The Transkei (translated, ‘beyond the kei’) region of South Africa is a beautiful part of the country. However, a troubled past and poor infrastructure has left it trailing the rest of the state and it is the health of the people that bears the scars. Dr Steve Alcorn and Dr Jenny Linnemann share their experiences of life and medicine in this part of the world. Their stories highlight the extreme nature of the work and the satisfaction it brings. It seems to be an area that can provide adventure outside and within the confines of work to medics willing to take up the challenging but also deeply rewarding work that is so desperately needed to be done by overseas medical staff.
Steve Alcorn, Isilimela Hospital
It’s 5 a.m., and pitch black due to another power cut, so it takes me a good few extra rings of the telephone to wake up, locate the source of the shrill ring tone and answer it in my sleep-deprived torpor.
My heart sank as I took the call. This patient was not expected to deliver vaginally. She presented in established labour, and had been found to have a tight stenosis of the cervical canal. I’d immediately referred her to the Maternity department of our referral hospital six hours earlier and called for an urgent ambulance. Unfortunately I was all too aware that in this remote part of rural South Africa, an ambulance could take up to a day to arrive.
It was day three of a 72-hour weekend on call as a lone doctor in a 110-bed hospital in the Transkei. If one of my colleagues had been around, we would have performed a Ceasarean section hours ago. But at the weekend, there’s only one doctor, and at times like this I felt every inch of the 17km dirt road that separated me from relative civilisation.
There was no time to question the wisdom of having chosen to work in such a remote location at that moment. I’d already spent hours, even days, mulling over what it was that brought me there, and whether my two years of Foundation training in the UK were adequate. Nothing for it but to pull on my clothes, grab my head torch and sprint down the hill to the hospital.
Arriving, breathless, in our tiny delivery room, there’s blood everywhere. The floor is swimming in the stuff. There’s a baby screaming in our ancient, dilapidated incubator. He looks healthy, so is clearly not my priority. Most of the hospital’s night staff are crowded into the 4m x 3m room already cluttered with two delivery beds, a CTG, the incubator, a neonatal resuscitation trolley and at this point, approximately 15 people, all staring at a woman who is rapidly exsanguinating.
It’s odd, the mixture of abject terror, exhaustion, adrenaline and something like grim determination that swirls around in my chest. It settles in my gut and seems to ultimately react and form a compound emotion manifesting as an eerie sense of calm. There is, evidently, nothing for it but to give her Syntocinon and our last remaining bag of Gelofusin. We send someone to grab all four units of the hospital’s blood supply, as we wheel her over to the theatre block. I draw up some Ketamine and instruct a nurse in how to administer it while I scrub quickly.
The next hour passes in what seems like just a few minutes. I identify scraps of torn tissue from the traumatic delivery, and attempt to identify and ligate the bleeding vessels. Growing in confidence, I start to recognise the anatomy which was previously so chaotic, and the bleeding starts to noticeably diminish. Dawn is breaking outside and I can still hear the baby’s cries from across the courtyard as I clean the bruised and swollen tissues after placing my last sutures. I’m already struggling to believe what has just happened and that my far from elegant surgical intervention appears to have worked.
It was one of those moments where I think of how I cynically referred to work as a Foundation doc back in the UK as “saving lives” when much of the time it felt like anything but. In the Transkei however, even with my admittedly basic, although reasonably broad, medical skills, I had the immense privilege of seeing lives saved on a regular basis.
Performing a vaccuum extraction for an obstructed labour, diagnosing SLE in a woman who’d been sick for years, successfully treating cryptococcal meningitis and advanced TB in an AIDS patient, placing a chest drain in a stabbed chest or caring for an extremely malnourished child were almost daily occurrences. The hospital wouldn’t have any medical staff if it were not for foreign doctors plugging the gaps in South Africa’s drained rural public healthcare system.
There are a vast range of opportunities available to foreign-trained doctors willing to work in South Africa’s underserved hospitals. I chose to work in a small, deeply rural hospital where I’d be required to deal with the full gamut of medical specialties, from surgery to Paeds to Psychiatry, as well as the specialty I’ve subsequently chosen, Anaesthetics. However there are plentiful posts in much larger hospitals that offer consultant-led units in specialist departments within easy reach of major cities like Durban. All offer the chance to fight a vast burden of disease in a poor and often neglected population, in addition to a level of clinical experience which is unimaginable in the UK.
Of course, the frustrations are myriad. Widespread corruption, managerial and political ineptitude, woefully inadequate public health education and occasionally colleagues who are unable or unwilling to treat patients, to name but a few. But the rewards are great. South Africa is a stunning country with breathtaking physical and human geography. Rural doctors receive a more than adequate salary and ample time and opportunity to explore: from the awe-inspiring peaks of the Drakensberg to perfect surf breaks on deserted subtropical Wild Coast beaches, and from the vineyards of the Cape to the otherworldly beauty of the semidesert Karoo.
