Doctors doing compulsory community service in rural hospitals are getting medical skills that would otherwise not have been possible, reports Khadija Magardie
It’s nearly 7am on a rainy Monday at Tintswalo hospital in Acornhoek township, Mpumalanga, and despite the bad weather, the trickle of people queuing outside the doors to the outpatients unit is increasing steadily.
By mid-morning there are over 200 people waiting for attention. Many are regular patients, and recognise and call out to the resident doctor by name.
Heading the outpatients department this week is Dr June Fabian, a medical graduate from Gauteng, who arrived at Tintswalo three weeks ago. She is one of hundreds of newly qualified doctors from around South Africa who will be spending a year in a public health facility performing their compulsory community service.
This is the second annual intake of students for the scheme – one of the most controversial reforms of the health sector introduced by the former minister of health, Nkosazana Zuma.
Fabian, together with a colleague, Cape Town graduate Dr Allister Keyser, look relaxed as they do their daily rounds in the 450-bed hospital. The hospital serves a huge population within a 70km to 80km radius in the Bushbuckridge region.
The outpatients unit is bristling with activity; two middle-aged women wrapped in traditional blankets wheel in their elderly mother, whose wheezing cough is making it difficult for her to breathe. The nurses move her gently out of the wheelchair on to a vacant bed, and hook her on to an oxygen machine. As she moves from bed to bed, Fabian quietly discusses the condition of each patient with an accompanying nurse, who serves not only as an assistant, but an interpreter.
In the adjacent female medical ward, Keyser picks up the chart at the foot of each bed, as he moves with a nurse from patient to patient. An elderly woman with a glowing smile jumps out of bed to greet him. She babbles excitedly to him, and vigorously shakes his hand, before tottering slowly back towards her bed. He explains that the woman, like countless other elderly patients he sees regularly, is suffering from dementia.
Keyser says the weather has resulted in fewer patients. On busy days, over 400 people pass through the hospital doors.
The patients who come to Tintswalo from day to day have a variety of ailments, ranging from influenza to tuberculosis to malaria. In most cases, say the nurses, the incidence of any particular illness is seasonal. For instance, the hospital, located in the high-risk area around the Kruger National Park, sees thousands of malaria cases, particularly during summer. The hospital has also recently started an HIV/Aids clinic.
Tintswalo is relatively well-resourced – the hospital has a fully operational theatre, X-ray lab, an electro-cardiogram machine, and sonar facilities. It also has a specialist psychiatric ward. Despite staffing pressures in public health facilities around the country, the staff to patient ratio at Tintswalo is reasonably good. In addition to the doctors doing community service, the hospital is staffed by intern doctors, four senior doctors and three session doctors who do specialist procedures. This ensures that junior doctors always have a senior “on call” to assist.
For Fabian, the year at Tintswalo is the perfect opportunity to develop well-rounded medical skills that would otherwise not be possible in an academic teaching hospital such as Johannesburg hospital, where she spent her internship.
During their relatively short time at Tintswalo, some of the junior doctors have learned to perform procedures such as minor surgery, Caesarean sections and anaesthesia, which would normally be done by a resident specialist. This type of “learning on the job” medicine, says Fabian, coupled with “getting to make decisions on your own” has been invaluable experience. The community service doctors have had to become multi- skilled in a very short time. This in addition to adapting to less than perfect working conditions that are a far cry from the suburban hospitals in the cities.
Last week, a potentially disastrous power failure left the entire hospital without electricity for over a week. Luckily it had no fatal consequences for the running of the facility. Despite the serious nature of the event, Keyser laughs it off as yet another occupational hazard.
Another doctor at Tintswalo, who has been there for a longer period, attributes the enthusiasm of the new doctors to “greenness” – they have only been at the hospital for a short time, and have yet to be hit by the reality of the conditions, such as the permanent lack of hot water.
The water pressure is non-existent because the community drill holes into the hospital’s water pipes. But these are just some of the countless situations doctors working in rural, underserviced areas of the country have to deal with, and adapt to.
Keyser, who lives with his wife in one of the ramshackle housing facilities provided for doctors near the hospital, says he does miss the comforts and luxury of suburban life. There are, he says, also “upsides” to the area. For one, the Kruger National Park and other game reserves are just a stone’s throw away. The community service doctors also pay low rental for their homes, and are given a “rural allowance” of approximately R1E000 a month, ostensibly to compensate for their circumstances.
Together with Fabian, he admits to countless frustrations, ranging from lack of refrigeration facilities to drunk X-ray machine attendants, but says they have learned to take things in their stride.
“You might, however, need a little Prozac to adjust initially,” says Fabian.
When compulsory community service was introduced, it was heavily criticised with several doctors in their final year of study threatening to pack their bags and move overseas. Junior doctors slammed the proposal as “dictatorial”, saying the Ministry of Health had not bothered to consult them. Health officials countered that the measure was necessary to pump much- needed services into under-resourced hospitals, as well as to stem the tide of health professionals leaving to work abroad.
Despite the initial teething problems, many doctors completing their community service, as well as those just starting it, are now more enthusiastic.
Both Fabian and Keyser say they too were among those vehemently opposed to compulsory service, but say they have since realised the necessity of the ministry’s action. They are divided over the issue of whether it should have been compulsory or not. According to Keyser, many doctors would have opted for voluntary service, provided they had been given “incentives” to work in the rural areas. Fabian disagrees, saying that it was necessary for the ministry to be “tough”. The lure of specialisation and private or overseas practice would have made it impossible for the Department of Health to stock rural hospitals with volunteer doctors, she says.
Nearly all doctors, despite their location, experience a combination of frustrating and depressing work days. Tintswalo, say the community service doctors based there, is no different. What makes it unique, they say, is the level of responsibility placed on them, despite their junior status. “Basically the buck stops with you,”says Keyser.
l The Junior Doctors Association of South Africa (Judasa) has acknowledged that, in the majority of cases, the community service programme has “progressed”.
According to Judasa chair Dr Anthony Levy, there are significant factors to be taken into account when assessing the successes and failures of the programme, such as the place and conditions the doctors are working under. He said that several pressing issues remain unresolved, such as the allocation criteria for posts, particularly in urban areas, safety of doctors working in remote areas, and the working conditions to which doctors are still subjected.
Despite problems in certain provinces, he said the programme was “going forward”. He cautioned against over-optimistic declarations on the success of the programme, saying that cases varied from area to area.
Levy called on those involved in the implementation of the programme to “improve standards” and remain vigilant to ensure that problems are effectively addressed and resolved.