Why I am not a rural doctor

I was destined by accident of birth to work in a rural hospital. My grandfather was a missionary doctor who founded and built a Church of Scotland mission hospital in Venda. He was quite literally the hero of the family. Having already been awarded a DSc in botany and well on his way to an academic career, he decided to change direction and study medicine after being inspired by the Reverend Donald Fraser.

He obtained his medical degree at Edinburgh University, then stayed on for a couple of years to do research and obtained an MD (the “real” PhD equivalent — not the American MBChB equivalent). My grandmother joined him in Edinburgh and obtained her PhD in botany — one of the first South African women to obtain a doctorate, I imagine. They then spent more than 30 years working in rural Venda, serving and “ministering to” the local people.

I studied medicine partly in order to emulate my heroic grandfather, and, as the first-born grandson, to fulfil the unspoken yet evident expectation of the family to produce another doctor, preferably one to follow in his footsteps. My grandfather died within three months of my starting at university.

My chance to work in a rural hospital, in fact the very hospital he built, came when I was a medical conscript. Armed with minimal experience, I was dispatched by the military’s medical services to the hospital accompanied by my wife and three-week-old son. (I must admit that a high-quality bottle of brandy for the relevant sergeant had facilitated the posting. Typical “good old” South African corruption and bribery.)

Being the grandson of “the doctor” was not without its own pressures — this, apart from the everyday stresses of a hugely overcrowded outpatients department, frequent interruptions for emergency Caesarean sections and, of course, after-hours duties.

Eventually one nightmare weekend I found myself in charge of the hospital — the superintendent had gone on long leave overseas, and the other “army doctor” had gone AWOL to do a locum and earn some extra money.

Late on the Sunday night, I was called to the labour ward to resuscitate a new-born baby, and ended up taking the mother to a theatre to try to stop a massive postpartum haemorrhage. I could not stop the bleeding. The hospital did not have a blood bank. She died on the table. The post-mortem showed that she’d had a ruptured uterus. Much to my chagrin I lost my temper with the staff during the horrifying process.

The next day we were expelled from the homeland and given 24 hours to leave. Years later, when attending a memorial service for my grandmother at the hospital, an official of the Venda government paid tribute to her by concentrating on my grandfather’s legacy. He appealed to the audience that should any medically qualified member of the family of “the doctor” be interested in working at the hospital, that person would be welcomed with open arms, or some such words. There was only one person there that matched that description.

Fuck you, I thought.

But then I am a selfish person.

Not like Dr Colin Pfaff. He is facing disciplinary charges for being a good doctor. He has chosen to work as a rural doctor in KwaZulu-Natal. Rural doctors nowadays, like my grandfather many years ago, work long hours, often live on the premises of hospitals, and are often woken up in the middle of the night to attend to emergencies — Caesarean sections, gun-shot wounds, car-accident victims. They have new problems that my grandfather did not have to deal with: HIV and Aids; MDR-TB and XDR-TB; chloroquine-resistant malaria; methycillin-resistant staph aureus. And stifling bureaucracy.

In my grandfather’s day, the mission hospitals were relatively independent and autonomous until the apartheid government decided to co-opt them into their highly fragmented health delivery system. By that time my grandfather was on the verge of retiring, but with others he opposed the take-over.

Rural doctors struggle daily to ensure that orders for medicines and equipment are filled and delivered regularly so that vital supplies do not run out. They usually have a whole network of clinics to support. They may have to attend to mechanical failures of equipment — setting up temporary and makeshift repairs. They have to badger their local or provincial departments of health for budgets and even salaries to be paid over.

Rural healthcare practitioners often develop their own bizarre sense of humour. Flashback: in a staff meeting during my brief rural experience, the room erupted into gales of laughter as one staff member in an official report indicated that the hospital possessed 11 ambulances, but only three worked.

Most rural doctors with children will need to send their children to boarding school, depending on how far away they are from a town or city. The sacrifice of family life by rural healthcare practitioners is not adequately recognised. It is not a choice undertaken lightly.

Dr Pfaff knew that dual therapy is more effective than monotherapy* in the prevention of mother-to-child transmission of HIV (PMTCT). He was able to obtain the necessary medicines, in an innovative donor process, to implement dual therapy. He showed exactly the kind of initiative and leadership embodied in the KwaZulu-Natal department of health’s own “Batho Pele” principles, not just as listed in torn or curling posters randomly stuck over peeling paint on various hospital or clinic walls.

