Doctor Ben Gaunt is puzzled. One of his HIV patients has just told him that he has run out of antiretroviral (ARV) drugs three weeks before he is due to collect his next monthly batch from the local clinic.
Gaunt calls the hospital pharmacist on his cellphone (there is no internal line) from a tiny, dilapidated consulting room in Zithulele Hospital in the former Transkei. He asks her to find the file of the patient who had been to see him because of “TB-like symptoms” and a sore throat.
The pharmacist knocks on Gaunt’s door a few minutes later and says: “He forgot to collect this month’s round of treatment so he ran out of pills. We’ll have to sort out something here for him and explain to him the importance of sticking to the dates on his card.”
If the drugs are not taken regularly at the same time every day, the HIV virus can build up a resistance to them, making them ineffective.
In poor, remote areas the reasons for failing to fetch ARVs can be many, including being unable to afford transport to the clinic, caring for and being unable to leave a sick relative, feeling ill oneself, or simply not understanding from where or at what time medication must be collected. Clinics often run out of drugs as well, making patients reluctant to return to them.
As the clinical manager of this district hospital about 100km from Mthatha and deep in a rural area, Gaunt deals with these situations every day. About one in three people in this region is HIV-positive, few have jobs and tarred roads are practically nonexistent.
“Our patients are really, really sick because they reach us in a late stage of their illnesses,” said Liz Gatley, one of the hospital doctors. “It’s so hard physically to access healthcare here. It could take someone up to a day to walk to us, or cost close to an entire month’s government grant income in taxi fare.”
The hospital faces huge procurement challenges and has run out of TB drugs, antibiotics, oxygen, baby drips, needles and surgical gloves. It has no ambulance and, according to Gatley, it can sometimes take up to two days to transfer patients to specialist facilities in Mthatha, often in ambulances without trained paramedics.
“Sometimes patients die,” Gatley said. “People die if they don’t have oxygen or don’t get to a hospital quickly enough.”
But despite these difficulties, the 147-bed hospital in the impoverished Oliver Tambo district has achieved successes that are unheard of in other areas served by the beleaguered public health system.
Zithulele’s team of dedicated health workers has put more than 2 700 HIV-positive patients on ARVs during the past five years, more than doubled the number of hospital-delivered babies and reduced the number of infants dying in the first week of their lives by a third.
Unlike many other state hospitals, Zithulele, which serves 130 000 people, has filled all its positions for doctors — and seven of its 10 doctors are South Africans and not the foreigners who are in the majority at many other rural public hospitals.
Zithulele has become “a little, unexpected piece of heaven”, in one patient’s words, in what remains largely a wilderness of want and suffering.
Nearby Madwaleni Hospital, which serves a population double that of Zithulele, has just four doctors.
Until relatively recently, Zithulele was as crisis-racked as Madwaleni is. The rot set in in 1976 after missionaries handed control of the hospital to the then-homeland government of the Transkei. For decades mostly foreign doctors came and went. “Sometimes,” said Gaunt, “there was no doctor at all.”
Zithulele’s nurses were demoralised and, because so many babies died during delivery or shortly after birth, pregnant women stopped using the hospital.
Then, in July 2005, Gaunt and his wife Taryn, also a doctor, arrived — on the birthday of the oldest of their three children. “We didn’t know how our kids’ education would work.
But I figured out home schooling and it’s worked really well,” said Taryn. “It’s great that our children are exposed to the harsh realities of life in this part of South Africa.”
At the end of 2006, the Gaunts were joined by another doctor couple and former university friends, Karl and Sally le Roux.
“That got the ball rolling,” said Gaunt. “We’ve done a lot of employment [for Zithulele] by head-hunting or finding people through networks or someone somebody knows. For us, those are far more effective ways of finding quality people than impersonal advertisements in newspapers.”
Gaunt said applicants were invited to visit the hospital and familiarise themselves with the isolated and poor area before they were offered a position “so that they can figure out whether they really want to be here”.
Today, Zithulele offers what few other rural hospitals do — supervision of junior doctors by senior colleagues. The Gaunts and Le Rouxs have been based at the hospital for almost six years and hold several postgraduate diplomas between them, including qualifications in child health, HIV management, anaesthetics and obstetrics.
“I think some other rural hospitals also have good staff, but what makes us different is the fact that we’ve managed to get our staff to work here for reasonably long periods,” Gaunt said.
