THE FUTURE OF MEDICINE
by
BONGANI M. MAYOSI
B.Med.Sci.; M.B., Ch.B. (Natal); F.C.P. (S.A.); D.Phil. (Oxon); F.E.S.C.;
F.A.C.C.; F.R.C.P. (Lond.); M.A.S.S.Af.
Vice-Chancellor and Principal of the University of Cape Town, Professor Njabulo
Ndebele; Deputy Vice-Chancellor and Vice-Principal, Professor Martin West; Deputy
Vice-Chancellors, Professors Cheryl de la Rey and Thandabantu Nhlapo; Dean of the
Faculty of Health Sciences, Professor Marian Jacobs; Dr Nosisa Matsiliza,
ikhankathakazi lam; Friends, Family, Ladies and Gentlemen.
Thank you, Professor Jacobs, for your very kind and generous words of
introduction. I am delighted that both my mother, Mrs. Nontle Mayosi, and the only
surviving sibling of my father’s, Mrs. Nontuthuzelo Mbuli, are present to hear these
words. I am sure that their impression of me will improve after this day. My late father,
Dr. George Timketson Sikhumbuzo Mayosi, is sadly not here to witness this occasion.
Ndithi kuye namhlanje, lala ngoxolo, Rhadebe, soyifeza iminqweno yakho.
My siblings and I owe a great debt to our parents for instilling in us a love of
learning, and to our mother in particular who suspended her own career as a nurse for 14
years to raise and almost single-handedly educate her brood of five children. We received
home schooling from my mother and other mothers in the village of Ngqamakhwe in the
Transkei; this home-based education was supplemented by the meager offerings of the
Bantu education system of the 1970’s. My mother’s name is Nontle, which means ‘the
mother of beauty’, and I stand in front of you as an example of the success of her labour
of love. Mama, enkosi.
I would like to acknowledge, too, with gratitude, the love, support, and
understanding of my wife, Nonhlanhla, and my children, Vuyi and Gugu, our pride and
joy, for without them, my life would be incomplete.
And to everyone here tonight – my relatives, colleagues, and friends who have
come from all over the country – a very sincere ‘Thank you’ for finding the time to
honour me with your presence.
It is with humility that I stand before you this afternoon as the seventh Professor
of Medicine and Head of the Department of Medicine in its 87 year history. I am also
deeply conscious of the distinguished example of my predecessors, three of whom are in
the audience today.
I indeed stand upon the shoulders of giants. The first Professor of Medicine,
Professor A.W. ‘Oubaas’ Falconer, arrived from Aberdeen, Scotland, in February 1920 to
establish what was then known as the Division of the Medicine at the new University of
Cape Town Medical School. He was a leading spirit who contributed greatly towards the
establishment of clinical teaching which took place at Somerset Hospital at the time.1
2
In 1938, Groote Schuur Hospital opened, at which time Falconer retired as
Professor of Medicine and went on to become the Vice-Chancellor and Principal of the
University of Cape Town.
Professor Falconer was succeeded by Professors Jack Brock and Frank Forman
who were the joint heads of the Department of Medicine from 1938 to 1954. The
numbers of students in the medical school continued to increase in this period, and,
naturally, the emphasis of the department was on clinical teaching. The legendary
combination of Brock and Forman served the department well. While Frank Forman was
inspiring generations of medical students in the finest traditions of clinical medicine,
Brock, who was appointed Professor of Medicine at the tender age of 33 years, began to
lay strong foundations for medical research in the department.2
In 1954, Professor Brock assumed the sole Headship of the Department. It was
during his term from 1954 to 1970 that the department expanded through the
establishment of specialist clinics and the escalation of the research effort. This period of
expansion arguably represents the golden era of the Department of Medicine in which,
for example, the publication count grew from two papers per year in the 1940s to an
average of 100 peer-reviewed publications per year by the 1960s. The establishment of
specialist clinics, like the Cardiac Clinic in 1955, made it possible for great achievements
such as the first human heart transplant to occur on this campus. Professor Solomon
Benatar remarked in his Inaugural Address of 1981 that ‘the foresight and vision of the
University of Cape Town and the Provincial Administration in designing the Joint
Agreement…and the tenacity of all concerned in sustaining it through difficult periods
must be acknowledged, for without this mutually beneficial arrangement between the
Province and the University it is unlikely that research or clinical activities would have
developed to the same extent’.2
Brock was succeeded by Professor Stuart Saunders in 1971 as the fourth Head of
the Department of Medicine. Saunders steered the Department successfully through a
period of changing fortunes. The harbinger to the changing times was the banning and
eventual move to exile of Professor Bill Hoffenberg for his anti-apartheid activities in
1968. The political repression and unrest of the 1970’s had a significant impact on the life
and work of the department, resulting in the first major exodus of highly qualified staff in
1977 and 1978, following the 1976 uprisings of school children against Bantu education.