Unfortunately, non-medical bureaucrats decided that Dr Pfaff had exceeded the limits of what he was allowed to do, and he was charged with misconduct and acting unlawfully. The reaction has been intense. The Rural Doctors’ Association of South Africa and the SA HIV Clinicians’ Society, among others, have issued statements supporting Dr Pfaff.

The KwaZulu-Natal MEC for health, Peggy Nkonyeni, is meanwhile reported to have made the most extraordinary statements on a visit to Manguzi Hospital where Dr Pfaff works. She stated that antiretrovirals (ARVs) are “toxic”, and questioned the motives of rural doctors who provide Aids treatment. She suggested that they are working for pharmaceutical companies and aren’t primarily concerned about their patients.

The echoes ring across the years from nearby Mpumalanga. The then MEC of health, Ms Manana, evicted the rape-crisis NGO providing post-exposure prophylaxis at Rob Ferreira Hospital, and instituted actions against Dr Thys Mollendorf. Petty bureaucracy took precedence over patient welfare; Batho Pele all but forgotten.

The stronger echo perhaps comes from Pretoria, and the national Department of Health’s minister herself with statements such as “antiretrovirals are poison”. In a meeting of all the provincial MECs of health, the minister of health stood by “Manana”, as she referred to the Mpumalanga MEC, and stated that Manana was quite right and had done nothing wrong. A very strong message indeed to the MECs that she would stand by them if they chose an anti-ARV stance. Post-exposure prophylaxis in cases of rape is now standard of care. Ms Nkonyeni was not yet the KwaZulu-Natal MEC of health, but no doubt the minister’s stance has filtered through.

MEC Nkonyeni claims that she is merely informing patients fully. She said in an interview (à la Anthony Brink): “It tells you [it’s toxic] on the label!” It would appear that her definition of “fully informed” only concerns side effects, and nothing about benefits. The “side effects” of possible HIV infection, chronic illnesses, Aids and eventual death in a baby or child are seemingly not being communicated or considered.

The general manager: corporate communication of the KwaZulu-Natal department of health, Leon Mbangwa, released a statement on behalf of the department stating: “[W]e will not allow anyone to pull vulturistic theatrics to mystify this matter for their own political gains. We will continue to put the interest of our people first, unlike these [political] opportunists.”

No doubt “vulturistic theatrics” referred to something the DA stated. However, any mystifying must belong solely to the KwaZulu-Natal department of health. Mr Mbangwa, like Ms Nkonyeni, is not a medical doctor. Their assumption that they are putting “the interest of our people first” by following the letter of the law is both short-sighted and possibly destructive. How many health professionals considering a career (or just a stint) in a rural setting are now having second thoughts? May we all have long memories so that when or if there are any future complaints about “lack of capacity” in rural KwaZulu-Natal, we will remember who is at least partly responsible.

Not only am I selfish, I am also a coward. I would not have had Dr Pfaff’s courage to initiate dual therapy in a rural setting in 2007, were I to work in such a place. However, I will not again work in a rural hospital in my life. I will not again work in a context where bureaucracy, red tape and the Public Service Act can interfere with the management of patients. I will not again work where I am prevented from fulfilling the principles of Batho Pele to the best of my ability.

As an academic, I strive to ensure that my students learn to question things: statements made, reports submitted, applications of science — even authority itself. It defeats the purpose of acquiring critical thinking skills if healthcare professionals are subsequently made to toe the line unquestioningly by unqualified people blindly adhering to, or trying to enforce, out-of-date protocols and guidelines.

* PMTCT monotherapy involves the administration of single-dose nevirapine to the mother when she goes into labour and a single dose to the baby within 72 hours of being born. It is about 50% effective in preventing intrapartum transmission of the HI virus, but is associated with viral resistance. Dual therapy adds a second drug — in this case zidovudine (AZT). The mother starts taking it at about 28 weeks of pregnancy, and the baby receives a week’s treatment after birth. Dual therapy further reduces the transmission rate to about a quarter or less compared with no treatment, and reduces the development of viral resistance.