‘If you don’t have a dream then how will your dreams come true?’. Such was the vision and passion of the clinicians and health professionals who spoke to us today.
Looking out over the vista, green rolling hills bathed in sunshine fell down to the crashing sea. Brightly painted rondavels (traditional round thatched houses) sprinkled the landscape in turquoise, peach and white. Rivers carved the hills into valleys and cattle roamed free. The Wild Coast, a magnificant setting in the Eastern Cape (or the former ‘Transkei’ the homeland of Nelson Mandela) remains one of the poorest and most remote regions in South African.
In a country where you can indulge on vineyard tours in the Cape, over 80% of this community has no access to running water, instead relying on rainwater or river water which can get highly contaminated in the summer rainy season. In a country where you can buy the latest Apple computer in a shopping mall in Durban or dance the night away at a warehouse rave in Soweto, 70% of this area is without electricity. In a country in which skilled doctors performed the world’s first heart transplant, a majority of child deaths in the local area happened before the child even reached a medical facility. The scale and intensity of the inequality is stark and overwhelming but this room was full of people driven to serve this population and try to improve their health outcomes.
I am at Zithuele Hospital where a innovative rural research centre has just been opened. The theme of the day: ‘Striving for excellence – lessons from rural health’. The Zithulele story is quite amazing. Over 10 years ago a team of 4 doctors arrived here with a commitment to stay for the long term and uplift the hospital. An old missionary hospital, Zithulele had spent many years without doctors and when this team arrived there were just a few junior doctors holding things together. Bloods were sent to the lab once a week, doctors were only doing routine working Monday to Thursday. As standards were raised, more professionals were attracted and they now have a large team of dedicated staff with statistics that tell the tale. Perinatal mortality has dropped from 44/1000 to 24.6/1000. In hospital paediatric morality from 9.46% to 1.81%. Taking on such a challenge requires great determination and commitment. The leadership team have a vision to provide excellent medical care even in this context and some of their core values reflect this ‘prioritising patient care’, ‘respectful relationships’, ‘a hopeful attitude’. The ethos being that their patients should not receive sub-standard care just because they are poor and rural.
But the achievements here stretch much wider than those of the clinical doctors. A key theme of the day was of community focused care and moving service provision from the hospital and clinic to the patient. Effective primary health care is much cheaper and more efficient than curative hospital care. You can fund a paediatric intensive care unit to stabilise a shocked or septic child, intensively manage a man with cryptococcal meningitis or fund the rehabilitation of an old lady with a stroke. But if you could provide clean running water and accessible primary health care, effective HIV testing and treatment services and chronic disease management for hypertension then you may not need to do any of the above. The ‘hospecentric’ model of care was challenged during this seminar and alternatives promoted.
The Pilani mentor mothers project is tackling maternal and infant moratality from within the home. Mothers are carefully selected for their own successful child-raising alongside personal attributes. After 6 weeks of training in the field they work within their own villages to support mothers through pregnancy and infancy. Each visit is action-oriented. If a mother has not booked for antenatal care then she gets referred to clinic, children are weighed so malnutrition identified early, missed immunisations are acted on. Mothers are engaged and educated through this process. But this model is expensive and the trial to assess impact and cost-effectiveness is still pending. The research team here are also conducting cohort studies to better understand the factors involved in maternal and infant health and mortality. Evidence can then inform more effective interventions.
In this deeply rural and traditional setting there can be a great cultural and physical disconnect between the lives and beliefs of patients and Westernised medical care. How best to bridge this gap to enable optimal health outcomes for patients in a way that complements rather than contradicts elements of their traditional lives? A focus on health promotion and enabling people to be active participants in their own care was discussed. One family physician acknowledged the use of indigenous knowledge and said we should be asking ‘what do people have to assist themselves and what do they need us to assist them with?’. Members of the wider community contributed to this debate. A social scientist emphasised the strength in traditional community and family relationships. In the village, for example, one will never be homeless as the community takes responsibility and extended family networks are called upon to provide care and housing for the individual. A spokesperson for traditional medicine spoke of working alongside medical clinics, suggesting that adherence to treatment prescribed by a sangoma (traditional healer) is likely to be better than that we prescribe. Tension arose around several of these issues for instance whether traditional birth attendants should be upskilled to provide antenatal care, or all mothers should be delivering in hospital where best emergency care is available. I felt challenged by the idea of a Sangoma initiating ARVs or the suggestion by one participant that rather than aspiring for piped drinking water for all, we should clean up the rivers and enhance biodiversity. But this lively and colourful debate was about sharing, exploring and debating ideas.
What is the government doing about all of this in an area that it feels they have rather left behind? I was staying in a community owned hostel which has its own NGO so got further details from one of their staff. The government are working on piped water for all but due to technical issues this is yet to become a reality. One solution to the electricity issue is solar power and free solar panels have been distributed in the community around the hospital. In the village we stayed in, the nearest clinic is a 2 hour walk away (roads are poor and most people don’t have access to cars) so after much campaigning, they have been given their own ambulance to enable access to emergency medical care.
In a medical world which most often celebrates its specialists, it was exciting to be inspired by a room full of committed generalists with a passion for community health. There are so many challenges to health and development in the rural setting in South Africa. I hope that as more people realise the importance of these issues then many small steps might start to make a difference and dreams of excellence may eventually be realised.