The chronic problem of healthcare budget cuts and the flight of staff into the
private sector or overseas continued in the era of Professor Solomon Benatar from 1981
to 1999. Professor Benatar valiantly stabilized the department in the midst of an
increasingly hostile environment, and handed over to Professor Ralph Kirsch in 1999 a
department that was sound with respect to the quality of clinical teaching, medical
service, and research output.
The Department I inherited in 2006 is probably the finest Department of Medicine
in Africa, and a tribute to the fighting spirit of Ralph Kirsch and his predecessors in
ensuring the survival of academic work in Cape Town under very difficult conditions. I
am privileged to work with the fine men and women who make up the Department of
Medicine of today, all of whom are committed to providing the best clinical care to their
3
patients, to producing competent doctors and specialists, and to conducting research as
perfect as any in the world.
Our departmental staff of 169 people consists of 12 Full Professors, 18 Associate
Professors, and 63 Senior Lecturers, who are supported by 40 research staff and 36
administrative and clerical staff. We play a major role in teaching undergraduate medical
students and in training specialists and subspecialists in medicine. We teach 1183
students at any one time, who are made up of 1014 undergraduate medical students, 81
masters students (of whom 50 are specializing in internal medicine and 15 are engaged in
subspecialty training) and 35 doctoral students.
Today I have chosen to speak on the Future of Medicine. To address the question
of the Future of Medicine, we need to start from the beginning. It has been said that our
memory of the past, informs our present, and guides our future. Therefore, I will do three
things in my talk: first, I will comment on the origins of Medicine, second, I will talk
about the health status of Africa, and finally, I will venture into the future.
The African Origin of Medicine
According to Charles S Finch,3 an American scholar of ancient history and a
medical doctor, ‘healing as a vocation may have begun at the time when a remote,
nameless ancestor – taking cues from the habits of animals – brought leaves, grasses or
roots to an ill relative in an attempt to relieve her distress’ and found a beneficial
response. The origin and evolution of healing as a special skill probably antedates other
important human inventions such as agriculture and animal domestication and might well
deserve consideration as ‘the oldest profession’ in the world.3 The accumulated
observations and trials of thousands of years have brought a wealth of healing knowledge
to mankind, and medicine as a systematic discipline has emerged in different modes in all
the cultures of the people of the world.
As with so many other human achievements, Finch argues that the art and science
of medicine emerged first in the Nile Valley of Africa, reaching its highest level of
development – until modern times – in Egypt, land of the pharaohs. When Egyptian
dynastic history begins, medicine is already an established, fully-formed science. The
information to support this assertion is contained in the most important medical textbooks of ancient Egypt, now known as the Ebers Papyrus and the Edwin Smith Papyrus,
which are copies of medical papyri which date back to pre-pyramid times, to the very
earliest historical dynasties of Africa.3
From the beginning of her history, Egypt possessed a mature, well-validated
system of medicine containing systematic pathology, a completely-formulated
pharmacopoeia, a formal knowledge of anatomy and physiology, a large medical
literature, a well-defined medical curriculum, and a skill in surgery that was hardly
matched outside Africa until the modern times. According to Finch, it is unthinkable that
such knowledge, which is so sophisticated on a scientific level, could have emerged
without a long period of anterior development. There is a 2400 year span from
Hippocrates of Greece to modern medicine and the mature medical science that existed at
the start of the dynastic period in Egypt would have had a pedigree at least as long.3
4
If the onset of the Egyptian dynastic period is dated around the first known
calendar date of 4236 B.C., which is believed by some to be closer to the actual
beginnings of Egyptian dynastic history rather than the conventional 3200 B.C., the best
educated guess would push the origins of Egyptian medicine back, close to 7000 B.C.3
If Egyptian medicine was of a caliber beyond that of all later medicine up to the
modern time, we have to presume that not only was the scientific spirit alive and well in
ancient Egypt, but that scientific medicine actually originated in Africa. It is therefore a
misnomer to characterize our practice of scientific medicine as ‘Western Medicine’,
when in fact, like all human beings, it originated in Africa.
