Upon receiving confirmation that my medical elective was to take place in South Africa, I felt immediate excitement at the prospect of embarking on a journey back to my home country. Despite growing up in South Africa, my medical education has primarily taken place across European cities, leaving me unacquainted with the South African system. Doing my elective at Klerksdorp-Tshepong (K/T) Hospital Complex in my hometown of Klerksdorp gave me the opportunity to become familiar with the health system, the medical personnel and health-related issues that are prevalent in my community. It also allowed me to draw comparisons between my home country of South Africa and the United Kingdom, where I have undertaken the clinical years of my medical degree.
My elective started in the obstetrics and gynecology department and consisted of exposure to the antenatal clinic, gynecology outpatient department, gynecological oncology wards, labor ward and theaters. Since South Africa has a high birth rate, the community that depends on Klerksdorp Hospital services is vast, with the labor ward recording more than 500 births per month. I had ample opportunity to examine patients, deliver babies, suture the perineum after delivery and assist with Cesarean sections.
Despite my junior position in the medical team, I was oftentimes called to perform a highly skilled task or give a valued medical opinion. This crossing over of junior and senior roles highlighted the unforeseen need in the community — in stark contrast to the United Kingdom, where doctors fit into a medical hierarchy and follow strict roles according to their level of seniority.
The patients who are seen and treated in the public sector don’t have unrealistically high expectations, and my patients received medical care with immense gratitude. This was displayed through the manner in which they responded to me as a medical student; they had no reservations regarding my abilities or medical knowledge, nor did they doubt that I would perform a procedure or examination less adequately than a more senior member of the medical team.
By instilling this level of trust in me, I felt supported by and subsequently thankful to the patients through complex and uncomfortable procedures. This experience of living in gratitude to the patient was antithetical to the expectation that medical professionals have of serving and receiving thanks in return. This realization reshaped my perspective of medical practice and I believe that carrying this principle into future practice will improve my relationships with patients.
The second week of the elective was spent in the general pediatric and neonatal departments at Klerksdorp Hospital. Common diseases encountered there included meningitis, severe acute malnutrition and HIV acquired through maternal transmission. After several morning meetings discussing morbidity and mortality, I noticed that infant death was not unusual. The impassivity in conversations about infant death struck a chord with me, and a feeling of deep-seated responsibility set in as I realized many of these cases could have been prevented if medical care had been accessed in an appropriate and timely manner.
Despite relentless efforts made by the team to address this health care discrepancy, the lack of municipal support and funding for these services poses a huge barrier. It seemed to me that these futile attempts at improvement led to a cycle of discouragement and eventual indifference to the gravity of the situation. Breaking this cycle could greatly improve morale and subsequently improve the quality of care provided to those that do make it to health care centers on time. Furthermore, reaffirmation of good health care-seeking behavior could encourage early intervention for the infants’ future health care needs.
Another common presentation I saw the pediatric unit was anticholinergic poisoning caused by Datura stramonium, also known as Jimson weed or, in South Africa, “malpitte.” This plant is found along roadsides, in fields and in pastures. Since toxidromes in the United Kingdom are mostly due to overdoses of drugs such as opiates, the topic of poison plant ingestion was something I’d only read about in books — I hadn’t considered it a condition I would likely encounter in my future practice. I realized how important it is for physicians to be familiar with the determinants of health and local drivers of sickness where they practice. Having a high index of suspicion for diseases prevalent in the area leads to prompt diagnosis and treatment of the disease.
The third week was spent in the internal medicine department at Tshepong Hospital. In addition to chronic conditions such as diabetes, chronic kidney disease, liver failure, and coronary artery disease, I also saw cases of acute tuberculosis, pneumonia, meningitis and gastroenteritis. Since disease progression and management are complicated by the HIV-positive status that is prevalent in this population, patients are often unable to respond to treatment effectively; consequently, the overall life expectancy in South Africa is low.
Tuberculosis is the most common cause of death in South Africa. Throughout the week, I saw patients with tuberculosis presenting with both pulmonary and extra-pulmonary disease. It was striking to see the massive impact these infectious diseases can have on one nation while they are so well-controlled in another. In light of the HIV and tuberculosis epidemic, I felt humbled to witness the enduring resilience of a nation even in the face of death.
During the elective, I observed that practicing Western medicine in a country such as South Africa comes with its own challenges — patients often don’t share the same views as physicians regarding modern pharmacological treatments. For example, in many African communities there is the cultural belief that traditional healers (known as “sangomas”) can cure illness by providing herbal preparations (or “muthi”) to patients. Since the ingredients of the preparations are often not known, it may exacerbate symptoms and lead to a delay in seeking medical care from a clinic or hospital. In addition, patients may refrain from disclosing this information until they are severely ill or collateral history from a relative reveals the truth. This effect has led to early and preventable deaths in many instances.
After speaking to several patients who had sought the help of a sangoma before a medical doctor, it occurred to me that it must be a challenge for providers to educate the population on the benefits of Western medicine without denigrating or disrespecting their cultural beliefs. On the ward, one doctor virtuously addressed this challenge: a sangoma who had brought his partner into the hospital after several unsuccessful attempts at healing her illness was offered the opportunity to speak openly to other patients on the ward. He was even encouraged to document his opinion from a traditional medicine perspective in the medical notes. The practice of inviting traditional healers to integrate into the modern medicine setting could prove to be a critical first step in educating the doctor, the traditional healer and the patient alike.
More challenges to the efficacy of treatment are the area’s lack of resources and providers’ lack of insight into patients’ circumstances. The priorities of the population we treated were extremely basic: food, water and shelter. Some of my patients traveled distances of up to 15 kilometers on foot and in dangerous taxis just to get a place in the queues for medical care before dawn. Many who are burdened by the cost of travel often don’t get to the health care centers at all. Low compliance to treatment regimens is largely due to this logistical difficulty in accessing health care. Speaking to patients about this made me realize that it is a fundamental concern that needs to be addressed by the national health care system.
The fourth and final week was spent in the emergency department at Tshepong Hospital. Since assault and stabbings are common in this community, I had numerous opportunities to suture lacerations, dress wounds, treat burns and mold orthopedic casts. I also learned about the workup and immediate management of chest pain, asthma attacks, femoral fractures, syncope, epilepsy and less common presentations such as dog bites.
During my time in the emergency department, I sustained a needlestick injury, which is a common mishap among health care workers in South African hospitals. I subsequently learned the protocol that needs to be followed, which includes a month-long antiretroviral regimen and follow-up blood tests. Fortunately, this patient tested negative for HIV and hepatitis B so I did not need to undergo treatment. I realized that many of the health care providers I have seen are unconcerned by the occupational risks we face on a daily basis. This incident quickly wiped away my self-assured invincibility as I realized that the “it will never happen to me” attitude is a fallacy that only facilitates the possibility that it will.
Through this experience, I adapted to a new environment, improved my practical skills and had the chance to give back to my community. I believe medical students from all backgrounds can benefit from spending time in a developing country such as South Africa. The opportunity for hands-on learning across different specialties is an incomparable experience. Being exposed to patients who have different diseases, cultural beliefs and socioeconomic standings compared to the Western world can also create unique and eye-opening experiences. The lessons I learned have been humbling and I hope to carry the unyielding spirit of South Africa with me in my practice, wherever in the world I go.
Image courtesy of Athena Michaelides, taken with patients’ permission.