desirens, Regina
Petroni-Mennin, Stewart Mennin, Danette McKinley, Ray Wells, Ralf Rundgren Graves, and
Frank Simon (FAIMER). I must also mention the FAIMER Fellows in my class of 2007,
together with those from the 2006 and 2008 classes with whom we interacted in Philadelphia
–and subsequently on Mentor-Learning (M-EL) webs.
I have also, over the past 20 years, learned a lot from my UNITRA/WSU colleagues and
mentors, and I wish to mention but a few namely: Marina Xaba-Mokoena, Alex Nganwa-
28

Bagumah, Dan Ncayiyana, Khaya Mfenyana, Ortrun Meissner, HSS Kakaza (RIP) Jehu
Iputo, Augustine Kafuko, James Byaruhanga, Dan Kayongo, Grace George, David Mugwanya
(RIP), Dan Mkhize, John Byarugaba (RIP), Charles Kamanzi, Sylvia Kamanzi, Andrew
Stepien, Lech Banach, Geoffrey Buga, Banwari Meel, Ernesto Blanco-Blanco, Mirta Garcia-
Jardon, Orlando Alonso, Julio Aguirre-Hernandez, Foyaca Humberto Sibat, Myra Gari, Gisela
Milanes, Amalio del Rio, Jose Martinez (RIP), and many, many more who I am unable to
name here and now due to time constraints –but who, I am glad to note, I ‘know who they are’
to me.
Mr Vice-Chancellor, Sir, I must also make special mention of colleagues in my Department,
the Faculty Office, the Directorate of the School of Medicine, and the FHS Undergraduate as
well as the Postgraduate Training Units for their support in various circumstances relating to
my work and research, and their dissemination locally and abroad.
Mr Steyn Swanpoel has always been there for me, not only for photographic services (e.g.
relating to this occasion), but also by his preparation of excellent posters that I have, over the
years, presented to conferences, not only as near as Mthatha and East London, but also as far
as Canada, USA, Spain, Holland and Australia. Thank you, Steyn, keep up the good work, and
may you prosper! My wishes for Steyn are extended to all other MultiMedia gurus involved
in this presentation.
I contritely wish to thank Bishop Mzamane of the Diocese of Mthatha and based at the Cathedral
of St John the Evangelist. As The Right Rev Mzamane might attest, I am not a regular at St
John’s Cathedral; but I am sure he can also attest to my spirituality, and to our friendship. My
Lord Bishop Mzamane, I thank you for gracing this occasion with your [presence and your
blessings.
To the WSU Choir for all those sweet melodies, what can one say, except that may your voices
become even sweeter, and may your music bring joy to the entire creation!
To all the guests from far and near, and to the entire congregation, thank you for sparing a bit
of your precious time to honour this occasion, and to share my ‘big’ day!
Last but not least, to my good friend Rev Philemon Mathenjwa for his most able MC role, and
to the Caterers for ‘what we are about to receive’ and for which I am sure we shall be truly
grateful.
But before we are ‘truly grateful’, Mr Vice-Chancellor, Sir, please allow me to point out that
I have, over the years, also had the opportunity and honour of meeting, learning from, and/or
interacting with South African (-and not so South African) colleagues outside UNITRA / WSU
who I wish to acknowledge here; and I they are many … but I can think of Dek Sommers (RIP)
and CP Venter (RIP), Ben Potgieter, Bernhard Myer, Wimpie du Plooy, James Syce, Peter
Folb, Gavin Steele, Pierre Mugabo, George Amabeoku, Athol Kent, Marietjie de Villiers, Roy
29

