Unmask stigma – wear a mask and help to fight the stigma attached to TB

Monday 20 July 2015 08:08

“I’m dying Ma, the doctor confirmed that treatment is just not working for me and I’m getting sicker.”

The mother called her other daughters. This was not the first time they’d heard the treatment wasn’t working, but each time the doctors adjusted the medication and the family hoped she would get better.

It had been two and a half years of ups and downs. Death crept into their thoughts the minute doctors started responding to them with averted eyes. Doctors said the only reason she had lasted this long was that her disease was not complicated by HIV/Aids.

The Killer: Tuberculosis. Extensively Drug Resistant Tuberculosis (XDR TB). Extremely difficult to treat as it is resistant to the normal regimen used to treat TB, but it can be cured. “It can be cured” is the hope by which this family has lived and prayed, even as the odds stacked up. How does one begin the conversation about the impending death of a loved one?

A person with TB, especially the more drug-resistant types, is required to be isolated from the community while their medication reduces the number of TB germs in their system. Drug-resistant TB sufferers can spend as much as two years in hospital while undergoing treatment. They can no longer work. Their lives change dramatically.

I visited a friend at a TB hospital that has a special wing for XDR patients. What struck me to the core was seeing a body being removed from the ward. My friend saw my horrified expression and said: “That happens almost every other day – people dying and others waiting to die and I’m supposed to find the will to live with all this death around me.”

My friend also said that some of the patients escaped from the hospital as they could not take the isolation, the loneliness and the prospect that their way out would also be on a stretcher covered in a sheet.

A moral dilemma is presented to the families of patients: Do you inform those around this person that they are putting themselves at risk when exposed over time to the person with the disease? On the other hand a great number of people walk around with undiagnosed and untreated TB. That means we all walk around with an unseen risk of TB infection. Anybody is at risk of being infected but not everybody will necessarily be infected. The criteria for possible infection is simply breathing!

There is a campaign to de-stigmatise the wearing of the mask by TB sufferers. It is called Zero stigma/Unmask stigma. The slogan this year was “Behind the mask we are all the same”.

The campaign encourages the community to also wear the masks to normalise this practice so people with TB are not discriminated against.

Tuberculosis (TB) is a treatable infectious disease caused by a bacterium that spreads through the air we breathe. Every year 9 million people fall ill with TB. Three million of them don’t get the care they need and 1,3 million lose their lives. Stigma is a major contributing factor. Unseen, unfair and unforgiving” (unmaskstigma.org).

The challenge with the mask is that it attracts stigmatisation. Everybody will know that the person is possibly infected. One family I spoke to said they could not bring themselves to wear the masks around their loved one – it felt like they would reject, stigmatise and relegate them to feeling “unwanted”. They were well aware of the risk involved, but the emotional connection would not allow common sense to prevail.

TB is one of South Africa’s high stats contributors. As you count yourself lucky not to be a statistic, take a moment to think of the multiple sufferers, families and communities that live with this disease. Get educated about TB and support de-stigmatisation. Be the reassurance that a mask means protection.

The more you learn about TB, the less likely you are to discriminate. Infection could very well be in your next breath . . .

Mandisa Matross

Worcester

To end tuberculosis, we have to talk about it

By Bailey White, CBC News Posted: May 25, 2015 5:03 AM NTLast Updated: May 25, 2015 5:03 AM NT

The number of tuberculosis cases in Nain has residents worried, and some people are still afraid to come forward because of the way the disease is viewed.

The number of tuberculosis cases in Nain has residents worried, and some people are still afraid to come forward because of the way the disease is viewed. (Lefteris Pitarakis/Associated Press)

Tuberculosis in Nain doesn’t usually make news.

That’s not because it doesn’t exist — there have been 14 cases of TB in the small community since last October.

It’s precisely because TB is so common that it doesn’t make news. Compare that to St. John’s, when a student at Memorial University is diagnosed with TB there’s a media blitz. Not so in Labrador.

“It’s not new to us in the community,” Nain AngajukKak (Mayor) Joe Dicker said.

‘I just want to be on the safe side, right? I really don’t know much about this disease and just hearing so much about it makes me paranoid.’– Pauline Angnatok

And yet, the number of cases came as shock even to Dicker, who criticized Labrador-Grenfell Health.

“We as a community should be made aware so that we can take measures to protect ourselves,” he said.

