South Africa: State doctors: their real, everyday world

By Karen Milford - a doctor who has been working at state hospitals for the last six years

Firstly, I want to give you an idea of what a typical weekend morning is like in the trauma unit of a South African tertiary hospital. It’s 8am on a Sunday, and the morning handover round is just starting in the unit. The weekend’s carnage is plain for all to see. The resuscitation unit is over-full, serving as temporary home to seven ventilated patients. These are people so critically ill that they need what lay-people call ‘life support machines’ to keep them breathing: ventilators that push breaths in and out of their bodies because they can’t take those breaths themselves. In the passage is an eighth patient on a stretcher, being manually ventilated by a paramedic. They have been there for three hours, waiting patiently for a space to open up in the resus area for them.

Down the passage are more patients, wedged as closely together as possible. They’ve all suffered some sort of trauma: they’ve been stabbed or shot, hit by cars or thumped by thugs, throttled by their boyfriends or beaten by community members. Some of them are elderly people who fell and broke their hips whilst on the way to the bathroom, others are teenaged boys who broke their legs playing soccer. They’ve filled up all the stretchers in the unit, and have flowed over to the chairs, wheelchairs and benches. One has made a nest of blankets on the floor. They’re asking for water and bedpans and receivers to vomit into. They’re asking for help and pain medication.

The night staff handing over are hollow-eyed and pale. They tell us that the intensive care units are full, so there’s nowhere for the critically ill patients to go. Theatre ran at full steam all night, doing ‘red’ (that means very urgent) case after red case, leaving no time for the more minor but nevertheless critical operations: those patients who are ill, but not bleeding to death. 

They tell us that they’re on ‘one-to-one’ with the state hospital twenty kilometres down the road, which means that both major hospitals in the city are full to the brim, and that it will soon become almost impossible to accommodate even one or two more critically ill patients. We need to get through our round quickly, so that we can clear some space for those who are surely en route.

There’s a horde of people to discharge: those who waited hours and hours to be seen and investigated, because the tide of patients was too much for the scanty nursing and doctoring contingent to stem. We need to call relatives to catch taxis into town to come and fetch their people home, so that we can strip their beds and remake them for new bodies. We need to look at the ventilated patients and decide which ones we can save, and which ones we probably can’t. And then we need to switch machines off.

People aren’t happy, and we can hardly blame them. They’re at their most vulnerable: in pain, weak, sometimes confused, and now they’re lying in a big room where they have no privacy, little autonomy, and often no idea of what is going to happen next. They often don’t know how they got there and don’t speak the language of the people who are supposed to be helping them. Even if they do, it’s difficult to convey their needs and questions: the nurses and doctors are running around and shouting and have no time, no time. It’s a nightmare of tears, bodies and blood. And it’s happening in every town and city in this country, every single day.

Mandy de Waal’s article detailed the horrific shack fire in which Maggie Molefe and Godfrey Tenehi found themselves trapped. According to her report, they were taken to Chris Hani Baragwanath hospital by paramedics, but were initially refused entrance as the hospital was too full. After some heated words and a few phone calls they were allowed in, but Tenehi died later that day, despite being in the same building as a major burns unit. The family doesn’t understand.

I’ve been a doctor for almost six years. This is not a long time, I know, but I’ve spent all six of those years in state facilities of various types: huge tertiary hospitals near city centres, eighty-bed secondary-level hospitals in the middle of townships, a tiny district-level hospital in a farming town. So I know a lot more about the public health care system in South Africa than the average private medical aid user. And I can tell you, Tenehi’s story is not exceptional, or unusual. Whilst I was surprised that doctors at the Bara casualty would turn a patient away without first assessing their fitness for transport, I was not surprised or shocked by the outcome.

Doctors and nurses working within the South African public health care system are the face of a failing organisation. Even though we are simply employees of the organisation, we are the patients’ access point to the system. When they need to wait an unreasonably long time to be helped, we are the ones telling them to wait. When there is no bed for them to lie on, no blanket to cover them, and no food for dinner, we are the ones telling them they can’t have these things. When there is no help to be had, and they or their loved ones are going to die, for whatever reason - incurable disease, or absent resources - we are the ones who tell them. As such, we take a lot of abuse. We get accused of being lazy, of being too slow, of lacking compassion. And sure, most of us probably are guilty of these things sometimes. We are, after all, only human. Some humans are less perfect than others.

We shouldn’t, however, allow our feelings about how perfect we expect nurses and doctors to be to blind us to the real problem, which is the shambles in which the Department of Health has left our healthcare system. It is not clinicians on the ground who decide how many hospitals there should be, how many beds those hospitals should contain, what services those hospitals should offer, and how well those hospitals should be staffed. Those things are decided by administrators, as they should be. Those administrators are appointed by the Department of Health, also as it should be. And the Department of Health is run by a bunch of politicians, who are doing the most terrible job of representing the interests of the people who put them there.

Mandy de Waal’s article made me angry, not because I don’t want the horrors of state hospitals reported on, but because of her failure to put the opportunity she was given to good use. She scratched the surface and told us one thing: that doctors sometimes act without compassion and don’t properly communicate to patients and families what is happening. But she could have dug deeper and pulled out the evil root at the base of this ugly tree to show us. The public healthcare system is appalling. It is not equipped to deal with the burden of disease in this country. Whether this is due to a lack of funds or simply mismanagement and wasting of available funds is a question worth asking. Whether or not it can be fixed by changing the people running the system is another.

Mandy de Waal asked me in a tweet whether or not I’d eschewed my private medical aid in favour of public health, and my answer is no. This is not because I am afraid of the doctors I work with: many of the state-employed consultants I’ve had the privilege to learn from are considered world experts in their fields. My colleagues are dedicated and skilled, and I would trust them with my life. But I can’t trust the state to provide me with a ventilator when I catch a life-threatening pneumonia. I can’t trust the Department of Health to provide enough staff to run enough theatres to operate on me if I’m in a terrible car crash at the same time someone else gets shot in a hijacking.

I don’t know if Godfrey Tenehi could have been saved. Shack fires are always tragic, as is the loss of a loved one and a breadwinner. But there is more to this story than a couple of heartless doctors. We choose our leaders, and as a society trust them to manage the resources we give them: our tax money, our skills, our time. We expect them to use these resources to our advantage, to keep us safe and happy. The public health system is failing in this regard. It’s a waste of time to point fingers at a few miserable pawns. We need to unite, put our collective foot down, and make those who are truly responsible accountable.

Daily Maverick

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http://dailymaverick.co.za/opinionista/2012-07-05-state-doctors-their-real-everyday-world