HOW NEUTRAL ARE MEDICAL SCHOOLS ? BY ANTHONY ZWI.

48.

HOW NEUTRAL ARE MEDICAL SCHOOLS ? BY

ANTHONY ZWI.

HOW NEUTRAL ARE MEDICAL SCHOOLS ? BY ANTHONY ZWI.

The Medical Schools do not tackle or confront the root causes of ill-health in South Africa. They prefer to concentrate only on disease and the

technology required to limit or eradicate it. No attempt is made to isolate the causes of poor

health and to alter these causative factors.

Instead the Medical Schools produce graduates who are capable only of functioning in a narrow sphere of medicine and one which makes little or no

impact on the overall health status of all the

people of South Africa. Thus, the Medical Schools, part of a totally inadequate health care system,

function to perpetuate that system without altering it.

Although doctors and medical schools are by no means the major influence on the health status of people, they do have a limited role to play

in the improvement of the health of the people.

In this article, I would like to briefly look at the present role of medical schools in South

Africa, how they play their part in preserving the status quo, and to what extent their role could be altered. *

The Medical Schools train doctors who are expected to meet the health needs of the people. The

Medical Schools are therefore required to produce sufficient doctors of sufficiently high technical ability to meet the health needs of this country.

* The author's views are based on Wits Medical School and it is assumed that the issues raised are common to the other Medical Schools in South Africa. If this is not the case, the editors would be pleased to learn of this - Editors.

5 No attempt, however, is made to produce doctors who will attempt to influence the causes of

illness and will try to reduce the reliance of people on the medical profession. Efforts are

rather directed at increasing the number of doctors to enable them to deal with an increa-

sing population with increasing amounts of diseases. It is difficult to estimate what actual effect doctors have on the picture of ill-health in South Africa. However, one can look at where doctors are found and how they

function. At present, 65 J % of all doctors in South Africa practise in metropolitan areas, and a further 29% practise in cities or towns, while only 5\% practise in rural areas. (Beaton and Bourne, 1978). Of those in rural areas many are expatriates. The vast majority of doctors

(90% in 1973) are Whites who practise mainly amongst the White sector of the population and this further increases the disparity in the

distribution of doctors. The doctors produced in South African medical schools are largely

devoted to curative medicine and their

influence on health is limited to the numbers of individual patients they see and minimal

if any influence is extended on the community at large. Of the active doctors in South

Africa, approximately 25 per cent are

specialists and of these only about 2 per

cent are specialists in preventive medicine.

Only a small proportion of doctors are involved in industrial health care and the care of worker Very few South African doctors understand the

social and political milieu in which they

function, and even fewer perceive their role as one which may have important social and

political consequences. They therefore prefer to fit in neatly with the established social

elites in South Africa and play their part in ensuring the smooth and efficient functioning of

society in its present form.

Yet the medical schools claim to be attempting to meet the needs of all the people of South

Africa. But, in this country dominated by in- equality,, oppression, and exploitation, can the

medical schools actually separate themselves from society and function in the interests of all,

rather than only in those of the elite? Can the medical schools be neutral or do they take sides?

I believe that the medical schools cannot possibly claim to be neutral institutions. Rather, they

play a strong part in ensuring the continuation

of society in the way it functions at the present*

time. In this way it echoes the role of the

university - to produce graduates who will ensure optimal functioning of society in the form that the government (and not the majority of the

people) have decided as being in the "best

interests of the people" (i.e. some of the people).

The medical schools support the status quo in a number of ways. To a large extent this is by default, i.e. by what the medical schools do not do. Do they ever confront the real issues

behind ill-health in South Africa? Do they ever talk about the distribution of wealth or power or

land? Do they ever discuss the origin of the homelands, underdevelopement, and migrant labout?

Are the medical schools neutral if they produce doctors who accept all that they see around them without critically looking at society or the

causes of ill-health? Are they neutral if the products of medical education are usually doctors who readily become part of the elite and re-

inforce the unjust status quo? Is medical

education neutral if it does not even ensure that students and doctors are able to communicate with the majority of their patients, even if they do not speak either English or Afrikaans? Is it neutral

if students are taught their skills in highly

sophisticated institutions, and are not taught to function without this highly technical backup,

while a large proportion of patients will be seen in areas where this backup is not available?

Are medical students taught that health is not

determined only by medicine and doctors but by

52.

numerous other influences? Are they taught that they should be concerned with the health

of their patients and the communities from which they come, or are they taught that doctors are there only to deal with disease? Are students taught about the other health workers who are

essential parts of the health team if the health of the majority of people is to be improved?

Are they taught how to teach and how important it is to learn to teach, whether it be for the benefit of individual patients, communi ties, or col 1eagues?

Do the medical schools teach students how to analyse a health problem, assess what is influ-

encing the health status of the people concerned, implement appropriate programmes and evaluate

them? Do the medical schools ever question the role of doctors or the distribution of health

care in South Africa? Do the medical schools condone the building of large disease palaces in preference to the erection of Community Health Centres?

