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Mpumalanga healthcare critical
by Anna Maria Lombard
Written by Anna Maria Lombard
Friday, 5pm, Standerton Hospital, Mpumalanga province – say you're driving on the nearby N3 to Durban. Say there's an accident. You'd better pray the ambulance doesn't bring you here.
Dr Gerhard Herbst (Private General Practitioner): "It's chaotic, disastrous. A human tragedy is playing itself out under our noses and we're not seeing it."
Gerhard Herbst has been a GP here for 37 years. He's always been involved with the hospital.
Dr Herbst: "We can drive through here and be in a car crash. You could have to rely on medical help. In Standerton you won't get it if it's after hours or the weekend."
On 14 January the hospital sent out a letter to say there would no longer be doctors on call after hours. They'd already worked their pre-approved monthly overtime, although January was only halfway through. For a hospital to close its doors on its people is unheard of. But to understand how it's come to this, Herbst says you must tell the story from the start.
Dr Herbst: "Until 31 December 2007, there were 19 community service doctors in the hospital. From 1 January 2008 there were five medical officers. The community service doctors departed overnight."
In 2000, government introduced a year of compulsory community service for new doctors. Hospitals soon became totally dependent on the comservers.
Devi Sankaree Govender (Carte Blanche presenter): "In 2002, medical schools changed their curriculum. So instead of doctors doing one year of internship, they now do two. This is the year when those doctors are in their second year, which means that there's been no intake of community service doctors."
Devi: "Did it come as a shock when you suddenly found that [there's] only five doctors left at the hospital?"
Dr Herbst: "We saw it coming – they've known for six years."
Standerton has 18 private GPs. They do what's known as Second Call at the hospital, but Dr Molepi Mohale warns there must still be a state doctor on First Call.
Dr Molepi Mohale (Private General Practitioner): "The beginning of this year I got a call list without doctors doing the First Call " that is, the first contact between a doctor and a patient. This list didn't have any doctors there, but there were doctors on second call " those who would assist in theatre and a doctor who would do anaesthetic calls. So that was a bit bizarre because we didn't know how then we would know who would operate."
The GPs don't understand why last year's comservers weren't kept on, or why private doctors weren't offered workable deals to fill in gaps.
Dr Herbst: "It's impossible for us to do 19 doctors' work. It will keep us busy full time and we will have to close down our practices."
Which is what Dr Mohale does now. He leaves his practise daily to work at the hospital's AIDS clinic. He earns nothing in these hours.
Dr Mohale: "I've got passion to work in HIV AIDS section. These are very sick people there and every time I walk past there, you see these patients from early morning till late afternoon, unattended to."
The clinic doctor, one of the last five, also quit at the end of February. Mohale asked the hospital for an appointment, reasonable pay, but nothing came of it. He knows how dangerous it is for AIDS patients on lifelong treatment to miss even a day.
Dr Mohale: "I really felt that I really had to appoint myself. I literally walked into the Wellness Clinic and started to see patients myself from the beginning of this month.
Devi: "Did the CEO come and see you and say, 'What are you doing here?', or thanks or something?"
Dr Mohale: "Not a phone call, not a word, nothing. I've been working … I'm running that clinic single-handedly " no acknowledgement for my contribution. Not even a follow-up from my last talk with her."
Ask any doctor who's worked in Mpumalanga in recent years. They say it's a province-wide disease, this lack of follow-up " more particularly from top management in Nelspruit.
Devi: "This is Mpumalanga Province's seat of government. It's where decisions concerning the welfare of people in this province are made, or not."
Dr Confidence Moloko, head of the health department… fingers point to him for not making decisions. Problem is, they say he also made it hard for hospitals to take decisions. Take the issue of extra overtime.
Dr Gcina Mavuso (Former Medical Manager: Themba): "You'd submit and wait and wait until the HoD signed. It would take three months and sometimes it would take almost four months until overtime was paid."
Last October Gcina Mavuso resigned as medical manager of Themba Hospital – one of the province's biggest – a half-hour outside Nelspruit He couldn't bear to lose another professional because they were being treated like beggars.
Devi: "Surely you were phoning the HoD and telling them what is happening?"
Dr Mavuso: "Yes, we were; we were indicating that. At some stage I got so frustrated I went to the HoD the very same day. I wanted to find out… that was in August… we were worried about overtime for May and June that had not been paid.
Devi: "The doctors are not asking for favours. They need overtime to make ends meet. When they signed their contracts they agreed to 80 hours for overtime per month. That adds up to an extra R8000 per month."
But with the pressure on hospitals, they often need doctors and specialists to work more than 80 hours, or extra overtime. Working and claiming extra overtime has to be approved by the HoD.
