/ 6 June 2008

Unsung heroes

They have a reputation for being mad, bad, sad, or all three, but some show superhuman commitment, working in isolation, often with little support and rickety infrastructure.

South Africa’s rural doctors have been thrust into the spotlight by the cases of Colin Pfaff, who sourced funding for antiretroviral drugs for pregnant women when the politicians failed to do so, and Mark Blaylock, who put a provincial minister’s photograph in the dustbin in a sequel to the Pfaff controversy.

Rural doctors say their problems must be addressed to lure fresh clinicians to rural areas and to retain those already there.

Ian Couper, professor of rural health at Wits University, said specific problems include social and professional isolation.

”Anyone with personal issues who goes to a rural area will come face to face with them; you have to have internal resources. Also, often rural doctors feel urban doctors are climbing the ladder and studying while they are not.”

Bernard Gaede, head of the Rural Doctors’ Association of South Africa, remarked that rural doctors were often regarded as having an ”overdeveloped sense of responsibility, if competent, and if they don’t have missionary zeal then they are probably incompetent”.

Gaede said there was a grain of truth in the assumption that because rural areas were under-resourced and desperate for healthcare, they accepted lower standards.

”Some rural hospital doctors may have dodgy backgrounds, but then in urban centres such things are easier to cover up because there are more doctors.” But the impact of incompetence could be greater in a rural area, he said. ”If one in five doctors is dodgy, that means 20% of the work force is dodgy.”

Couper agrees that more support is needed, especially for inexperienced doctors: ”There is more danger of mistakes away from the media and the eye of the public.”

Counterbalancing this was the fact that mistakes could be highlighted in small, close communities.

But he agreed that rural communities might be more likely to accept lower-quality care, citing a case where the community had pressured a family not to sue a nurse whose mistake had killed a pregnant woman during labour. ”Poor care is better than no care in the community’s eyes.”

Rural doctors must often develop a wider range of skills than urban doctors, which Couper said was both an attraction and a challenge.

Said one anonymous doctor quoted in a research paper: ”You also know that you are a better doctor than your urban counterparts because here you definitely have to do things, instead of just relying on specialists.”

”There is no easy evacuation by air, it places a lot of stress on doctors, there isn’t full back-up,” Couper said. ”You don’t have all the people you need in the team, although this has improved with community service.”

Couper, who worked for many years in rural hospitals, said that while the diversity of work and the connection with the community weren’t the reasons he went to a rural area, it is what keeps him there.

Many doctors chose to go to rural areas because of the wide range of experience and high degree of freedom it can offer. The distance from head office means doctors can play a role outside direct clinical practice and see the impact of their work. The government also offers a rural allowance of between 12% and 18% of salary as an incentive.

The Rural Health Initiative-Placement Project (RHI) is an NGO set up by healthcare workers to lure local and foreign workers to work for at least a year in rural South Africa.

The seasonal recruitment pattern follows the training timetable of overseas medical professions. In August this year, for example, 35 doctors, mainly British, are coming to South Africa.

RHI’s Tracey Hudson said European doctors want the experience rural South African practice gives them. She goes to medical careers fairs to find new recruits – in some cases collaring them in the queue for Australia and luring them here.

But it is retaining rural doctors that is particularly difficult. For Gaede, isolation is the biggest stumbling block, particularly for doctors who are not from the area. The countryside is no place for ”a highly charged urban bunny”.

”They can feel vulnerable and isolated from things going on in the rest of the country’s medical environment,” he said.

”Doctors are not very supportive within the profession. In the health department there is limited support for rural doctors, they are generally ignored; urban doctors have much greater access. So rural doctors are under-represented and much less involved in policy-making.”

Couper said administrative staff often heightened the pressures. ”One of the biggest failings in rural healthcare is management. With the skills shortage a decent manager can get a job in the city that pays more.”

Rural practitioners also suffer from a lack of career development opportunities and facilities for leave to study with the intention of returning to their posts.

A lack of senior and specialist positions mean that rural doctors reach a career ceiling fairly rapidly. There is little local help available when difficult clinical decisions have to be made. There is growing recognition of this and some family physician posts are being created at district level.

Local medical schools now offer skills training courses and the development of rural specialities, including an advanced degree in rural public health.

Couper says that people from rural areas are five times more likely to return to work in them, so an obvious strategy is to select people for medical schools from rural areas.

Many rural clinicians are imported, often from Asian and African countries, on condition that they work where South African doctors do not want to.

Black doctors who are not from South Africa can experience ”quite a high degree of xenophobia”, said Gaede.