All the medical schools would answer that they are attempting to deal with these issues, but

that is true to such a limited extent as to make no impact on prospective doctors.

There are a number of reasons for failing to confront these issues. First of all, the

Medical School is but a section of the University, and as mentioned earlier the university is re-

sponsible for producing graduates who will fit into the present structure of society without disrupting it. They will help to ensure the perpetuation and smooth-running of society in its present form. Doctors contribute by

supporting the elite and allowing to suffer those who have been oppressed and dispossessed.

Secondly, doctors as a group are tremendously conservative and there is an amazing reluc-

tance to change, an avoidance of anything new.

They work together as a group to maintain their own

interests. The profession is far more impor- tant than the public.

Thirdly, doctors are generally ignorant of the causes of ill-health in South Africa. They have never been made aware of the history of disease in South Africa. Why is malnutrition such a major problem in the homelands? Are rural communities stupid or is there something - else influencing the high incidence and pre-

valance of disease? Doctors generally do not bother to isolate the causes of ill health in

communities. Mainourished children are treated (if the doctor finds himself in a hospital not only treating the upper and middle classes) and then they go home. What is at home and what

is in the community generating that disease is left for other people to tackle.

The medical schools do not encourage a look at the causes of health problems. Nor for that

matter, do they encourage students and staff to generate solutions to South Africa's health

problems. They prefer to casually fit into the structure of health services as they pre- sently exist.

Is it surprising that the majority of students aim to practise in cities and towns? In their training, do they ever leave the vast teaching hospitals? Do they learn 3bout the health

problems in the most isolated communities with little or no access to sophisticated medicine?

It is surprising that the graduates follow the example of their teachers and stay in the

comfortable surroundings of the city? Is it surprising that doctors wish to.stay in the

urban areas 3nd to serve the elite, even though the medical school and its teachers do all they can to encourage their students to work in

rural areas or with other communities and groups

in urban areas. Is it surprising that students

do what their teachers d_o rather than what they

say?

R E L E V A N C E

IS THE ESSENTIAL QUALITY

OF EDUCATIONAL OBJECTIVES

*

OBJECTIVES WHICH HAVE EVERY

QUALITY EXCEPT RELEVANCE

ARE POTENTIALLY DANGEROUS

t h e m s e l v e s in i n n o v a t i v e a p p r o a c h e s t o t h e h e a l t h n e e d s o f c o m m u n i t i e s , b e c c u s t e a c h e r s k n o w s o l i t t l e a b o u t t h e m . 0

r a r e l y l e a v e t h e i r v a s t t e a c h n o l o g i c a l p i e c e s a n d r a r e l y if e v e r c o m e i n t o c o n t h e r e a l i t i e s o f i l l — h e a l t h o u t s i d e t h e t i o n s . I t is h a r d l y s u r p r i s i n g t h a t w t a u g h t a b o u t r e f l e c t s t h e i n t e r e s t s a n d o c c u p a t i o n s o f t h e t e a c h e r s r a t h e r t h a n o f s o c i e t y ( S i m p s o n , 1 9 7 6

m e e t i ii t h e u • r t e m a s t e t a c t

s e i n h a t w

p r e - t h e

I r

a c h e r s r-

w i t h s t i tru- e a r e

n e e d s T h e m

h e a l t pi i n e s o c i o a n d o bei n g

e x t e n

;nembe eve r t r a i n

peopl

edical s c h o o l s do not t e a c h s t u d e n t s that h is i n t e r r e l a t e d w i t h n u m e r o u s o t h e r d i s c i - s such as social a n t h r o p o l o g y , p o l i t i c s ,

l o g y , a g r i c u l t u r e , social w o r k , p s y c h o l o g y , t h e r s . D o c t o r s are a l w a y s s p o k e n of as

at the head of the t e a m . V e t , to w h a t t do the s t u d e n t s e v e r even w o r k

rs Of t h e s e allied d i s c i p l i n e s ? a c t u a l l y w o ^ k t o g e t h e r as a team

W o u l d they know how to wo o are n o t d o c t o r s or n u r s e s ? vr ] ?

wi th

Do they

d u r i n g t h e i r

^k w i t h M e d i c a l s r h o o l s are not n e u t r a l but r s f l s c t a s 2t of : de;1 ogi es arid a s s u m p t i o n s p r a d a t e r n i ned by t':> slita of s D c i a t y . If t«ia snsjical

s c h o o l s w a n t s d :o a t t a n p t to b e c o ^ a n s a t r a l , or even to play a C D s i t i v e role in t.re Diirsuvt of j u s t i c e in t h i s c o u n t r y , w h a t w o u l d t h e y h a v e to d o ?

F i r s t of a l l , the m e d i c a l s c h o o l s m u s t d r a w up a set of o b j e c t i v e s for t h e i r e d u c a t i o n a l p r o -

g r a m m e . The m e d i c a l s c h o o l s m u s t s t a t e w h a t s o r t of d o c t o r s they w i s h to p r o d u c e . The p u b l i c should d e b a t e t h i s and i n f l u e n c e t h e d i r e c t i o n in w h i c h the m e d i c a l s c h o o l s m o v e .