Imhotep, the African: Father of Medicine?
Indeed, no individual more fully embodies the highest and finest of Egyptian
medicine than the figure of Imhotep (http://en.wikipedia.org/wiki/Imhotep). Sir William
Osler called him ‘the first figure of a physician to stand out clearly from the mists of
antiquity’.3 In truth, this African physician is the world’s first universal genius and
polymath. As chief counsellor to the pharaoh Djoser, he was a statesman of the first rank;
as designer of the world’s first great edifice in stone, the step-pyramid of Saqqara, he was
an architect of genius; as the renowned purveyor of wise sayings and parables, he was the
epitome of a sage; and finally, as a gifted priest-physician, he was accorded that rarest of
honours in ancient Egypt, that is deification as the god of healing.3
Hippocrates, the Greek physician who is customarily accorded the title of ‘Father
of Medicine’ was himself said to be descended from a long line of ‘Asclepiads’, that is a
devotee of the Greek god of healing, Asclepios. In the famous oath ascribed to
Hippocrates – which some believe was composed after his death – adherents of the
Hippocratic school are made to swear by all the important healing gods of Greece,
including Asclepios.3According to some scholars, by swearing by Asclepios in the
Hippocratic Oath, the members of the Hippocratic school were in fact swearing by
Imhotep since the two were synonymous in the Greek mind.
The reputed primacy of the Hippocratic school as the originators of clinical
medicine was finally laid to rest in 1930 when Breasted translated the Edwin Smith
Papyrus, a document whose original antedates Hippocrates by over 2500 years. The
diagnostic, prognostic, and therapeutic methods revealed in this document demonstrate
that even in our own day, our physicians have not surpassed the clinical acumen of the
priest-physicians of the Nile Valley of Africa, of whom Imhotep was the epitome.3
I submit, ladies and gentleman, that Hippocrates in no way merits the title ‘Father
of Medicine’, either by virtue of his antiquity or the level of his scientific thought. If such
a title belongs to anyone, it belongs to Imhotep the African.3
A study of other African systems of medicine is more problematical, however,
because of the absence of surviving written records. Thus, most of what we know comes
from the testimony of European missionaries whose contemptuous view of traditional
African culture was most pointed when writing about traditional medical practices.3
According to Finch, it can be shown that the best of the traditional healers in various
parts of Africa acquired a startling level of proficiency and, contrary to contemporary
opinion, were not without medical science.3 We will leave the exploration of the evidence
5
on this statement for another day…but I cannot resist the temptation to tell an anecdote
concerning the Khoi remedy for rheumatic fever that my mentor and good friend,
Professor Jimmy Volmink (Deputy Dean for Research, University of Stellenbosch
Medical School), brought to my attention recently.4
In 1876, there was a lively exchange of correspondence in the Lancet, the British
medical journal, between by Thomas Maclagan, a doctor from Dundee, Scotland, who
reported on his use of salicin to treat the symptoms of rheumatic fever, and Dr. Frederick
Ensor, a surgeon at the Provincial Hospital in Port Elizabeth. On 14 April 1876, Dr.
Ensor wrote to the editor of the Lancet as follows:
“DEAR SIR - I have seen with much interest your papers in the Lancet on the
Treatment of Rheumatism by Salicin, and thought that the following story might be
welcome.
“In 1861, I was district medical officer in Hope Town… the town is… occupied
by a race of nomadic Dutch Boers, who live in wagons or tents, traveling about from
place to place...
“On one occasion, I was sent for to visit the wife of a Dutch Boer, who was said
to be very ill. I found my patient…lying on a camp bed in a little tent, where the heat was
something terrific; a naked bush child trying to fan away the cloud of flies, which was
tormenting my poor patient, bound hand and foot, I may say every joint, in the cruel
bonds of as fierce an attack of rheumatic fever as I ever saw. She was perspiring
profusely…
I prescribed the usual alkaline mixture, with calomel and Dover’s power at
bedtime, and rode away.