“We have been providing a variety of education regarding the TB outbreak we had,” said Donnie Sampson, vice president of nursing at Labrador-Grenfell Health.

“Last week the medical officer of health did several media interviews to explain the outbreak and really try to reassure people that there was no cause for alarm.”

Call it a case of mixed messages.

It’s true the medical officer of health did speak to CBC’s Labrador Morning, but it was clear the number of cases was a worry.

“For one community, that’s quite a high number,” Dr. David Allison said. “It’s really a significant concern for us.”

‘Makes me paranoid’

It’s hard to understand from afar what’s going on in a town like Nain. I’ve never been there, I’m not part of the community, but over the past few weeks I’ve been calling people I know there and asking, “What’s the mood like? What do people think?”

A few people told me they would feel better if the whole town could be tested for TB. Fourteen cases is more than one per cent of the entire population. People said they wanted to know for sure they weren’t infected.

Dr. David Allison

Dr. David Allison, chief medical officer of health for Eastern Health, says the number of cases of tuberculosis in Nain are of concern for the health authority. (CBC)

Pauline Angnatok called the local clinic and asked that her 12-year-old daughter be tested. Angnatok worried because her daughter had spent some time at a friend’s house, and later one of the friend’s relatives was diagnosed.

Angnatok says a staff member at the clinic told her to check back with her daughter’s friend to see if the family had been tested.

“I really didn’t want to go and ask the family … it would have been took rude,” Angnatok said.

“I just want to be on the safe side, right? I really don’t know much about this disease and just hearing so much about it makes me paranoid.”

Labrador-Grenfell Health says Angnatok doesn’t need to worry.

“It’s very difficult to contract TB. You have to have prolonged contact for quite an extended period of time with someone who is actively coughing and who is sick. It’s not easy to catch,” Sampson said.

“If you feel have been in contact with someone who might have TB, absolutely, still call your public health nurse, and they will take an assessment and identify a priority for you to be tested, and that’s how the procedure works for us.”

‘Afraid to come forward’

Difficult as it may be to catch, TB is also difficult to get rid of — both on the personal and community levels.

Anyone diagnosed with the disease will have to take antibiotics for between six to nine months. Eradicating the disease from an entire population takes much longer.

Pauline Angnatok’s concern highlights the need for more information, but there is a balance to strike. People get treated differently when they have TB. Some still believe the disease is a death sentence, and treat patients accordingly.

“Because of all the attention it gets, people are afraid to come forward,” said Dr. Allison. “The stigma around tuberculosis is significant and it’s worldwide. We have to be very conscious of trying to avoid that.”

Therein lies the challenge: to end TB, health officials need to talk about it relentlessly, even when the community is well aware that it exists.

Because if a community is shocked by the news, people panic. When people panic, they treat patients like outcasts. If patients are treated like outcasts, they don’t come forward until it’s too late.

Almost deaf due to meds – but there is hope

Deur Michelle Linnert. Wednesday 08 July 2015 08:04
 
 

Dr Dalene von Delft advocates for a new MDR TB drug that has shown its effectiveness in patients like herself.

A medical doctor from Stellenberg almost went deaf from TB medication after contracting the dreaded multi-drug resistant (MDR) strain of the disease.

Now she is advocating for cheaper, safer new antibiotics for TB treatment through TB Proof, the NGO she now works for.

“I didn’t lose my hearing completely,” Dr Dalene von Delft told TygerBurger.

“The TB medication that causes hearing loss is an antibiotic we use to treat MDR TB,” she said.

This strain of the bacteria causes the same disease as “regular” TB, but Dalene explains it is resistant to first-line antibiotics because it has become mutated.

Dalene contracted MDR TB through her work in 2010. Because the bacteria is airborne, inhaling it causes the majority (up to three quarters) of MDR cases in the country.

“We are currently using a very old regimen of medication with a very old combination of drugs for treating MDR TB,” she said.

This usually consists of six or seven different kinds of antibiotics – including a group of antibiotics called the aminoglycosides – used to treat different types of bacterial infections.

“These antibiotics are widely used; they are ‘old’ drugs which have been in use since the 1950s. It is still frequently used in hospitals, but for short periods, usually less than two weeks. In MDR TB one has to use it long term,” she said.

The World Health Organisation’s (WHO) guidelines recommended treatment with aminoglycosides for MDR TB for eight months, with total treatment lasting up to two years.