“Community service staff members are far more likely to stay on for another year or two if they can work with doctors who know the system and who they can learn from.”
Gaunt knew from the start of his battle to improve Zithulele that decent accommodation was vital in securing the longer-term services of good health workers. “If you can sleep well, eat well and have peers to socialise with, half the battle is won in getting quality people to stay here,” he said.
In 2007, in co-operation with the Eastern Cape government and donors, Gaunt succeeded in building new staff quarters for Zithulele. But for families with children the two-bedroom semi-detached flats were not big enough.
The Gaunts and Le Rouxs then approached local chiefs for land on which they could build larger houses for themselves at their own cost. This long-term commitment itself had a positive effect.
Thembeka Gaushe, a nurse at Zithulele for more than 20 years, said: “When we saw them construct those homes we were actually shocked, because then we all realised that these doctors are not moving on after a year like all the previous doctors did.
“It was the building of those homes that made us change our attitudes. It gave us faith that here are doctors who believe we can do good work here, doctors who also had faith in us as nurses.
Suddenly we saw a future for the hospital.
“A sort of a family developed and we started to work a lot harder, because there was something to work for, something we were all building here,” said Gaushe.
Within a short time maternal services at Zithulele improved greatly and the news spread rapidly among villagers. The number of women having their babies delivered at the hospital rose by a third in one year. And the doctors resumed one of Zithulele’s most important services — emergency Caesarean sections.
In 2007 and 2010, when public sector strikes resulted in state hospitals throughout the country shutting down and some patients dying, not one of Zithulele’s 120 nurses stayed away.
“The unions intimidated us and told us they knew where we lived and would burn down our houses, but we still refused to strike,” Gaushe said. “We care too much about our patients. We’re not in an industry where we deal with equipment or pieces of metal. We deal with human beings — breadwinners, moms and dads — who may die if we leave them alone without healthcare.”
Shortly after his mission to transform Zithulele began, Gaunt said, he realised that doctors and nurses alone could not provide everything a good hospital required — allied health professionals such as occupational and speech therapists and physiotherapists who offered rehabilitative services were also “crucial” to patients’ wellbeing.
Although many other rural hospitals have none, Zithulele has employed five therapists since then.
“I don’t think this facility can do without them,” Gaunt said. “Doctors can, for instance, do little more than sympathise or control the blood pressure of stroke patients. But therapists can teach them to walk, talk and become functional again.”
Zithulele also has a dietician, social worker, a dentist and three radiographers. In January it became one of the first hospitals to be allocated “clinical associates” — health workers who are trained to provide healthcare at a level beneath that of a nurse. Gaunt said they performed simpler medical procedures and managed less complicated conditions.
But he and his team are not basking in the glory of any achievements. “That would be foolish because we are still facing many uphill battles,” he said.
The hospital wants to expand its services and create more posts. But staff accommodation is again a problem. In some respects, Zithulele is a victim of its own success.
“We have reached the point where we have to turn people away because there is nowhere for them to live and the health department does not have a sufficient budget to increase accommodation,” Gaunt said.
The Jabulani Foundation, which was established by senior doctors at the hospital, has launched a campaign titled “The 1 000 from 1 000 Challenge” to get R1 000 from 1 000 people to raise the funds to build more staff quarters.
“We’re confronted with really tough challenges — we’ve borrowed drugs from other hospitals and we need more doctors and nurses to staff our clinics,” said Gatley, before getting into her car to drive to one of the 13 district clinics that Zithulele serves.
“But we never give up. That’s why we’re all still here. We always make a plan.”
Tips for rural excellence
- Create a website for potential staff and donors to learn more about your hospital;
- Collaborate with non-government organisations, or start your own, to help your hospital expand its services;
- Head-hunt for staff : visit universities, get students to do their electives at your hospital and find people through your networks;
- Find the money to build decent staff accommodation, because it makes a huge difference in how long employees remain. Once you get families to stay on, it creates a social network that encourages others to stay too;
- Explore home schooling as an option for clinical staff with children;
- Create journal clubs through which clinical staff can stay abreast of recent medical developments; and
- Value occupational, speech and physiotherapists. They make the world of difference to patients.
Mia Malan works for the Discovery Health Journalism Centre at Rhodes University