Henbest, Max Price, Vanessa Burch, Bongani Mayosi, Wendy McMillan, Francois Cilliers,
Ben van Heerden, Juanita Bezuidenhout, Elizabeth Wasserman, Jacky van Wyk, Gboyega
Ogunbanjo, John Tumbo, Dianne Manning, David Cameron, Christina Tan, and Marietjie van
Rooyen; as well as all the SAFRI Fellows to-date. Other (international) medical education
colleagues to whom I am fondly grateful include: Gwendie Camp, John Hamilton, Isobel
Rolfe, Sally-Anne Pearson, Frances Kaye, Elizabeth Kachur, Deborah Murdoch-Eaton, Brian
Jolly, Sue Whittle, Michelle McLean, David Cook (RIP), Janet Grant, Ahmed Fahal, Sir Ronald
Harden, Ian Hart, Sam Leinsten, and James Ware.
It is when I get to think about my Clinical Pharmacology and Medical Education colleagues,
both near and far, that I realise how much we value each other, and how much we mean to one
another –and by extension, what we, as a network, are to those whom we train, be it in South
Africa, USA, Australia, UK, Sudan, Malaysia, or the Middle East. At the end of the day, Mr
Vice-Chancellor, Sir, whether we are Clinical Pharmacologists or Medical Educationalists, I
guess the bottom line is, to borrow from the late Michael Jackson: “We are the World”!
Mr Vice-Chancellor, Sir, Ladies and Gentlemen; I thank you!
30

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37

CITaTIOn
Professor Enoch Nshakira Kwizera was born on 13 June 1950 in Bufumbira, South-Western
Uganda. He was the fourth child and first son of Ernest and Edreada Nshakira, and he grew up
in a happy family, with five sisters and two brothers.
Kwizera started formal schooling in 1957 at Seseme Primary School in Bufumbira, and he did
his grade 3 at Kabindi Primary School, grades 4 and 5 at Nyaruhanga Primary School and grade
6 back at Seseme in 1962. His Junior Secondary School was also at Seseme, where he passed
with flying colours, and qualified for a place, with a full scholarship, at Ntare School, Mbarara,
Uganda. In 1966, the school headmaster decided to use the entire 1967 Senior 3 (Grade 11)
class in an experiment dubbed ‘Acceleration’, where they would write the Cambridge School
Certificate Ordinary Level Examinations (‘O-level’) at the end of Senior 3, instead of the usual
end of Senior 4. When the results were released in January 1968, Kwizera was one of the 3 top
achievers in the school, all from the ‘Acceleration’ class, and each with distinct aggregate in
six subjects. In March 1968, he enrolled at Ntare School for ‘A-levels’ in Physics, Biology,
and Chemistry; and passed these at the end of 1969 with excellent symbols.
Between January and June 1970, Kwizera served at a private Junior Secondary School where he
taught every subject except History. In June 1970 he enrolled at Makerere University Medical
School; and while there, he again excelled, scoring special merits (‘Credits’) in: Anatomy,
Physiology, Pathology & Microbiology, Pharmacology, Preventive Medicine, Obstetrics &
Gynaecology, and Paediatrics; and he was joint second best finalist in March 1975. It was also
at Makerere that Kwizera met his Pharmacology mentors: Dr William W Anokbonggo, and
Professor Sultan Karim (of the prostaglandins in obstetrics fame) in whose laboratories he was
employed as a Student Research Assistant during holidays between 1971 and 1974. He was
‘Circulations Manager’ of the student-run Makerere Medical Journal in 1973/74.
Dr Kwizera’s professional working life started in April 1975, as an Intern in Mbale Hospital
in Eastern Uganda, where his rotations were in Obstetrics & Gynaecology and in Internal
Medicine. He was also Chairman and Spokesperson of the Mbale Hospital Interns’ Committee.
On completion of Internship in May 1976, he was appointed Tutorial Fellow in the Department
of Pharmacology & Therapeutics, Makerere University Medical School. Three months later,
in September 1976, he commenced studies toward a Masters of Science in Experimental
Pharmacology at the University of Bradford, West Yorkshire, UK. This was successfully
completed in September 1977, and for his MSc research project, he pioneered the isolation
and use of liver cells in experimental research at the University of Bradford.
In November 1977, he was awarded a scholarship by the World University Service (UK) to
study towards a PhD degree in Pharmacology at the University of Bradford, which he went on
to complete (research, write-up and all) in record time of just under 3 years. In December 1980
he returned to Uganda to take up a position of Lecturer in the Department of Pharmacology
and Therapeutics at Makerere University. He was promoted to Senior Lecturer in 1983.
39