“Unfortunately one of the side-effects is hearing loss.” Some of the antibiotics from the aminoglycoside class most frequently used in South Africa are kanamycin and amikacin, Dalene said.

“Because these drugs are already 60 years old, their patents have long expired and they’re very cheap and made by different manufacturers,” she said.

“Yes, it comes with a warning that it could cause hearing loss, but it’s not like you can sue the drug company, because it is used ‘off-label’. This means the drug companies do not recommend long term use of these drugs for the treatment of MDR TB, but doctors are forced to use these drugs as there are no alternatives, and it is a deadly disease,” Dalene said.

The WHO recommends regular screening for hearing loss by means of audiograms,” she said, explaining this meant hearing at different frequencies and amplitudes.

“We don’t understand how it causes hearing loss, but it affects the nerve responsible for hearing – the cochlear nerve – and the outer hair cells which pick up high frequency tones, are affected first,” she said.

“Low tones still sound okay for patients, but they start struggling with consonants ‘f’, ‘s’, ‘k’, ‘p’, ‘t’. They might not pick up high soprano notes.

Studies estimate that about one third of MDR patients lose their hearing, Dalene said. And there are no alternatives.

“You either become deaf or dead. In most cases you cannot stop the old treatment even though you might lose your hearing.”

So when Dalene learnt these were her ­only two choices, she tried to access a new drug being tested in South Africa.

“I didn’t want to accept that. If I became deaf, I wouldn’t be able to listen to music or conversations anymore; I wouldn’t be able to practice as a doctor anymore,” she said. She spoke to people who have had cochlear implants, Dalene said, one of them a nurse who contracted MDR TB and had the implant done, but still had trouble using a stethoscope.

“I realised this was a career ending situation. Week after week it just got worse. My hearing deteriorated. Then I heard of a new drug – the first new TB drug in 40 years,” she said.

Janssen pharmaceuticals (part of Johnson andamp; Johnson) were doing clinical trials in Cape Town on a drug called Bedaquiline, offering a slim chance of hope.

“Treatment of MDR TB has been at a dead end until recently.”

She found out about the new drug and contacted the principal investigator and tried to get the drug available on compassionate use. “Sometimes they make new drugs available before the clinical trials are completed, seeing as these can take years and years. It already took about 25 years to develop Bedaquiline.

“We are very lucky. So far small studies suggest that this new drug is effective and there’s a chance it might replace the old drug,” she said

 

Exhausted doctors endanger health

Medical interns are leading the battle to reduce the dangerously overlong working hours that compromise the safety of patients.

It is common practice for doctors, particularly medical interns and community service doctors, to work shifts of more than 24 hours, and often up to 36 hours or more. (AFP)

COMMENT

All around South Africa, patients in public hospitals are being treated by young doctors so fatigued that some can’t even manage to stay awake at the wheels of their cars on their way home.

It is common practice for doctors, particularly medical interns (newly graduated doctors who have to do two years of mentored service at public hospitals) and community service doctors (those who have completed their internships have to do another public service year before they’re allowed to register as doctors), to work shifts of more than 24 hours, and often up to 36 hours or more.

An intern may start at 7am on a Wednesday, work through the day and night and then complete another day’s work and finish at 5pm on Thursday.

The practice is as entrenched in the profession as white coats and stethoscopes. Being on call or having to “spoed” (“speed”) is regarded by many as a rite of passage to becoming a fully fledged doctor. But being “on call” is mostly a euphemism; many work continuously, rarely having the opportunity to escape to bed, from which they can be called.

These hours are regarded as being part of the job and are rationalised in many ways. For example, internship years are seen as a teaching opportunity and longer hours are thought to translate into more learning. But there is no evidence to support this and at least one systematic review has shown that excessively long hours are detrimental to education.

South Africa suffers from a shortage of doctors and in many public institutions everyone has to chip in to lighten the load. But this has extremely dangerous consequences.

A 2006 review of the evidence, When Policy Meets Physiology, by Lockley and others for the Harvard Work Hours Health and Safety Group, concluded that medical staff who work for more than 24 hours a shift are 36% more likely to make serious medical errors and six times more likely to make serious diagnostic errors than staff whose shifts are limited to 16 hours. In addition, those working longer than 24 hours are also 2.3 times more likely to be involved in vehicle accidents immediately after their shifts.