“Some two months after, my former patient entered my surgery, looking
remarkably well, and I very naturally congratulated myself and her that she had recovered
so completely. I was quite taken aback when she bluntly told me that my physic hadn’t
helped her a bit. On enquiring what had helped her, she said that the old Hottentot
shepherd had made her a decoction of the shoots of the willows which grow on the banks
of the river, and that after taking this for a few days she began to get better.
“Your papers in the Lancet brought the picture of the stout Dutch woman back to
my memory. I afterwards learned that a decoction of willow-tops is a favourite remedy
for fever, and what the Boers and native Hottentots call ‘sinkings koors’ or rheumatic
fever.
“Trusting that this remedy which you have scientifically thought out may prove as
beneficial as the ‘willow-tea’ selected by these children of nature.”
Commenting on the information he had received from South Africa, Maclagan
wrote:
“(it is)…a curious commentary on our civilisation…that one of the most common
and painful diseases of the civilised world should have remained one of the opprobria of
medicine for many years after a remedy for it was known to the rude Hottentots of South
Africa….the untutored Hottentot shepherd used the proper means, while the
accomplished European physician was trying this, that, and the other remedy, with results
6
so unsatisfactory that he had almost given up the idea of ever being able to do more than
watch the natural progress of the malady…”4
The Khoi people made the extract of willow tea by boiling the leaves of the
willow plant (Salix alba) and used this for pain relief and to treat fever. We now know
that the effect of the willow leaf is largely due to the activity of a glycoside, salicin,
which is changed following ingestion to salicylic acid, a compound that is related to
acetylsalicylic acid, the active ingredient of aspirin.5
The State of Colonial and Post-colonial Medicine in Africa
The Khoi people, who were the original inhabitants of the Cape peninsula and
called Table Mountain hoerikwaggo, of course did not survive the relentless advance of
colonialism in Africa. My colleague and friend, Del Kahn, the Professor and Head of the
Department of Surgery at the University of Cape Town, reminded me of a statement that
set scene for medicine and politics in South Africa for almost 100 years following the
assimilation of the Khoi people. The statement is contained in the book compiled by
Professor Jannie Louw, the second Professor of Surgery at the University of Cape Town,
on the history of the first 50 years of the University of Cape Town Medical School. The
statement reads as follows:
‘At the turn of the century, the health of the public was receiving a good deal of
attention, thanks to Dr Barnard Fuller, who was then part-time Medical Officer of Health.
In the 1900 annual report he referred to the outbreak of bubonic plague in the city. The
first step decided upon was to remove all Bantu (people) from the city precincts and to
house them in a Bantu location in Uitvlugt (or Ndabeni). At that time Dr Fuller was
convinced that this racial group played an important part in the spread of plague and
aggravated the slum conditions which then existed in District Six and the Malay Quarter.
This is illustrated by his reference to the influx of ‘uncontrolled hordes of aborigines into
the city confines’.1
This diagnosis and prescription of Dr Barnard Fuller proved to be effective not
only in terms of the ideology of apartheid that was formalized in 1948, but also in terms
of the policy towards the admission of Bantu-speaking people to the University of Cape
Town Medical School. When I applied to enter medical school in 1982, Bantu-speaking
students were still excluded from admission to the University of Cape Town Medical
School, unlike the practice at Wits, the other white liberal institution which pushed the
legal boundaries to admit a small number of black African students throughout the dark
days of apartheid. I chose to enroll at the University of Natal Medical School where my
father had qualified about 18 years earlier.
It is worth pointing out to my children and others who have no experience of the
apartheid era that the policies that were pursued at that time continue to have an impact
on the status of health of the people of South Africa. The focus of the apartheid
government was on controlling the movement of Bantu people, and in reducing the
fertility rate of the black population. Motivation for these policies stemmed from the
promotion of quality of life and access to resources for whites at the expense of black
South Africans.