Dr Mohale: "He said he'd be calling back to me, I must leave my number with the PA there. And he never called me till this day. I didn't know what to say to those guys. They won't stay in the provinces if they're not going to be treated as professionals. It is bad to see professionals coming into my office asking when their overtime is going to be paid, as if they're begging for their money."
Doctors everywhere work overtime. And it's not just about the money. Second-year intern Sikumbuso Mabunda speaks for all the province's junior doctors when he says family, relationships and clinical judgement suffer.
Dr Sikumbuso Mabunda (Junior Doctors Association of South Afirca): "I'll give you Witbank Hospital as example, you have a Dr Pienaar working a Saturday."
You have the same doctor working 24-hour shifts twice a week, in addition to a normal working day. They don't even have weekends to recharge.
Dr Mabunda: "So do you expect that person to have a life at all, and be functional?"
Devi: "But if there are gaps on a call roster, what's happening at the hospital?"
Dr Mabunda: "On 15 February, you do not have a medical officer on this day. There was just an intern and, for all you know, the intern just graduated from medical school. In this case it's a Dr Smith… I don't even know Dr Smith. Dr Smith would have to deal with whatever is happening in casualty and in the wards. He would also have to discuss with Dr Godi, who is not on the premises. That is definitely a problem and stressful for the poor intern."
Devi: "Imagine you're an intern, fresh out of university, with very little practical experience, and you were based at Rob Ferreira Hospital – a regional referral centre for really complicated cases. And imagine you're the only doctor on duty."
Dr Mabunda: "At Rob Ferreira Hospital it happened, as a matter of fact " one doctor in casualty by [themselves] was instructed to do a Caesarean section without someone senior supervising him."
So you're working in casualty; facing one traumatised patient after the next without backup, and you don't even have the equipment you need to help you make the right decisions.
Robert Shongwe landed in Rob's Casualty after a car crash in February. He said his arm felt dead, but the casualty doctor said his x-rays showed no damage. He was released with a neck brace and told to return in two days.
Robert Shongwe: "I'm crying, saying why… and he never [give] me [nothing]… tablets for the pain, nothing."
Robert was still on duty during the accident, so he could be taken to a private clinic, and Workmen's Compensation paid.
Dave Godley (Employer): "I was unhappy with the service, and they seemed to just take their time. I don't know whether they don't have enough staff at night; if they've only got one doctor. I don't know what the full story is."
The full story came out at the private clinic where Robert got an MRI. It showed a slipped disc and injured spinal cord.
Dave: "They said they'd have to keep him there overnight, and the next day they'd have to operate."
Rob Ferreira doesn't have a specialist radiologist or MRI. Patients needing them are taken to private clinics as non-emergencies. So what hope did a casualty doctor, armed with only an x-ray, have?
Robert: "The doctor told me that if he had never made the operation, then my arm would have been paralysed."
Devi: "Who knows if Robert would have been this well if he'd gone back to Robert Ferreira later. It was a chance he couldn't take. They don't have the right skills or equipment. Days go by where there is no anaesthetist available – not just after hours, but during working days. Patients sometimes have to wait for surgery for weeks, even months, if their condition is not life-threatening."
You could try Witbank. They should have all the services. But the head of surgery sent out a letter in January to say other hospitals must no longer send patients, please " they don't have the doctors to operate. Which leaves the few doctors in outlying towns like Standerton with their backs against the wall.
Dr Mohale: "The case of a child who I was phoned here… he fell at school and broke his arm. I said please refer the child to the casualty because it's an ordinary fracture. I don't know what went on at that hospital, but that child lost his arm."
Dr Herbst: "A good friend of mine died of tetanus because of negligent wound care… something I have not seen in 40 years here, and it's surfacing again."
Devi: "Can there be any excuse for allowing patients to suffer because of processes and delays? Like the baby who died of dehydration after waiting in line to see a doctor. But that baby is not alone."
A woman halfway through pregnancy comes in, bleeding heavily. Her records show hour after hour – nurses try to get guidance from doctors. Hour after hour, all they get is voicemail. Only the next day does she see a doctor and get a life-saving transfusion.
Dr Herbst: "The patient is bled out and in shock. You cannot leave such a patient in nurses' hands. They have done their best. The nurses are doing wonderful work at the hospital."
But Herbst says you can't blame the handful of doctors either.
Dr Herbst: "They are like sleeping ghosts. They wander around the hospital. They are tired and it's absolutely unfair to the doctors. Those doctors can't be blamed. They're trying their best."
Devi: "A lack of doctors is not unique to Mpumalanga. It is a problem all across Africa. But we would think the trick would be to hold onto the ones you have."
Dr Gcina Mavuso was there last year when a new Health MEC, William Lubisi, was introduced to senior managers and the head of the department. It was March. Lubisi was clear.