Besides the substantial evidence highlighting the dangers posed by tired doctors, the international science journal Nature has reported that, “after 24 hours of sustained wakefulness”, cognitive psycho­motor performance decreased to a level “equivalent to the performance deficit observed at a blood alcohol concentration of roughly 0.10 [g per 100ml]”.

The legal driving limit for alcohol in South Africa is 0.05g/100ml.

According to Harvard sleep researcher Christopher Landrigan, fatigue is not something you can become conditioned to.

Reacting to the situation in South Africa, medical students, interns and community service doctors launched the Safe Working Hours Campaign last month. It was started by Stellenbosch University’s medical students and calls on Health Minister Aaron Motsoaledi to review working hours and to limit continuous shifts to 24 hours. He has agreed to talks with the organisers but no date has been set for the meeting.

A petition, which is part of the campaign, has garnered the signatures of more than 1 700 doctors, interns, medical students and members of the public.

A Cape Town doctor who signed it said: “Doctors and patients deserve better. I have made mistakes out of sheer exhaustion, working 30-hour shifts with no sleep, and have seen others do the same.”

Motsoaledi said in a reference to the campaign during an interview on CapeTalk last week: “Throughout the world, we are missing four million healthcare workers.”

To address this, he said, South African medical schools are expanding their intakes, more medical schools are due to open and 2 700 South Africans are training as doctors in Cuba.

Safe Working Hours accepts that there is a critical staff shortage and acknowledges the lengths to which the health department is going to address it in the long term, but it contends that, in the interim, shorter, regular shifts (coupled with improved handover procedures) can reduce the risk to both patients and healthcare practitioners and improve the quality of healthcare.

Many public institutions have managed to limit shifts to 24 hours or less, or with frequent rotation have introduced 12-hour shifts.

But interns working at some hospitals experience vastly different shift systems between departments, which begs the question: Are shift structures the result of patient load and staff numbers, or because of shift co-ordinators’ and administrators’ unwillingness to deviate from tradition, even at the risk of adversely affecting patient safety?

Safe Working Hours advocates that every institution should seriously consider implementing improved, bare-minimum standards by taking all the evidence into account. It believes the 24-hour limits advocated by the department of health and the Health Professions Council of South Africa (HPCSA) could be a valuable move in the right direction.

According to the South African Patients’ Rights Charter, patients are entitled to a safe environment.

The Safe Working Hours Campaign aims to challenge and stimulate debate about the issue and to involve as many stakeholders as possible. The campaign wants to effect a lasting change to the way doctors and healthcare administrators approach fatigue, risk and safety.

But it is unlikely that the issue will progress without public awareness and participation.

The HPCSA took steps in 2007 to limit interns’ shifts to 30 hours but there are many reports of this being violated.

The council did not respond to requests from Safe Working Hours and journalists to comment on the petition or on the conditions that have led up to it.

Koot Kotze is a fifth-year medical student at Stellenbosch University and is involved with the Safe Working Hours Campaign

“Doctors and patients deserve better. I have made mistakes out of sheer exhaustion, working 30-hour shifts with no sleep, and have seen others do the same.”

Meet Pat Bond.

My name is Pat Bond, and I am a registered nurse who was working in a private dialysis unit in Cape Town, South Africa when I contracted MDR TB in 2010.

I was initially diagnosed with a lung infection, and treated with antibiotics and a corticosteroid inhaler. My health did not improve, but I continued working at the unit. In December, I began having night sweats and had more chest X-rays and a TB skin test. That was the last day I worked at the unit.

The X-ray showed TB in my right lung and the skin test reacted immediately. I was very concerned as only 2 days previously I had been in a car traveling for over 4 hours with my Mom, son and his girlfriend, to have Christmas lunch with my daughter in Langebaan. Fortunately, nobody else was infected.

I was admitted to hospital, still not fully realising the implications of what having TB meant. To me it was unheard of to contract TB. I lived in a well-ventilated flat. I was not malnourished or sick. Then a few days later I was given the news that I had MDR TB!

Even now, I feel nauseous when I think of that medication. I felt so ill, weak and tired. My hearing deteriorated, a side effect of the Amikaycin. I now struggle with deafness and need to wear hearing aids. Another very important but often unspoken side-effect of the medication is depression. Mine would continue long after I stopped taking the medication.

I was readmitted for extreme nausea and vomiting, and my meds were adjusted. Just when I thought it couldn’t get worse, during my last hospital stay, my flat was burgled. I felt so vulnerable.

