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Profiles in Commitment: Conversations with ELAM Students

Profiles in Commitment: Thabo Mnisi, MD, Clinical Manager
Alexandra Health Centre and University Clinic, South Africa


The interview below is testimony to Cuba’s 40 years of training doctors for the developing world - nearly 4,000 through 2004. It is also a reminder that each one of them has a story to tell, often dramatic, like this one from South African Thabo Mnisi, who graduated from Santiago de Cuba’s medical school in 1983. Today, these physicians are among the Third World’s health ministers, policy makers and professors - and many, like Dr. Mnisi, can be found on the frontlines in the battle for health, bringing innovative health care and leadership to their communities.


Profiles in Commitment:
Thabo Mnisi, MD
Clinical Manager
Alexandra Health Centre and University Clinic, South Africa

By Gail A. Reed

Alexandra, 2005

Eight miles away loom the glass skyscrapers of modern, promising Johannesburg; on the opposite hill rests a cemetery, where baby bottles and stuffed animals serve as tombstones, precious companions to the inhabitants of too-small graves. Somewhere in the middle is Alexandra - or simply Alex to its nearly 500,000 residents - one of the legendary “townships” of apartheid South Africa and now a residential community fighting its way out of history.

Founded in 1912, as a “native township,” Alexandra was one of the few areas where black people could own land under freehold title, a right that was swept off the books in 1948 when the Department of Native Affairs decided to expropriate properties and start forced removals to reduce the population.

From 1958 to 1973, over 50,000 people were removed, but the township was never completely razed, in part because it provided such a large labor pool for the wealthy white suburbs around Johannesburg. Individual homes, however, seemed always in danger: in the sixties, the apartheid government decided to wipe out individual units altogether and rebuild Alexandra as a “hostel city,” with plans for 25 hostels, each to house 2,500 laborers.

All the while, the people of Alex were simmering, sometimes boiling over, into bus boycotts, protests against the inclusion of women in the pass laws controlling the daily movements of black people, and finally the 1976 student rebellion, known internationally as the Soweto uprising. In clashes that pitted youngsters against anti-riot squads and army helicopters, 19 people from Alex died, students who had rebelled against being taught in Afrikaans.

This is where Thabo Mnisi’s story begins. “I was one of the students protesting,” he tells me, suddenly recalling that our interview was taking place on the eve of Soweto, 19 years later. He’s standing beside the house where he was raised in Alex, his arm resting on the shoulder of an older cousin. “We started out protesting Afrikaans as a medium of instruction,” he says. “But we ended up protesting against the government, about all issues affecting blacks in South Africa. That night the police started looking for me, they raided my house; they arrested some of my friends. Some of my friends were killed. And so I had no other option but to leave the country.”

“We were excited, we were angry, we were throwing stones,” Mnisi remembers. “But the ANC (African National Congress) helped us ask the question ‘what next?’ Helped us to understand that we had to have the capacity and the skills to prepare ourselves for a new government, a different future.” And that is how he made his way to Cuba and to a scholarship in medicine. “I loved medicine, and my mother was a nurse. Sometimes I would go with her and help a patient from Alex who needed something. I was very enthusiastic to become a doctor, and even when I was in exile, my parents encouraged me a lot. And we certainly didn’t have enough doctors.”

In 1977, Mnisi began his studies at the Higher Institute of Medicine in Santiago de Cuba, returning to Havana to specialize in surgery. He would spend nearly 10 years on the island, taking away his MD, a fine command of the Spanish language, and experiences he says serve him well today.

“When I was studying in Cuba,” he says, “is when I realized that a country that has a government that gives support and invests its funding in the health of its people - even when resources are limited - is a country that will achieve something.”

Plot 3035, Alexandra cemetery

We walked through Alex as we talked, Mnisi stopped here and there by a shout, a handshake, a small girl’s giggle. What first struck me was the sheer number of people crowded into this maze of narrow streets and alleyways where thousands upon thousands of shacks have been thrown up one against the other, sometimes leaning alongside sturdier houses of brick or blocks. I learn that these streets were paved, electricity brought in, and sanitation improved only after the fall of apartheid a decade ago. But there is a ways to go, as tap water is still communal in many places; there is little green to breathe; and woefully, 60% of adults are unemployed. Many people are simply desperately poor, with HIV/AIDS sapping the strength and the lives of too many, too young. The cemetery is witness.

Are his studies in Cuba relevant to Alex? “I think Cuba has got one of the best medical schools,” he told me. “Now we are talking here about family medicine, district health. But that already existed in Cuba, where we also had the experience of interacting with the best doctors and health specialists there.

“What I liked was that the Cubans don’t hesitate to talk about other good experiences like the British primary health care system. What the Cubans did was to take all these experiences and produce their own model, and that’s what makes the Cuban health system so outstanding. Cuba’s is a health system that is accessible by even the poorest in the country. And it is also community-oriented. That is one of the biggest lessons we learned in Cuba: that the problem of health does not lie in the hands of the professionals alone, but in a joint venture between them and the community.”