7
Perhaps the most important result of many years of apartheid policies is the
extreme income disparities that persist among South Africans. South Africa has the
dubious distinction of having the highest income inequality in the world, which is
comparable only to Brazil and Chile.6 The disparities occur along racial, gender, and
rural-urban lines. The socio-economic legacy of apartheid was summed up by that astute
commentator on Africa, Mahmood Mamdani, the former A.C. Jordan Professor of
African Studies at the University of Cape Town. He observed in the mid-90’s that if
white South Africa were a country on its own, its income per head of population would
be 24th in the world, next to Spain; but if black South Africa were a separate country, its
per capita income would rank 123rd globally, just above the Democratic Republic of the
Congo.7 The magnitude of the disparities between rich and poor in South Africa creates a
special responsibility on all of us to ensure that our policies and programmes promote
equity, and not just the health of individuals.6
The similarity of the level of development of the majority of South Africans to
their cousins in the Democratic Republic of Congo and elsewhere compels us to examine
the health status of the rest of the continent’s people if we are to understand the real
challenges of the present and the imperatives of the future.
Fortunately the first African Regional Health Report of the World Health
Organisation was published in 2006; the report reviews how the health of the people in
the African Region has developed over the last 10–15 years and tracks progress — or
lack thereof — towards achieving the health-related Millennium Development Goals set
by the United Nations.8 The report has appeared at a crucial time for Africa, a time when
major international efforts are under way to reduce poverty. For example, in July 2005,
the Group of Eight industrialized nations provided debt relief and increased aid to
African countries. In December 2005, the 148 members of the World Trade Organization
agreed on a package of trade and aid measures intended to help the world’s poorest
countries. The package is a small first step towards the “trade-for-aid” goal of the Doha
Development Round; it seeks to abolish tariffs on African products and subsidies paid to
farmers in wealthy countries, tariffs and subsidies that make it difficult if not impossible
for African farmers to compete internationally.
The 2006 African Regional Health Report shows that, among factors affecting the
health of the 738 million people (in 2005) in the 46 member states of the African Region
of the World Health Organization, poverty remains an intractable problem. About 45% of
Africans live on less than US$1 per day, and we are the only region in the world that has
not improved on this situation in the 1981-2001 period.
Not surprisingly, the top five leading causes of death are diseases of poverty:
infections such as HIV/AIDS, malaria, and lower respiratory tract infection, and perinatal
conditions and diarrhoeal disease of children. HIV/AIDS, tuberculosis and malaria kill
more than three million people every year, a number that is equivalent to the population
of Cape Town.
It is of interest that chronic diseases such as stroke and heart disease are in the top
10 causes of death in the African region. This is a warming to all of us that we need to
work simultaneously to eradicate infectious disease on the one hand, while making sure
8
that we prevent the rise of circulatory disorders, such as high blood pressure and
ischaemic heart disease.
Progress towards achieving the Millennium Development Goals is slow, and very
few countries are likely to achieve the targets by the year 2015. This is illustrated by the
progress made in relation to under-5 mortality, maternal mortality, proportion of the
population living on less than US$1 per day, and percentage of the population without
access to clean water.8
The African Regional Health Report singles out one key public health challenge
for Africa if we are to make progress, and that is the building and reinforcing of health
systems that are capable of delivering essential and quality health care to the population.
Countries in the African Region have weak and dysfunctional health systems.8 The recent
events related to the budget cuts in the Western Cape Academic Hospitals and the Frere
Hospital affair indicate that this challenge also applies to our own health system.
Several key elements are required for health systems to function properly: first,
adequate numbers of skilled health workers; second, basic infrastructure and equipment;
third, essential medicines and supplies; and finally, health finance and proper financing
systems. It is also important to establish effective health information systems, including
vital registration, to measure the scale of a given health problem in order to gauge the
appropriate response.
Health care in the majority African countries is provided by a mix of public and
private providers, often resulting in “vertical” or single-disease/issue programmes. Funds
for health care come from a variety of public and private sources, including donor funds.
Some governments have started to take a “sector-wide approach” to avoid duplication
and to improve the coordination of those funds so that they can be used more effectively
in a national health system.
If we are to strengthen health systems, we need to forge strong collaboration with
a range of partners at provincial and national levels, including government, the private
sector, civil society and communities. Universal access to essential health care can only
be achieved by scaling up essential health system interventions, such as essential drug
lists. This will be difficult to achieve without adequate investment and without taking the
delivery of essential health services as close to the communities as possible through
strong and effective district health systems.
