/ 8 April 2014

SA needs rural doctors

Although working conditions are tough in rural areas
Although working conditions are tough in rural areas


I am a medical student; one of a mere 1 200 that will graduate each year in a country besieged by challenges in delivering health care to a primarily disadvantaged population. It is not hard to imagine that medical students (and the doctors into whom we are moulded to become) have an inherent social conscience. As students, we want to help and heal people. All of us have worked incredibly hard to access one of the most sought-after study programmes in the country, and continue to work hard to graduate after six intense years of non-stop exams, clinical rotations, skills-building sessions, and hours spent in teaching hospitals around the country. 

There is, however, a significant disconnect between student idealism and professional reality, which has been made apparent by the application to the Constitutional Court that junior doctor Miguel Desroches brought against the minister of health and the Health Professions Council of South Africa in February. Desroches objected to being placed in a rural area for his compulsory community service year, which follows two years of internship at a select group of state hospitals or clinics, and is required for doctors to be able to practice medicine in South Africa. The court challenge revolved around him being placed in an area he did not choose to be in, the hospital's lack of resources, and unreasonably lengthy and exhausting hours.

SA doctors don't work in rural areas
Despite the court dismissing Desroches's case on February 19, this incident underscores a painful reality: South African trained doctors do not end up working for the people of South Africa. According to a 2009 survey conducted by the Health Systems Trust and Africa Health Placements, of the doctors that graduate annually a tiny fraction – 35 out of 1 200, or just 3% – end up working in rural areas. Yet, just under half of the country's population resides in rural areas.

Each statistic rubs further salt into the wound: According to a 2011 health department document, the three provinces with the highest number of rural inhabitants have the lowest number of medical practitioners, and  rural provinces have an average of only 13 general practitioners and two specialists per 100 000 people.  The same document noted that in 2010 more than three quarters of all medical posts in Limpopo were unfilled. The districts with the highest HIV prevalence, such as the Sisonke district in KwaZulu-Natal and the Gert Sibande district in Mpumalanga, are all more than 50% rural. As someone preparing to enter the system, these statistics weigh heavily on my mind. More importantly, so do the people that they represent.

Desroches may be able to cite plenty of reasons why he is entitled to avoid the often gruelling working conditions in rural areas. But how far does entitlement extend in a profession where lives and livelihoods are at stake? Dr Mzamo Jakavula, a senior medical officer who served at St Barnabas Hospital in Libode in rural Eastern Cape for his community service year, offers up another perspective. 

Rural areas provide opportunities
He believes that rural work shouldn't be simply endured, or if possible avoided, but rather viewed as an opportunity to refine your craft and gain an understanding of the real face of South African patients. His words are passionate and inspiring: "Community service is an invaluable tool by which the government forces us medical practitioners to develop a conscience and to serve the poor and neglected. How many young doctors would have otherwise run away immediately after internship? Young doctors have very negative perceptions about rural medicine; the government has to intervene." 

Jakavula admits that his community service year was difficult and frustrating, fraught with substandard accommodation, salary and human-resource issues, and a lack of resources with which to serve patients. However, his resolve and commitment is evident and admirable. "Despite … [the issues] there isn't a single day that I did not look forward to going to work. You know why? The patient. The typical rural patient is so appreciative of your efforts. 

"They made me enjoy my work so much. I learnt a lot from working there. I learnt how to be humble. I learnt to love older people and how to communicate with them. I wouldn't substitute that experience for anything for it is exactly what is lacking in my colleagues today. It is the rural experience which gives doctors the humanity our patients yearn for in us." 

Make rural positions attractive
Current and future doctors like myself have inherited a health system fragmented by historical inequalities, interspersed with ongoing financial, administrative and logistical challenges that make patient care that much more difficult. It is a field where the rewards and the pitfalls are equally enormous, and the insecurity of operating in a rural area can be so intimidating that we may feel compelled, like Desroches, to fight to stay in our comfort zone. 

But patients in rural areas need us to be their voice and advocate for equitable health care for all South Africans. Government and civil society efforts need to focus on making rural health an attractive career option for aspirant doctors, and resources must be diverted into equipping and restoring rural facilities. 

Over and above, I believe that we need a change in mindset. 

Students and young doctors need mentorship from doctors like Jakavula, need to hear from the dedicated health professionals who endure the difficulties of rural medicine because it shapes them into practitioners who are versatile, skilled, compassionate and courageous. 

We need to be reminded why we do what we do and who we do it for. We need to be constantly reminded of a fundamental truth: community service should not be regarded an inconvenient period in a medical career. A medical career should be cultivated as a continuous act of community service. 

Michelle Robinson is a fourth year medical student at the University of the Witwatersrand.