Past the gate at the Alexandra Clinic, we entered an oasis of sprawling lawns, freshly painted pastel buildings, and murals everywhere. And we came upon a small round structure dubbed “the quiet room,” a sort of layman’s chapel for “people who need peace of mind,” explained Mnisi, “people who have had difficult news about their families, and want to be alone or together, to work out their stress or their pain.”

Thabo Mnisi , MD : “…with a little, you can still do a lot, as long as you involve your communities.”

Dr. Thabo Mnisi is the medical director of the clinic, which is an independent institution receiving most of its funding from the South African government. Mnisi is quick to point out that a major fundraising campaign is going on to expand the labor unit at the heart of the clinic’s maternal-child services. But he says functional independence gives the staff the creative latitude to work with the community on the kind and quality of services needed and wanted in Alex.

He returns to his experience in Cuba: “I realized at that time that people have the power to change conditions and make them what they want. Not what others want, but what they want. People approaching problems together and seeking solutions as a team. That’s what I saw in Cuba, and I treasure that. When I came to Alexandra Health Centre, I found there were certain similarities with Cuba - the partnership between the clinic and the community is very dynamic, capable of overcoming any obstacle. ”

“This is one of the oldest clinics in the township,” says Mnisi, walking on. “During the apartheid era, community members would come and hide in this clinic when the police came, and at one stage it was bombarded by the regime and there were casualties among staff. So this clinic identified itself with the aspirations of the community early on. Because of this history, it was very easy for the clinic to get the community involved. The board of directors is formed by elected community members. And then (as part of the outreach program) we also have satellite clinics and mobile clinics where we do immunization; school health services, services right in the community.

“Now we are facing the problem of AIDS, so we organized the Community Health Forum, to get each and every street involved - a project with the ups and downs that come with lack of resources. But we keep on, because if you go back to the concept of Cuba, you realize that expertise alone never will resolve health problems. Alex clinic is doing a lot of good work. I think it’s one of the models of primary health care, one institution that with limited resources is able to do so much. And I think this is one of the things we learned from Cuba: that with little, you can still do a lot.

These AIDS orphans receive food from the Phutadichaba Community Centre-Satellite Clinic, a project led by legendary Alex resident Linda Twala, now seeking funds for a new clinic building.

As we walked through the health center, Dr. Mnisi explained, “We have three major components: emergency services, consisting of the labor unit, casualty and of course the antenatal clinic. Then we have the outpatient department (OPD), including sub-units such as male and female clinics, pediatric service, and the chronic clinic which specializes in diabetes….And finally, we have the community outreach service, as I said, to take our services to the community - in which medical students (from the various universities) also participate. At the end of the day, these students must understand that when we talk about community health - what in Cuba they call medicina familiar - is not just the doctor going there, it’s the doctor going and interacting with the community. That way, both white and black students are also exposed to different realities.”

At first, he said, patients were asked to pay a small fee at the clinic. “But we didn’t get anywhere with that. We ended up in conflict with the community - some could, but many couldn’t pay. We realized that we were doing a service for this community - so nobody must pay. Contributions can come as donations from people who have the money.”

“The casualty (emergency service) was built for Alex because during the apartheid era, no blacks were admitted to the nearest hospital - they had to go very far to Tembisa Hospital,” Dr. Mnisi continued, as we rounded a corner towards the department. “So, the community requested this 24-hour casualty. It’s a very busy place. We are seeing a reduction in gunshot and stab wounds with better control of crime, but also a rise in motor vehicle accidents. And of course, those who come in with complications of chronic diseases and HIV/AIDS.”

Just minutes after birth, a healthy baby delivered by trained midwife-nurses at the Alexandra Health Centre.

Over 15 newborns are delivered in the small labor unit each day, with women coming not only from Alexandra, but from surrounding communities as well. “I think they appreciate the service, and that’s why they come here,” says Dr. Mnisi. But this, too, presents problems: “The biggest crisis that we face here is that a significant number of mothers come to the clinic already in the stage of delivery - they’ve not been through the antenatal clinic. And so they can come with complications, especially with the prevalence of HIV/AIDS now. With HIV/AIDS, we’re also seeing a lot of associated diseases among babies as well, like respiratory infections and diarrhea.”

It was afternoon, and we sat down on a bench vacated by patients who have already been seen - testimony, Mnisi noted with a smile, to the clinic’s determination to reduce waiting times, which stretch to over 12 hours in some hospitals. What made him return to Alexandra, once he was repatriated to South Africa as a young doctor in 1992, with so many other possibilities before him? I asked, mindful that at some South African medical schools today, over 70% of the graduates leave the country, never mind the townships.

“I actually came back first as a patient here,” he recalled. “I had cerebral malaria and was admitted to this clinic. At the time, it was facing a serious crisis.

One of my colleagues who also trained in Cuba had me transferred right away to Johannesburg General Hospital. But when I recovered, I made the decision to come back to Alex, to my community, to inject some of my experience from abroad - and especially from Cuba - into this community clinic, to restructure it in line with the needs of the community.

That’s what brought me back….I think that before you are a doctor, you must be a human being, and be sensitive to people’s problems. But not only that, whatever your class or profession, you must do something about them.”

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