Our challenge as academics is to help define an essential package of healthcare,
not only at the primary level, but also at the secondary and tertiary levels that must be
delivered to the population. Such a ‘prescribed minimum package of care’ for the public
service will hopefully eliminate the need for Professors of Medicine and Surgery in Cape
Town from protesting under the Palm Trees of Groote Schuur Hospital, but spend more
time
in
the
wards
and
theatres
of
the
health
service
(http://www.capeargus.co.za/index.php?fArticleId=3699079).
What is the Future of Medicine in Africa?
If the past is anything to go by, attempts to predict future changes in medicine are
generally wildly inaccurate.9 Nevertheless, according to Michael Peckham, Director in
the School of Public Policy at University College London,9 looking at the future may
9
have some merits. It may alert us to opportunities which would otherwise be downplayed
or missed. A view of the future may help shape society and prepare individuals to live
with and master new trends and technologies. Finally, by detaching ourselves, if only
transiently, from the daily routine in order to reflect on what might come, we may be able
to see contemporary problems and potential solutions more clearly.9
In this talk, I will not embark on a futuristic exploration of the impending
wonders of genomic medicine, or the allures of stem cell therapy, nor the promise of new
imaging technology to penetrate to the very soul of man. Neither will I address the very
real threats to the public’s health which have been identified by the 2007 World Health
Organization Annual Report. There is a long list of these dangers, including
environmental threats (i.e., global warming, ozone depletion), old and new infections
(HIV/AIDS, tuberculosis including extremely drug resistant forms, malaria, SARS, ‘bird
flu’, human pandemic influenza), and socio-behavioural pathologies (i.e., violence, war,
drug abuse, and mental illness).10
My emphasis in concluding this talk will be on the adoption of a way of thinking
about our intellectual work as we embrace the future.
The future of medicine has been the subject of several reports in the United
Kingdom, the United States, and other countries, but not to my knowledge, in Africa
where the art and science of medicine originated. In fact, health problems are often
articulated from viewpoints that do not include an African perspective. For example, the
1998 World Health Organisation report, entitled ‘Life in the 21st century – a vision for
all’, suggested that ‘as the new millennium approaches, the global population has never
had a healthier outlook’. It went on to say that ‘…the most important pattern of progress
now emerging is an unmistakable trend towards a healthier longer life’.11 It is true that
there are grounds for optimism but only provided that ways can be found of tackling
problems in the poor regions of the world where the majority of the world’s population
live. Civil unrest, wars, famine, genocide, and major infectious diseases form part of the
daily experience of a significant proportion of African people.
I do not deny the fact that medicine has benefited from the most exciting
developments in the last 100 years, some of which were pioneered here in Cape Town.
The first human transplant which was carried out 40 years ago by Chris Barnard and his
team epitomizes of the innovative spirit of Cape Town. An even greater achievement,
that is less well known to the majority of South Africans, is that of the invention of the
computed tomography scan, or CT scan. Allan Cormack, a University of Cape Town
physicist, conducted the first experiments on the idea of the CT scan in the Old Main
Building of Groote Schuur Hospital in 1957. He was awarded the Nobel Prize for
Physiology or Medicine for the development of the CT scan, together with Godfrey
Hounsfield, the English engineer, in 1979.12 These two events give us hope that
innovation and invention is possible even at the lowest tip of Africa, a location that is
remote from the traditional centres of innovation and invention of the North.
What is to be done?
It has been pointed out that at every point in history the possibility existed that
things might have gone differently from what ensued; individuals and people acting with
a common purpose can change the course of history. The historic political deal that led
10
to the end of apartheid in South Africa is a case in point. This experience of our recent
past assures us that there are no predetermined futures. The future depends on what we do
today to ensure a better life for our children and our children’s children.
I have found the words and counsel of Franz Fanon to be illuminating at this time
in our history. Franz Fanon was a psychiatrist and essayist who has become a key figure
in postcolonial and cultural studies of Africa. Born in 1925 on the French Caribbean
island of Martinique, he studied medicine and psychiatry at the University of Lyon in
France. He completed his best known book, entitled the Wretched of the Earth in 1961
just before he died of leukaemia at the age of 37 years.
This is what he had to say on the condition of the middle classes in developing
countries following independence13:
‘The national bourgeoisie of the under-developed countries is not engaged in
production, nor invention, nor building, nor labour; it is completely canalised into
activities of the intermediary type. In such a situation, privileges multiply and corruption
triumphs, while morality declines’.