Dr Mavuso: "And there are two things that he had identified that were chasing doctors away, and gave instruction in the presence of everybody to the HoD as to what to do with that. And one thing was that there was a realisation that our salary structure… as professionals … in Mpumalanga, salaries were below what Limpopo was getting for instance. So a junior guy at Limpopo would earn more than a senior guy here."
The second long-standing problem was overtime. In the presence of everyone, the MEC instructed his administrative head to clear bottlenecks and adjust salaries by June. Now it's a year later, and the problems remain.
Dr Mavuso: "We couldn't promise our comservers what we would definitely offer them because we were supposed to offer them letters, by November, that they were going to be appointed as senior medical officers. We failed to do that. As a result, most of them left. They went to provinces that offered them… some of them, by October, they had letters from KZN appointing them as senior medical officers."
Just before our trip to Mpumalanga, the controversial HoD, Confidence Moloko's contract with the state was "terminated by mutual consent". So we met the MEC where he was welcoming this year's interns to the province.
[Public Address] MEC William Lubisi: "Mpumalanga is committed to providing quality health care to all our people.
MEC William Lubisi has to revive a troubled department. Carte Blanche has chronicled briefly one scandal after another. In eight years, they've had five MEC's. Lubisi was MEC in 2004 before being shifted. He returned last year, only to find Moloko HoD " and the department limping.
Devi: "The department you returned to wasn't in the same condition you had left it in – in a very short space of time. You couldn't have been happy about that?"
William: "I wasn't happy. To be honest with you, I wasn't. It was shocking to see the situation having gone to that level. But, as I say, we do have a team that is committed, dedicated. And if we work with the team and assist them to do what they can do, under an environment where they can thrive, I am sure the situation will improve."
Devi: "Dr Moloko and the department have agreed not to reveal to the media and the public what was behind the move to terminate his contract."
Dr Confidence Moloko (Former Head of Health: Mpumalanga): "With the community service doctors, I have to state very clearly that we could have done better service."
Devi: "Doctors are leaving because their overtime was not paid? They waited for months"
Dr Moloko: "Even some of the doctors were not submitting their overtime on time. Particular areas were submitting their claims late all the time."
Devi: "Did you come down on them? Did you come down on these managers?"
Dr Moloko: "Yes, we did. On various levels of administration we did that. That's why it improved. It's very well known in the department that the issue of overtime was prioritised."
Devi: "It's enshrined in our Constitution that people have a right to health care. Do people in Mpumalanga get that?"
Dr Moloko: "I do believe that people in Mpumalanga have that… right to health."
Devi: "Access to quality health care?"
Dr Moloko: "Yes, thanks."
If that's true, then what do you make of this story? As a stopgap, Standerton hospital gets a stand-in doctor on weekends. To the bafflement of local GPs, these doctors come from other provinces…Esther Morajane was rushed in for an emergency Caesarean after hours. The stand-in doctor operated.
Dr Herbst: "The doctor operated without an assistant, because of the shortage of doctors. So it was just an anaesthetist and the doctor who performed the Caesarean. In retrospect that doctor was totally unqualified to operate."
He cut right through her bladder, to the womb. He delivered the baby through the bladder, sewed the womb up, but sewed the bladder to the womb. The front of her bladder he left open. Anyone could make a mistake, but neither the surgeon nor the state doctor doing the anaesthetic took steps to get help.
Dr Herbst: "He didn't sew up the bladder. He sewed up the stomach. She was kept in the ward for three days. She was discharged."
The next week at home alone was hell for Esther.
Esther Morajane: I was in pain all over my body. I had cramps in my stomach, and the cut from the operation was starting to leak. My stomach was swollen. My body started going numb."
Dr Herbst: "They took her back to the theatre. They operated on her and removed seven and a half litres of urine from her stomach. They called in my partner. He operated on the patient for three hours. Her bladder was ripped in shreds. It looked like a bomb exploded in her pelvis. The patient could have died and… it is unthinkable, unthinkable."
Esther still has pain. She doesn't know if she can have kids again, and it hurts when she urinates. She's waiting for her husband to get his R1200 salary at month-end, then she will fork out more than 12 percent of it " R150 – to consult a private doctor.
Esther: "There is absolutely no way I am going back to that hospital where they nearly killed me. There's absolutely no way."
The hospital admits there was a mistake "which is not unusual and can be repaired". They're investigating and "corrective action will be recommended".
In the month since Moloko left, the department's vital signs seem to be returning. Decisions are flowing again from Nelspruit. But Mpumalanga will remain in crisis till these interns become comservers next year.
Moloko says he introduced transformation plans that, if implemented without the resistance his presence seemed to generate, will put the department on the right track for the future.
Dr Moloko: "If my taking leave of the province allows the department to take a look at itself and to continue with the transformation process…. if my absence assists that process, then I'm very happy."
This insert was broadcast on M-Net's Carte Blanche on 20 April 2008
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