More than anything, though, is the heart-rending gratitude of people who happily accept that you are not the most experienced doctor in the world, that you may need to pause or look something up before arriving at a management plan or even a diagnosis – but know that had you not chosen to be there, the likelihood is that they would have no doctor at all.
Jenny Linnemann, Madwaleni Hospital
AM / So Jenny, why South Africa?
JL / South Africa had never really appealed to me. I had always had an image in my head of myself running around doctoring in some dramatic, dusty war-torn place, dodging land mines and fixing up machete injuries.
I thought South Africa was a little bit European, a bit tame. But a friend had worked in Kwazulu Natal and had come back with nothing but positive things to say. So I started looking into it and now here I am to encourage others to do the same.
AM / Where were you working?
JL / I spent 15 months working in the 180 bed Madwaleni Hospital in the Eastern Cape, a rural area formerly known as the Transkei. As one of the poorest regions of the country, the standards of infrastructure and living are more comparable to Kenya than to a European country.
The land is one of rolling hills and bumpy dirt roads, wild coastline and sleepy villages. It is also the birthplace of Nelson Mandela. His current residence stands inconspicuously near the hospital. It is a beautiful spot. Living there, you get the feeling that very little has changed since Mr Mandela was running round the hills as a boy.
The hospital overlooks its large catchment area. The busy outpatient department serves as A&E and GP, with walk-ins and nurse clinic referrals. Try as it might to be a modern hospital, goats still shelter in the corridors of Madwaleni when it rains and litters of stray kittens are born in the maternity ward, much to the midwives’ dismay.
AM / What were the patients like?
JL / In the heyday of mining, the majority of the men worked in Gauteng and sent money home. Lately, a significant amount of this work has dried up, leaving the community to rely on the government. Our average patient lived with a large family in a single-roomed rondavel, a traditional circular mud hut with a thatched roof. They would collect water from the river and had no electricity at home. Malnutrition was common amongtst children, and communicable diseases such as TB endemic.
To get to hospital, some patients would walk many hours. When rains were heavy and the bridges flooded, some would be unable to attend. The majority of patients spoke no English, or were too shy to attempt it. So, we had the added challenge of learning Xhosa, a language famous for its clicks, and practicing through translators, who were usually nursing students.
Stigma surrounding HIV lead to late presentations of cases such as cryptococcal meningitis, PCP and malignancies. Stabbings occured daily, so we quickly developed skills in suturing and chest drain insertion. Reproduction was the main pastime, so obstetric cases formed a large part of the workload. Getting called to see a woman who is fully dilated, breech, with undiagnosed twins, no antenatal care and undetected and untreated HIV was not unusual.
AM / How about the doctors?
JL / The patient load increased with the advent of HIV and the accompanying spike in TB, so in 2007 a few hard-working individuals started up an HIV programme to provide counselling, testing and ARVs to thousands of people. It now boasts some of the best outcomes in the country managed jointly by the Donald Woods Foundation and Department of Health.
What used to be manageable by a couple of doctors would now be a challenging task for fifteen, if all the medical positions were to be filled. But due to chronic recruitment issues, Madwaleni currently scrapes by on around six doctors. This may sound like a nightmare, but it made for the most enjoyable job I’ve ever had. With difficulties attracting south African staff, Madwaleni ends up as a multicultural melting pot with focused, adventurous staff from around the world who have chosen the place for the challenge.
Though the healthcare of the region could really move forward with full and long term medical contingent, it is amazing how much a small group of motivated people can achieve.
AM / What did you get out of the job?
JL / The most wonderful thing about working in South Africa is the opportunity to gain experience. For those interested in a particular specialty such as surgery or obstetrics, there are large hospitals in South Africa that will give you vastly superior training and experience compared to the UK.
If, like myself you are a generalist and fascinated by a bit of everything, I cannot recommend working in a rural hospital such as Madwaleni enough. My passion for medicine was genuinely rekindled, as the variety of presentations, coupled with the hands-on nature of the work made it by far the most interesting job you could hope for.
You will be given more responsibility than you’ve had before. It’s both a positive and negative. Having done a six month paediatric SHO job, I found myself running the kids’ ward and children’s HIV clinic single-handed. This was pretty daunting but I was ready for the extra responsibility.
Many junior doctors find that we’re sheltered in the western world and rarely get the opportunity to make clinical decisions. I felt ready to get my teeth into something, which was just as well, as we didn’t have a CMO (consultant) for most of the time I was there and the other doctors were of a similar level of experience.
AM / It can’t have been easy?
JL / It takes some getting used to, having your own ward. Nothing makes you more conscientious than having the ultimate responsibility for your patients. For the first time in my career, I was able to look at a patient and realise that I, myself, had saved their life. Had I not been there, no one else would have done it.
That responsibility often weighed heavy – I had many sleepless nights following Caesarean sections wondering if everything was ok, or worrying about ward patients, dwelling on the decisions I had made. However, you learnt from one another and became mini-specialists in your respective wards, and asked each other for advice a hundred times a day. This was one of the most fun parts of the job.