In 1985, Dr Kwizera was offered a Commonwealth Medical Fellowship in Clinical
Pharmacology and Toxicology, at the Robbens Institute of Industrial and Environmental Health
and Safety, at the University of Surrey in Guildford, UK. There, attached to the Nephrotoxicity
Unit, he researched and published on drug and chemical-induced kidney damage. And while
in Guildford, Dr Kwizera was appointed Associate Professor of Pharmacology at the then
UNITRA, a position he took up in December 1988. After a frustratingly long moratorium
on promotions at the institution, Professor Kwizera was promoted to Full Professor, effective
January 2004. He has also been HOD, Pharmacology, since 2004.
At WSU, not only has Professor Kwizera taught, researched and published in Clinical
Pharmacology, but he has also served on Eastern Cape Provincial Drug and Therapeutics
Committee, as well as on the National Essential Drugs Committee. He has also put in Sessional
clinical work at Mthatha General Hospital in Family Medicine (1989 – 2002) and in Forensic
Medicine (2003 – to date), contributing to the clinical care of patients in these facilities.
Over the past 20 years, Professor Kwizera has developed deep interest in Health Professions
Education which has become his second academic passion. In 1993, he was elected to the
Council of the South African Association for Medical Education (SAAME) to represent
UNITRA and the Border Region. SAAME has since morphed to SAAHE (South African
Association for Health Professions Educationalists), and he represents the Eastern Cape on
the SAAHE Council. More recently, Kwizera was, in 2007, awarded a Fellowship of the
Foundation for the Advancement of International Medical Education and Research (FAIMER)
based in Philadelphia, USA, which he completed with distinction in 2008. As an offshoot to
his FAIMER Fellowship, he is currently on the Council and is Faculty at SAFRI (Southern
African FAIMER Regional Institute) which aims at propagating FAIMER activities in sub-
Saharan Africa.
Professor Kwizera has widely published locally and internationally on pharmacology,
toxicology, and on health professions education; and he has attended and presented papers at
numerous local and international conferences. The last two of the latter were in Malaga, Spain
and Khartoum, Sudan in August and October 2009, respectively, and the next one is next month
in Miami, USA, where he will make a presentation on a novel way of evaluating the learning
of Pharmacology at WSU. He is Associate Editor of two international peer-reviewed online
journals: BioMed Central Clinical Pharmacology, and BioMed Central Medical Education,
and he is on the Editorial Board of the African Journal of Health Professions Education. He is
also a reviewer for Medical Education, and for the European Journal of Radiography.
In his illustrious academic career as a Pharmacologist, Professor Kwizera has directly
participated in the training of more than 2600 doctors (in both Uganda and South Africa) and
more than 500 biomedical scientists in the UK. In addition, he has been involved in the external
moderation and/or examination of a further 300 doctors and 150 pharmacists in Tanzania, as
well as 200 Pharmacists and 300 dentists in South Africa.
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In recognition of his past, present, and potential contribution to Pharmacology in this country,
Professor Kwizera was, in 2009, invited to join the Colleges of Medicine of South Africa as
an Associate of the College of Clinical Pharmacologists. This recognition has ramifications
which go beyond his CV, in that there is now a real possibility for WSU to train Clinical
Pharmacology Registrars within the Mthatha Hospital Complex.
Professor Kwizera is also a past First Vice President of Mthatha Lions Club, and he is a keen
stamp collector, scrabble player, gardener, and amateur golfer. Kwizera is also an experimental
braai master, and he hopes that when he retires, he will earn a living ‘braaing for profit’!
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Design: Mthatha Health Resource Centre