There’s more: I had to have a lobectomy. Around April 2012 I started to turn a corner. I was still taking my medications and suffering through depression, when I was pronounced clear of MDR TB.

Unfortunately, I have not been able to return to nursing, which has left a massive void in my life. I feel that MDR TB has robbed me of so much.

But here’s the thing: after all this I still feel lucky. I survived TB. And I’m here telling my story. Now it’s time for other healthcare workers to tell their stories. If you know a healthcare worker, please, ask them to share their #TBunmasked stories here:

http://www.tbunmasked.org/#tell

But thankfully, on a positive note, I became a member of TB PROOF in January 2013, and gain such pleasure by doing TB advocacy work, speaking to other healthcare workers and raising awareness about TB. If I can prevent just ONE person from being infected, by telling my story, then I believe it was not in vain.

Thank you and all my best,

-Pat

Docs so tired they may as well be drunk

Comment on this story

Copy of ca poss p1 docs done INDEPENDENT NEWSPAPERS Fifth-year medical students were shocked to find most medical errors in South African hospitals were systemic. File photo: Matthew Jordaan

Cape Town – Young, inexperienced, exhausted. And your life is in their hands. Junior doctors across South Africa are asleep on their feet as they are forced to work shifts lasting up to 36 hours, placing themselves and their patients in serious danger.

These doctors at the bottom of the medical pecking order are sick of treating patients while so tired they might as well be drunk, and are petitioning Health Minister Aaron Motsoaledi to review their working hours.

“Your competence decreases because of exhaustion. You end up blaming yourself when people die. You feel like you’re abused, and lose your passion for medicine.”

Dr Courage Khoza is the president of the Junior Doctors Association of South Africa (Judasa). He is doing his community service year at Bernice Samuel Hospital in Mpumalanga.

“You still have to drive home after not having slept for 30 hours or more,” Khoza said. “You are a danger to yourself and to others on the road. A doctor who has not slept for that long is just as dangerous as drunken driver.”

A 1997 study showed that after being awake for 24 hours, cognitive psychomotor performance drops to the same level observed in people with a blood alcohol level double the legal limit for driving. And doctors drunk on fatigue are much more likely to injure themselves and others.

Copy of ca p4 Med Students9044 Elsie-Marie van Straten, Victoria van der Schyff, Koot Kotze and Helene-Mari van der Westhuizen started the petition calling for safe working hours for junior doctors. Picture: David Ritchie INDEPENDENT NEWSPAPERS

“In the long term, if you make mistakes you can have needlestick injuries and get infected with HIV. It poses a huge risk,” Khoza said. “You are also a danger to people that you treat.”

In South Africa, doctors spend six years studying for their degree. After they graduate and can officially be called “doctor”, they must complete two years of internship and one year of community service as employees of the national HealthDepartment.

Only once their superiors have signed off these three “junior doctor” years can they legally practise medicine in South Africa wherever they choose. Interns sign up to work a maximum of 80 hours paid overtime a month in their contracts with the government. However, many hospitals ignore this regulation, and interns have no choice but to work far longer – unpaid.

Khoza said the problem was nationwide, as junior doctors were placed by the Health Department in hospitals anywhere in the country. A few complain to Judasa about their working hours, but most keep quiet and endure it because it’s only three years.

“They’re also afraid they won’t get signed off and won’t be able to become practitioners,” Khoza said.

There is legislation in place to protect junior doctors against unsafe hours – but many hospital departments are so understaffed that they end up abusing interns.

Dr Zameer Brey, provincial head of the SA Medical Association (Sama), said this battle had already been fought and won seven years ago when he was part of Judasa.

“I have personal experience having worked intensely for 20 hours, then making potentially life threatening mistakes just due to fatigue,” he said. “Realising how much of a risk I was to patients, I went through a labour relations process and challenged the system.”

The Health Professions Council (HPCSA) capped intern hours at 60 a week, 30 in one continuous shift, and 80 hours overtime a month. But the gains of Brey’s battle are being forgotten as hospitals try to fill their service gaps with junior doctors.

“Unfortunately our experience in the Western Cape is that a number of hospitals seem to be taking advantage again,” he said. “There needs to be some intervention. Interns are there primarily for training, not to fill gaps in the call roster.”

An article published in the South African Medical Journal in 2012 described interns as “slaves of the state”, enduring “forced labour and sleep deprivation amounting to and cruel and degrading treatment”.