You also became your own teacher and were motivated to read up on cases. It could be very tiring and at times I was desperate to talk to a consultant. However, you formed alliances in other hospitals and learnt from who you could ask advice, so you were never completely alone.
AM / What were the hours like?
JL / Don’t go to South Africa expecting a working holiday, you must be prepared to work harder than you ever have before. There is no EWTD, and you work until the work is done.
Depending on staffing, this can mean several on-calls in a week, and weekends from Friday to Monday with no time off before or after, and the possibility of getting called 24/7. The frequent interesting cases get you through. Every day you see something new, extreme, or just plain bizarre. There are many traditional practices still undertaken in the community, such as ceremonial circumcisions and attending witch doctors. Donkey and cattle injuries are common.
AM / Could you choose your specialty?
JL / Some doctors arrived after doing several years of infectious diseases training, so focused more on the TB/HIV side, where as some of us had done bits and pieces of everything before so remained more generalist. All doctors working in rural hospitals are required to cover everything when on call, so having a special interest is great but expect to up-skill in your weak areas and become a jack of all trades.
There are so many opportunities to develop new skills if you have the inclination and enthusiasm. My weakness was definitely O&G, having never done any previously, but I had a colleague there who loved it and taught me a huge amount. I was then sent to a tertiary unit for 2 weeks’ caesarean training and a few months after arriving I was doing my own caesarians, assisted deliveries, D&Cs and ultrasounds.
Where else can you could go from being obstetrician to paediatrician to anaesthetist to physician all in one day? There are also plenty of opportunities for professional development, with courses in pretty much everything around the country available to anyone interested. While there I did the ATLS course and also the FAST scanning / Basic Ultrasound course, both of which were useful in my everyday practice and recognised around the world.
AM / How was life outside of work?
JL / Socially the place was great fun, as everyone lived in the hospital grounds. There were barbecues several nights a week, and someone was always going for a run or a bike ride. Weekends were spent at various beach houses, backpackers or on trips to the city for a treat or to stock up.
The surfing in the area is meant to be some of the best in the country, but the sharks also love the coast so you might not want to hang around too long! You can’t beat waking up in the morning to see whales and dolphins just outside your window. Living and working with the same people can be intense, but you forge bonds that will last a lifetime. There was a small shop nearby, and a supermarket in a large village half an hour away. Our nearest city was Mthatha, where we went for shopping. Our accommodation was old but full of character. We mostly lived in houses with two or three others; Internet signal was good (3G recently arrived) and we had hot water, electricity and all the usual home comforts.
AM / How about coming home?
JL / More and more British doctors are spending time working in South Africa. It is an experience interview panels look positively on and can give you an edge over the competition. You can learn practical and procedural skills for the future, and encounter conditions that you would struggle to see at home. If you are organised and career-savvy, you can keep a reflective log, and do workplace assessments as you go to keep your portfolio up to date.
Audit is actually worthwhile there, because there are endless things to improve on. Several doctors have also undertaken formal research and there are many opportunities in that regard if you are sufficiently motivated.
I faced the biggest challenges of my career so far but it was unquestionably worth it. I feel I am a more competent, confident doctor and better person for the experience.
Doing it yourself
Both Jenny and Steve advised consulting African Health Placements. They are a nonprofit NGO with the difficult task of recruiting overseas doctors to staff the rural hospitals of South Africa. They guide you through the bureaucracy but allow yourself time, as it can take over six months to sort out. Past requirements stated that we needed at least two years of postgraduate experience, but more recently we have heard they are trying to extend this to three. This will obviously make it difficult for UK doctors.
Safety / Our mothers all gawped at the news that their beloved child was going off to the land of crime and brutality. However, South Africa’s reputation for danger far exceeds the reality. Rurally in particular you are very safe and the community looked out for us. We could go for morning runs in pairs and our house was inside the hospital boundaries, so even bikes left outside went untouched.
Money / This isn’t volunteering. As a result of the recruitment difficulties, the government offers hefty financial incentives to those working rurally. Combined with the overtime pay (we worked some pretty long hours), I was getting paid a salary equivalent to the UK but with no shops nearby to spend it. Most rural hospitals provide accommodation and the cost of living is cheap, so your earnings are yours to spend or save.
HIV / A significant number of our patients were HIV positive, yet needle-stick injuries were relatively rare. The few colleagues who did have contact with infected blood took post exposure prophylaxis. Aside from feeling pretty rubbish for the duration, they had no subsequent issues. There is no denying that HIV is a risk, but it is a small one.
Limited resources / It was a great frustration to know that a patient’s outcome could have been better if they had had access to more sophisticated resources. Drugs-wise, we were pretty well-stocked with the essentials. The free ARVs in particular make the world of difference.
There was no access to an MRI scanner or a dialysis machine. However, the individuals who might have been helped by those, were exceeded a thousand-fold by those who were saved using simple resources such as antibiotics and ARVs.
Frustrations / The bottom line is that if you have no patience or tolerance for things not running smoothly then working there is probably not for you. The flip side, however, is that there is so much space for improvement, that anything you can add or change really does make a difference.