Abstract
After qualifying as a GP in October 2016, I made a temporary move to KwaZulu-Natal, South Africa where I worked as one of 12 medical officers at Bethesda Hospital, a 260-bed district general hospital. The hospital was founded by the Methodist Church and is run by the provincial government. It is one of five hospitals based in the Umkhanyakude health district, one of the most deprived districts in the country. Bethesda Hospital is located several hundred kilometres north of Durban, in a remote rural setting sitting high up on the Lebombo mountain range surrounded by sugar cane plantations and accessed by roads either unsurfaced or filled with potholes.
I worked and lived here for 15 months with my husband, an emergency medicine registrar. We shared similar responsibilities, working mainly in the Outpatient Department and rotating around the medical wards. We also covered one of six rural clinics on a weekly basis giving medical support and operating a developing primary care health service. A medical manager led the team of medical officers of varying experience from community service officers to senior family physician trainees and fellow doctors from around the world.
An orientation course covering infectious disease and focusing mainly on human immunodeficiency virus (HIV) and tuberculosis (TB) management provided a huge resource of information, but nothing could have fully prepared me for working in this setting and the reality of managing patients first hand. Not only was the pathology so variable and different to the UK, but the patients were medically much more complex than I had ever encountered.
The burden alone of HIV is heavy. South Africa has one of the highest rates of prevalence in the world at 18.8% (UNAIDS, 2017), but in this rural impoverished region our own experience was of rates much higher than this with the added complexity of HIV and its far-ranging sequelae. There is also a rising burden of non-communicable disease and chronic disease with management limited hugely by the medications available.
The language barrier we faced was ever present, always having to await a nurse before commencing a consultation. Despite several Zulu lessons, picking up a new language is not one of my strengths, and sadly I found it difficult to learn more than a handful of words, nowhere near enough for conversation.
There was a lot of maternity and paediatric work, in addition to the vast burden of HIV and TB-related disease. Trauma victims and septic patients were seen frequently in the Resuscitation Unit. Babies as young as a few weeks often presented incredibly sick with reduced conscious level, visibly dehydrated with sunken eyes and clearly reduced skin turgor. The prolonged return of skin after pinching to test skin turgor is something I had never properly experienced in the UK. Similarly, Kussmaul breathing from severe metabolic acidosis was sadly a presentation with which I became all too familiar. Often the young child had been taken to local sangomas ‘traditional healers’ with a precipitating illness, perhaps gastroenteritis and been given a concoction of ingredients in the form of an enema. Remarkably and fortunately, despite the severity of their presentation, these children often did well with careful fluid resuscitation and monitoring.
Despite the efforts of nursing staff and doctors to educate patients about the dangers of these and other practices during pregnancy, birth and at other times, harmful practices continued. This was one of many examples of detrimental health beliefs prevalent in the society, and so difficult to tackle.
There have been huge increases in HIV awareness and testing set up throughout communities. Increasing numbers of women are tested, particularly antenatally, and this has been extremely successful in reducing vertical transmission rates. Sadly, large numbers of patients, especially men, remain very reluctant to have HIV testing. It was all too common for patients to know someone personally that had ended up dying in hospital after positive results and this association probably deterred them from testing despite ubiquitous counselling.
As a result, it was often young men who presented late with opportunistic infections and advanced HIV. They may have had no other co-morbidities, but by the point they presented at the clinic it was often just too late to save them. We witnessed the heartbreaking deaths of many such patients with new HIV presentations.
We were able to intubate and ventilate patients for a few days, taking up one of our two high care beds, but following this the patients would have to be referred to an ICU in a tertiary hospital about 4 hours away. Getting patients transferred and accepted to the appropriate team was often a struggle. Relying on limited ambulance services would delay things, and many patients deteriorated before transfer. At the time of transfer the accepting teams would then reject the referrals. In these cases, patients had to be extubated and conservatively managed, effectively then with palliation only.
As expected with limited resources the criteria for onward referral were much stricter. I recall a young 32-year-old patient with acute renal failure and a creatinine of 1300 µmol/L. He had required several potassium shifts, and with deteriorating renal function and marked metabolic acidosis, the renal team did not accept him for dialysis because he was still passing small amounts of urine and was not yet fluid overloaded. A rationale that is quite unfathomable here in the UK.
My skill set widened from the first day there. With so many HIV-positive patients and with headaches seemingly as common in South Africa as in UK primary care, performing lumbar punctures became commonplace for me. However, in Bethesda, lumbar puncture would often yield positive results for TB and cryptococcal meningitis. Our rota varied week by week, but often we would complete a month or two of rotating round the wards. When assigned to the resuscitation unit and as the only doctor in the hospital on night shift I found I was the first to receive trauma and burns patients and manage high-care patients. I learned how to assess and manage these patients before calling for senior help when needed. I picked up skills required for de-roofing significant burns, tying off arterial vessels, inserting chest drains and central lines, and managing patients on ventilators.
Due to the sheer number of maternity patients, caesarean sections were frequently performed, but unlike many other rural hospitals, staffing levels did not require us to learn this skill. However, I carried out spinals independently, as well as administering sedation for other procedures. In the paediatric outpatient department we performed many procedures including biopsies, suturing, and incisions and drainage. I monitored patients under ketamine sedation alone or in combination with benzodiazepines.
There was much that could have been improved in how the clinics and hospital were run. Lost patient files, lost notes, lost referral letters and missing results provided endless frustrations, to name just a few. After several months of settling in and becoming familiar with the workings of the hospital and primary care clinics, it was then difficult to make significant changes in a relatively short period of time. We did discuss and propose changes in meetings with colleagues and the medical manager.
It is difficult to assess whether there was any gain to the community from our work as foreign doctors offering transient help. Perhaps on an individual basis we can hope that we have made a positive impact on patients’ lives. The workforce in these rural hospitals is reliant on foreign doctors to fill posts. In these undersubscribed areas a more permanent management and workforce would help implement long-term change.
The medical experience was phenomenal. As my knowledge and experience grew, I was able to do more and more that was beyond my previous limitations. Different clinical procedures, managing drug-induced liver injuries and adjusting TB and HIV medications were all achievements I never imagined would be within my capability. Many of the South African doctors were inspirational and some of the most-well-rounded generalists with whom I have ever worked. They are passionate about the patients and medical care and have been an integral part of developing the hospital and services over many years.
We lived alongside our colleagues, all members of the multidisciplinary team we so heavily relied on – physiotherapists, dieticians, speech and language therapists – that formed our support network and entertainment inside and outside of work. We were spoilt with our surroundings, and this made it surprisingly easy to detach from work. My husband and I would spend our weekends visiting the numerous game reserves on the doorstep, sampling beaches all the way up the coast to Mozambique, from renowned scuba diving centres, to isolated fishing lakes, or stunning national parks, to name a few. The options seemed limitless. For more local relaxation, we stepped out of the hospital grounds to run or walk along the mountain ridge, all that was needed to find isolation and peace.
This experience is something I wholeheartedly recommend to anyone interested in a change and ready for a challenge. There are few places that provide the opportunity to learn skills and medical care among a population in such great need and within a health care system that has reasonable resources and offers the possibility of learning exponentially. We formed such special bonds with those around us, and as a newly married couple, it was truly special to have this precious, humbling time to mark the beginning of our journey together.