The article said junior doctors were working up to 200 hours overtime a month, “rendered involuntarily under threat of not qualifying to practise medicine in South Africa”.

The Western Cape Health Department investigated the claims.

“We confirm that we are aware of the issue of the working hours of junior doctors and can confirm that the department strives to strictly adhere to the Guidelines for Internship Training as published by the HPCSA,” said Western Cape Health Minister Theuns Botha.

He summed up the situation: the Western Cape has 2 613 doctors in the public health service, of whom 321 are interns and 174 are community service doctors. Each hospital with interns has representative structures which are supposed to offer safe platforms for interns to raise their concerns. Hospital heads are tasked with ensuring that overtime hour logbooks are completed correctly.

“Interns are by and large responsible for their own roster allocation,” Botha said. “Each hospital in the province monitors the working hours and conditions of interns as per the policy parameters.”

But Brey says some hospitals don’t play by the rules, compromising patient quality of care “in a very direct manner that affects morbidity and mortality”. The ordeal is often the result of poor management.

“Too often I’ve heard managers saying we can’t afford to get a locum to cover the call shift; let’s get an intern,” Brey said. “It’s an unreasonable expectation on junior doctors, and it’s pushing them out of the profession.”

For Dr Jennifer Crombie, community service at the new Khayelitsha District Hospital was enough to put her off working in state hospitals for the rest of her career.

“I couldn’t handle any more government work. Part of it is the hours, partly the patient burden, partly the working environment.”

She and her husband Kenneth did their community service in Pietermaritzburg.

“Interns are very junior doctors,” Kenneth said. “We weren’t very prepared. We often felt out of our depth. The stress burdens you.”

Kenneth started taking antidepressants within the first few months of the internship. Before their shifts were synchronised, he would go a week without seeing his wife – even though they lived together.

“Often we were working up to 100 hours overtime,” he said. “A lot of doctors turned to medication just to sleep, then lots of coffee and Red Bull to stay awake. Some people didn’t cope.”

When the Crombies moved to Cape Town in 2012 to do community service in Khayelitsha, they thought it would be easier. But the new hospital had teething problems of its own, and the trauma ward was too chaotic for Jennifer to bear.

“You’re stitching up drunken men while they laugh about their injuries,” she said.

“I put a chest drain in for a 12-year-old girl after she and her friend decided to stab each other in the back. There is no regard for life.”

Jennifer had a nervous breakdown.

“I felt like I was putting my life on the line for the job.”

She and Kenneth both suffered needlestick injuries and he had to take a course of antiretrovirals. The lack of sleep, bad nutrition and little exercise made them sitting ducks for infection. Both are now on treatment for tuberculosis.

“You can never prove where it came from, but it’s most likely from working for the government for three years,” Jennifer said. “Why should you be punished with intense hours and traumatic circumstances for wanting to help people?”

While she now practises as a GP in private practice, Kenneth is working at Groote Schuur. He said that surviving as a junior doctor might be tough, but it produced excellent doctors.

“South African doctors are trained well, and it’s probably because we’re thrown in the deep end from a young age.”

And even while they’re battling, they are offering top-notch medical care. “We are providing a great service to a great number of patients,” Kenneth said. “We just need more doctors.”

For the four Stellenbosch medical students who started the petition calling for safe working hours for junior doctors, even a 24-hour work limit would be a victory.

The students’ campaign began with an ethics assignment and a shocking revelation.

Fifth-years Elsie-Marie van Straten, Koot Kotze, Victoria van der Schyff and Helene-Mari van der Westhuizen were investigating the causes of medical errors in South African hospitals.

“We were shocked to find that most errors were systemic,” said Van der Westhuizen. And the studies clearly showed that more errors occured when doctors were exhausted.

Hosted online by change.org, the petition says: “You would not trust an exhausted pilot to fly your plane, so why should you trust an exhausted doctor with your life?

“If doctors work more than 16 hours continuously, they become a danger to themselves and their patients.”

The four Stellenbosch students are not yet interns, but they saw the effect of fatigue on their older friends – and resolved to change the system before they themselves were too overworked and exhausted to campaign about it.

“When we qualify in 18 months, we want to give our patients the best,” Van der Westhuizen said.

Kotze, who comes from a family of doctors, said hospitals exploited interns because it made financial sense.

“An intern has the lowest wage. On paper it’s cheaper to overwork interns.”