The critique of Franz Fanon is as relevant to postcolonial Africa of the 1960’s as
it is to South Africa 12 years after apartheid. An intermediary is a ‘go-between’ or a
person who acts between others to bring about an agreement. I suppose the issue of
‘fronting’ in black economic empowerment activities, whereby a black person acts a well
paid intermediary between white business and the government is a cogent example of
what Fanon referred to as ‘being absorbed in activities of the intermediary type’.
The four challenges of Fanon to produce, to invent, to build and to work are
relevant not only in commerce, but also to the project of securing a bright future of
medicine in Africa. It is a matter of public record that the intellectual production of our
universities, as measured by published papers, is falling, and that this decline is related to
a severe contraction in the output of clinical medicine from South African medical
schools. Our efforts to produce should also be concerned with the training of an
appropriate and adequate health workforce for Africa. The African Region has 24% of
the burden of disease in the world, but only 3% of doctors and nurses.14 The Millennium
Development Goals of the United Nations are unlikely to be achieved given the global
shortage of 2.4 million doctors and nurses in the 57 least developed countries of the
world.14
On the question of invention or innovation, we are also deficient in Africa.
Innovation, through finding new ways of using old techniques or through the invention of
new technologies, changes the way medicine is practiced and this in turn feeds back into
the type of facilities needed, the human resources required, the flow of patients, and other
modifications to existing services.9 Despite the fact that healthcare, perhaps more than
any other sector, is presented with a profusion and great diversity of new methods and is
subject to constant change, development and innovation are concepts and functions that
have had a remarkably low profile in our medical curriculum and healthcare system,
whether private or public. Yet the affordable exploitation of new opportunities should
have the highest priority.
11
The urgent task in relation to building is the health system and the infrastructure
for clinical and medical research in Africa. In terms of funding for health programmes, it
is no longer acceptable to fund only vertical programmes for the care of specific diseases.
What is needed is the strengthening of an integrated health system for all conditions, and
the adoption of lessons that have been learnt from experiments with single disease, such
as HIV/AIDS, to the whole health service.
While there has been some progress made in investing in basic and population
research facilities in South Africa, as evidenced by the Institute of Infectious Disease and
Molecular Medicine in Cape Town, and the Wellcome Trust Africa Population Research
Centre in KwaZulu Natal, there has been no serious effort to build the workforce and
infrastructure for clinical research in Africa. There is a need for the establishment of an
All Africa Institute for Clinical Research, to be based in Cape Town, with a view to
training at least 1000 clinical PhD scholars who will change the fortunes of clinical
medicine in Africa for the next 100 years.
Indeed, it was Dan Ncayiyana, the former Deputy Vice Chancellor of UCT,
writing in the British Medical Journal in 2002, who said: “Only when a critical mass of
African researchers working on African soil has been restored will Africa begin to
generate new knowledge relevant to its most pressing health problems”.15 Solly Benatar
has also written saying that ‘Africa's great potential for solving its own problems would
be greatly helped by a much deeper understanding of the systemic nature of the problems
affecting the continent. Privileged elites must understand both their involvement in
Africa's plight and the need to provide effective developmental support.’16
The urgency to develop a technically skilled labour force in Africa was brought
home by David King, the South African-born Chief Scientific Adviser to the British
Government, who says that the development of highly trained scientists, engineers,
medical practitioners, and agriculturists must be developmental priority in Africa.17 The
great danger is the rise of the new managerialism which values managers over technically
qualified people. This tendency is seen even in our public service, where people who
labour on the coalface of our social fabric, such as nurses, doctors, teachers, policemen,
and engineers receive relatively low pay compared to those in the management ranks. We
will build the future through the sweat of our brows, and those who sweat need to be
valued and paid accordingly.
Public academic health centres must take the lead in setting the pace for the future
of medicine in Africa. There is a tendency for the privatization of excellence in medicine
through the flight of skilled and experienced doctors to the private sector, and the
concentration of new medical technology in private hands. The public academic health
centres need to exercise leadership by putting forward an agenda for increased
productivity, innovation, building, and skills that was advocated by Fanon. In this way,
we will reclaim our role as the pacemakers of the health system and secure the future of
medicine in Africa in the new millennium.
I thank you.
12
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