Three Months in a South African Public Hospital

I spent three months doing an elective rotation, working in a rural hospital in Limpopo, the poorest province of South Africa. It has been so many things to me: fascinating, humbling, beautiful, relaxing; but also depressing, tough and humbling.

The beautiful part: I got to live on a farm on a game reserve with all kinds of non-deadly animals like giraffes, zebras, wildebeests and impalas roaming around freely. On our first day, our host welcomed us with a bowl of homegrown passion fruits, and told us we could pick fresh veggies and fruits from the garden if we needed any. On my twilight runs it was not uncommon for a giraffe to be staring at me while the sun set behind the northern Drakensberg mountains. It was nice and warm, and we had a beautiful garden with a swimming pool. On the weekends, we would drive into Kruger for safari, or into the mountains for stunning hikes past canyons, waterfalls and wild rivers. I spent the last two weeks solo in a hostel in Cape Town, exploring its beautiful mountains and coastal regions.

This is in stark contrast to the hospital we worked it, which is understaffed, under resourced; as well as troubled by litigation, work refusal, and bureaucracy.

At some point, two weeks in, we ran out of all syringes but the 2 ml ones. Now, 2 ml of blood is just enough to fill two tubes of blood. If you need more than that, you have to place an iv cannula and let the blood drip from the iv tubing into the blood tubes. Instead of a syringe, you’re also wasting tubing and an iv cannula for someone who doesn’t need. Besides, there’s way more exposure to contaminated material. Similarly, we ran out of non-sterile gloves many times, leading us to use a pack of sterile gloves every time. The X-ray machine broke in my second week and did not get fixed for the rest of my time there. That means everyone who came after 1 o’ clock, which is when the last patient transport left for X-rays at another hospital, would need to wait until the next day. An “urgent” CT scan took at least a week. That means we couldn’t treat someone with a suspected stroke because we had no way of knowing whether the patient had a brain bleed or an ischemic stroke. An ischemic stroke is when a blood clot prevents blood from carrying oxygen to the brain cells.

The hospital’s clinical manager estimated that half of the hospital budget was spent on lawsuits. That percentage has been climbing steadily for years. The destructive cycle is obvious: the more money spent on lawsuits, the less money spent on healthcare, the worse healthcare gets. How does that happen? Well, a good example is the filing system. When a patient has an appointment at the hospital, they will fetch their medical file in the morning, and wait until the file ends up on the doctor’s desk. This can take hours, so patients end up taking their files home to save time. That’s illegal, so the hospital gets fined 75,000 ZAR for every file they lose. Lawyers know this, so they will request a bunch of files, and then sue if the file is not there. A visible consequence of this were the broken windows and the defunct air-conditioning. A direct result of the 2000 ZAR (100 euros) annual hospital maintenance budget. Generally, things looked and felt like they were about to break. Most patients’ would be shivering in their beds, their main complaint always being the cold.

Now, before getting into work refusal, a little background on the way rural hospitals get staffed. After medical school, South African doctors have two years of compulsory but paid internships, where they work in all specialties. Then they do their community service, where they are placed in a rural public hospital to work for one year. These doctors carried the majority of the work load in my hospital. Aside from them, there are also medical officers, MOs for short. They have permanent contracts and in theory, they are responsible for their departments. In practice, many of them show up at 9:30 and leave by 11:00 on a given day. One time, a nurse entered our room asking where doctor so-and-so went. A patient complained because the doctor left the room without saying where they went two hours ago. They didn’t come back for the rest of the day.

This is infuriating, and that doctor is a piece of trash from my point of view. At the same time, it’s hard to say what twenty years in that hospital would do to my morale. Regardless, it increases the workload on the community service doctors, who are already burdened beyond their skillset because there is no supervision. The hospital has no medical specialists, so the community service doctors do most of the surgeries, including the anesthesia. As if that’s not enough, the referral system is so clogged that you can’t really refer patients to more specialized hospitals. That means they have to take care of very complex patients for which they don’t have the expertise. This inevitably leads to mistakes. I have seen them be troubled by such mistakes, and the burnout rates among them are high. It’s an unfair load they shouldn’t have to carry.

Lastly, a ridiculous example of how bureaucracy is causing deaths every day. At some point, my colleague took part in a resuscitation, and she asked where she could get an AED. “There’s no AED”, the doctor responded. Later, we learned there were plenty of AEDs in the hospital. They were brand new and donated by some philantrope about a year ago. To this day, they have been locked away in some storage room, because someone has not signed them off.

I cannot even begin to untangle the complexities that shape modern South Africa. The remnants of Apartheid, which only ended in 1994 when Nelson Mandela became president, are present everywhere. I don’t have the knowledge to place these anecdotes in the right context, but I know they are inseparable from it. My visit to the Apartheid museum and my stay in this country has led me to think a great deal about the privileges I have and I am grateful for that, with a tinge of guilt.

My stay has taught me many things, notably the taste of impala testicle and how to change a tire. I have grown tremendously and I have returned more relaxed and more self-reliant. I have also learned that I may not be the person to live and work abroad, far away from my family and friends. I’m not too good at keeping in touch so I need those people near me. In addition, I was admitted to a master’s program in data science earlier this year 🎉. I remember programming a simple stock calculator in Python during COVID. I did that out of sheer boredom and look where it took me. So I put med school on hold until may and I have dived into this new adventure in Tilburg. Currently, I am engulfed by a challenging course on computational statistics, very different and very exciting!!