There is even an incentive to work them beyond the allowed 80 hours overtime. “Interns are compelled to work these hours to be signed off,” said Van der Westhuizen.

She said interns didn’t speak up because they’re too tired.

Van der Westhuizen said the on-call system had been devised in a bygone era when hospitals dealt with far fewer patients.

The HPCSA and the national Health Department did not respond to requests for comment.

chelsea.geach@inl.co.za

Getting Rural Right

GRRGetting rural right is a 40 minute documentary which focuses on the key challenges in rural healthcare in the Transkei, which is in the Eastern Cape province of South Africa. With honesty and passion, this documentary examines the harsh reality of rural healthcare in the Transkei, and across the country. A must see, this humbling piece of film will make you question what you know about rural life and healthcare in South Africa:

Getting rural right – Part 1: http://bit.ly/ol4W4u

Getting rural right – Part 2: http://bit.ly/qeErpc

Getting rural right – Part 3: http://bit.ly/p9Fjix

Inspired by this documentary AHP wanted to know more about the people behind the camera. AHP spoke to Bart Willems and Arne von Delft, to find out how this documentary came about, what it means to them and what the future holds.

Hailing from the Eastern Cape themselves, Bart and Arne are cousins who have been great friends since childhood. Bart was born in Port Elizabeth, grew up in Stellenbosch, Worcester and Durbanville and after school found himself at the Tygerberg Medical School of Stellenbosch University. Here he was joined by Arne a year later. Arne was born in East London and as a child moved to the Western Cape with his family after his father, who was a medical officer in East London, decided to specialise in paediatrics at Tygerberg.

Getting Rural Right was filmed in 2005, but this story started long before that. Bart explained that one of his choices for their fourth year electives was to work in St. Elizabeth hospital in the Transkei. Seeing this as an excellent opportunity, Bart and three of his peers, Sameer Surka, Jamie Shelly and Bradley Griffiths were soon on their way to the Wild Coast. The Hospital is located just outside the small, but economically significant town of Lusikisiki in one of the most rural and underserved parts of South Africa. As Bart explains; “being in a place that rural is like being in a different country”.

During their month at this facility a great deal was learnt about the hospital itself, its peripheral clinics and the community it serves. Bart recalls that while he was “amazed by the amount of people in dire need of medical care, the beautiful new healthcare infrastructure and the fantastic natural beauty of the area,” it was the “the total lack of medical personnel” in these facilities that struck him the most. This was the start of things to come.

On the way back to Cape Town after the elective, with his experience from Lusikisiki fresh in his mind, Bart and two of his mates set off through the Transkei in on a surfing trip. En route they decided to stop at as many hospitals as possible in an effort to get a clearer understanding of the challenges facing these facilities. Bart recalls; “what struck me the most was that there were no doctors to talk to” indicating the seriousness of the problem.

Moved by the experience of his first trip, Bart initiated a second trip to the area two years later bringing with him; Oliza Boshoff, James Taylor and Arne (pictured in order). According to Arne, Bart organised everything for the trip from planning the route, taking care of logistics and recruiting friends (“the GRR Team”) to join him. Permission was granted by the Eastern Cape Department of Health, and reaffirmed later by the MEC for Health during a chance encounter and subsequent interview at Nelson Mandela Academic Hospital. Arne also told AHP: “I was easily recruited – a few weeks of surfing, with some work in between, sounded pretty good to me. For me we were breaking new ground by going to the Transkei. Bart was enthusiastic about the area, and health but mostly rural health, so I went along for the experience of a lifetime”.

So off they went – on a surfing holiday/epic road trip/documentary mission. Bart with the plan and map, James as the “multimedia boffin”, with Oliza and Arne “along for the ride”… The rest is history and the documentary is proof of what they found along the way.

For two weeks these four travelled from one healthcare facility to another to record the stark reality of life and rural healthcare in this region. This involved a great deal of travelling, filming and hospital visits. During this trip they managed to visit and film at Elliotdale Clinic and Madwaleni, Isilimela, St. Elizabeth, Zithulele, Nelson Mandela and Canzibe hospitals as well as the Conference on Rural Health held by the Rural Doctors’ Association of South Africa (RuDASA) and hosted for the first time by a Rural Transkei community.

Their mission was simple; to expose the situation in the Transkei to other medical personnel, friends and classmates.