At p r e s e n t the m e d i c a l s c h o o l s p r o d u c e the sort of d o c t o r s they g r a d u a t e , k n o w i n g and e n s u r i n g t h a t they h a v e t r a i n e d the sort of d o c t o r not w a n t e d and needed by the p e o p l e .

The m e d i c a l s c h o o l s m u s t c r i t i c a l l y a n a l y s e the role they p r e s e n t l y play in S o u t h A f r i c a n

56.

health care eind must attempt to ensure that they are not producing doctors who merely accept and condone the present unequal d i s t r i b u t i o n of

health c a r e , but rather analyse critically and then act according to their f i n d i n g s .

The medical schools should stimulate an awareness of the relationship betv.'een health and socio-

e c o n o m i c , p o l i t i c a l , c u l t u r a l , and ether f a c t o r s . These relati ensni ps are ccniplex and unci ear but only through analysis and debate can a clearer

understanding of the relative importance of these different influences be arrived a t . The m

staff peopl f aci 1 commu Soci e -ly 1 The m probl the c

impro

edi ca and es of

i tate n i c a t ty an n t h e ore s

e m s , halle vemen

1 scho s t u d e n

S o u t h d by e e w i t h d e n c o

i m p r o tudent the mo n g e s o t of h

ols should e n g e n d e r in their ts a commitment to all the

A f r i c a . This can best be

nabling students to interact and a broad spectrum of South African uraging them to p a r t i c i p a t e active vement of health in c o m m u n i t i e s ,

s learn about South Africa and its re willing they will be to accept f w o r k i n g for c h a n g e , and the

ealth care of all the p e o p l e . The med

blems o for the shoul d of thes

how bes i s no c the maj how bes amount t e a c h i n i n v e r s e t h e s e p h o s p i ta

i cal s f Sout

provi ensure e prob t to d

Tear u or hea t to a of tim g of p 1 y rel roblem Is (S

chcols h Afri si on o

that 1 ems a e a 1 w i nderst

1th pr ttempt e and arti cu ated t

s e.re

impscn

mus t ca an f hea stude r.d th th th andi n obi em

to s empha lar h o the seen

) .

analyse t d establi s

1th c a r e , nts are ta e alternat em. At p g of what s in South olve them, sis devote ealth prob

frequency outside of

he health pro- h pri ori ti es

Courses

ught thoroughly ive methods of resent there exactly are

Africa or Y e t , the d to the

lems is almost with which

the teachi ng The medical schools rrtist see themselves as part of society with a responsibility to it. The

orientation of the nedical c u r r i c u l a must clearly

with the most prevalent health problems by

using the most appropriate methods of solving them. This is in contrast to emphasising the.

highly sophisticated techniques required to

influence the course of extremely rare diseases, as is done presently.

The medical schools must involve themselves in actually providing the health services needed by society. At present, the medical schools all help in the provision of urban curative

services, but they should also become far more involved in providing alternative forms of

medical services. The medical schools should run community hospitals and clinics in rural

and urban areas to teach their staff and students about the problems encountered in community

setting and theierivation of that ill-health.

The medical schools should become involved in training health workers in urban and rural

communities and should devote attention to the health needs of workers. Where else are

doctors influenced but during their training?

If the course gave students a broad awareness of the problems of society and the techniques

required for solving them, then doctors would be much more willing to devote their lives to serving communities rather than only serving their own personal interests.

The medical schools must become more involved in researching health systems and aspects of

health care. Attention must also be devoted to critically evaluating present methods of meeting health needs. Medical schools must

advocate those solutions that would be most

appropriate, and must not be bound by precedence and conservatism. Students should be part of

a dynamic search for solutions to health problems, rather than silent supporters of the present

inadequate approaches.

Of course it is highly unlikely that the

medical, schools would actually contemplate radically changing medical education towards something far more relevant. Medical

Education will probably continue to benefit and pepetuate the interests of the elite, and

the majority of people will continue to suffer.

There is little pressure for the present

approaches to change, and they will continue until circumstances force us to confront the alternatives.

REFERENCES:

BEATON AND BOURNE, Some Notes on the Distribu- tion of Doctors in South Africa 1975, paper presented at SALDRU/SAMST Conference on the Economics of Health Care in Southern Africa, • September 1978.

GUILBERT, J.J., Educational Handbook for Health Personnel, W.H.O. Offset Publication No. 35,

Geneva, 1977.

SIMPSON, M.A., The Uses of Objectives, notes.

SIMPSON, M.A., Medical Education - A Critical Approach, Butterworths, London, 1972.

CENSUS OF HEALTH SERVICES (1972-1973), Medical

Practitioners and Dentists, Government Printers, Pretoria, 1976.

THE LEARNER, Volume 7, No. 1, 1979