The story line of Getting Rural Right was largely inspired by the Director General of Health’s vision for rural health, as presented at the RuDASA conference. During filming it became clear that “there was no long-term planning or structure in place for rural health and mismanagement was rife”. Bart also mentioned that although these issues were easy to identify, he “found it hard to conceptualise how to develop rural areas like the Transkei” – people live everywhere and very spread out, there are no towns and therefore access to basic things like water, sanitation, education and clinics are difficult. “Rural infrastructure is almost non-existent.” Bart went on to describe that the more facilities they visited, the more obvious it became that “there was a great disconnect divide between health planning and what is actually gets delivered to patients, what was needed by patients and what patients perceived to be necessary”.

Post-filming, the editing process took Arne nearly a year to complete as he was a complete editing novice and busy with his final year of medical studies. Following closely upon a greater awareness of the need and opportunities presented by the rural Eastern Cape, the Department of Family Medicine at Stellenbosch University developed a five week final year medical student rotation at Madwaleni Hospital in the deep rural Eastern Cape. Arne and his future wife, Dalene du Plessis, were privileged to be the first students to pioneer this rotation. During their rotation there they developed a research protocol designed to test the impact of the film on the attitudes of healthcare students and young professionals towards Rural Healthcare. Bart joined them at Madwaleni from East London (where he was doing his internship) and together they took the film to the subsequent tenth Annual RuDASA Conference held in Natal in 2006, where it was premiered and reviewed. The research protocol was informed in a large part by the staff at Madwaleni as well as rural healthcare stakeholders attending the RuDASA Conference. The protocol was subsequently implemented at Tygerberg Medical Campus among junior and senior medical students and the findings were written up as a final year medical dissertation (available on request).

During this time of production, research and subsequent further promotion Arne and Bart tried repeatedly to bring the Department of Health of the Eastern Cape on board. The film was screened at various staff induction functions, workshops and conferences, but unfortunately plans to distribute it on a larger scale at various medical schools and to the broader medical community never came to fruition. Suffice to say the human resource department failed to deliver on repeated promises spanning from 2006 to 2010.

Bart and Arne ultimately decided to promote the film and message on a more independent basis and launched an internet campaign early this year. If you would like to help the team behind Getting Rural Right with this mission to improve the standard of healthcare in the Transkei contact them on their Facebook page: http://www.facebook.com/getting.rural.right

After the movie was filmed, Bart worked in East London for two and a half years, worked in Ireland for six months, and then started locuming in the Cape Town area, but is now back at Stellenbosch medical school completing his MMed in Public Health. “I don’t know where the road will lead, all I know is that I want to end up in public health, I want to assist communities with healthcare… I’m just not sure how I will eventually fit in”. One of his special interests is the way(s) in which health is affected by the environment, how we can reduce human impact by planning, innovation and regulation and hopefully in the future ensure a healthier environment with healthier humans living in it.

Arne and Dalene subsequently joined Bart in East London for their two years of medical internship. It was during this time; Arne told AHP that “I lost that positive energy I had when we were filming. It is just so hard not to lose it when you see such poor management and poor planning. You have state-of-the-art equipment, or new theatres without any doctors or nurses to use them. Rural health is so dependent on dynamic individuals to help make it work. These are the people who get lots done, but the sad reality is that their hard earned individual gains in service delivery are not sustainable if they were to leave again and they are frequently guilted into staying. This coupled with poor or non-existing support can easily transform positive energy into resentment and eventual abandonment of rural health altogether. As somebody trying to improve the system, I quickly got a taste of this disillusionment that kills off the youthful energy and naïve enthusiasm of so many of our peers.”

Arne is currently working at Tygerberg hospital in the field of Haematology and explains that he is not entirely sure what direction his life and career will eventually take, but admits “I am more suited to the academic side of medicine, while Bart is suited to public health as he sees the big picture and is able (and willing!) to handle big and complex problems”.

The potential of Getting Rural Right is huge, particularly in terms of creating awareness around the challenges and rewards that exist in rural healthcare. “At the moment rural areas appeal to a certain subset of healthcare workers in South Africa. What we intend to do is foster this interest and perhaps push those on the fence over.”

Filming: James Taylor (main), Arne von Delft, Bart Willems

Editing: Arne von Delft (main) and Bart Willems

– See more at: http://www.ahp.org.za/news-detail/172/getting-rural-right#sthash.vR9kDZbk.dpuf