Introduction to the country, area and the hospital.
I spent 7 weeks at Zithulele Hospital in South Africa. South Africa is an extremely diverse country; it is a huge mixture of cultures and contrasts with 11 different national languages. The hospital itself is located in the old Transkei region in the Eastern Cape of South Africa. It is an extremely rural location, set in rolling hills and a 30 minute walk from the coastline. The area is also very underdeveloped and under resourced. This was very visible in the hospital and the local area; with very poor condition dirt roads (where roads existed), huge education difficulties and hugely under resourced hospital supplies. The local district is in fact one of the poorest in South Africa: 68.3% of people live below the poverty line and employment is less that 8%. However the hospital has been headed up by a group of doctors for the past 8 years who are transforming it to become a centre of excellence in rural health care.
The hospital itself sits in the middle of Zithulele Village. There is a male and female ward, a paediatrics ward and a maternity ward. In total the hospital has beds for 140 patients. There is also an operating theatre which is used mainly for Caesarian sections. During my elective I also assisted with amputations and other minor procedures such as abscess removal and 3rd degree tear repairs. The biggest department in the hospital is the Outpatient department. This is the busiest part of the hospital where people can walk in and queue up to see a doctor.
There are currently about 10 doctors, 2 physiotherapists, 2 occupational therapists, a speech and language therapist, audiologist, dietitian and pharmacist. The wards and buildings themselves are poorly resourced. It was rare to find a tap with running water and ward curtains were non-existent. The hospital also lacked any of the basic equipment that is so freely available in the UK; such as oxygen saturation monitors and blood pressure cuffs. There was, however, an x-ray machine, an ultrasound scanner and a small laboratory which could (very slowly) process blood results. An aspect that I really enjoyed was working out patient's diagnosis without the easy access to tests which we can carry out so easily in the UK!
Common disease patterns
The 2 main diseases seen were HIV and Tuberculosis (TB). It was fascinating to learn about the huge stigma that still surrounds HIV testing and its management. Something I noticed was the importance of good compliance in order to achieve good viral load suppression and to treat TB. However this is very difficult in a poor community, where patients have to travel for miles to get to the hospital on dirt tracks (a trip to the hospital usually costs 50% of patients monthly income, which is mainly from government grants due to the lack of employment).
Malnutrition was another big problem that we encountered daily, especially in paediatrics. Many children presented with characteristic Kwashiorkor and Marasmus patterns of malnutrition. It was amazing, however, to observe how these children were transformed with proper treatment and nutrition. Epilepsy was also very common amongst the population. According to the doctors this is due to the high rates of neonatal trauma in childbirth.
Elective aims and Daily Activities
I went on my elective with the hope of experiencing a different aspect of medicine compared to the UK. I also hoped to see how medicine is practiced differently in a different culture and with different disease patterns. Global health is a subject I am interested in am currently considering working in sometime in the future.
Our daily routine consisted of a morning meeting at 7.30am. This would vary between teaching sessions on relevant topics, grand ward rounds and mortality meetings. I would then spend time on one of the wards during the morning (General medical male and female wards, Paediatrics and Maternity). We were able to choose freely where we spent our time. I tried to spend about 2 weeks on each ward. During ward rounds I would see patients and then discuss the management plan with the doctor. I would then do practical jobs that needed doing such as lumbar punctures, pleural taps and putting up drips with assistance from one of the doctors. In the afternoon I would generally spend time in the outpatient department; where patients could arrive and queue up to see a doctor. Here I would do my own consultations where there was an available translator and then check my management plan with a doctor. All the doctors and health professionals were excellent teachers and would readily set aside time to teach us.
Other activities that I did involved going out with a doctor to the community clinics. These were often routine 3 monthly appointments for patients on Antiretroviral drugs (ARV's). I would usually assist with this and then would see the "non-ARV" patients to assist the doctor. I also went out with the Physiotherapist and Occupational Therapist on home visits. This was an eye-opening experience, relying on asking locals (through a translator) for directions, as there are no addresses or roads to people's houses. Many of the patients we visited were people with Cerebral palsy. It was fascinating and inspiring to see how the therapist can vastly improve the lives of these patients despite the fact that they simple don't have any of the equipment that is readily available here in the UK.
Cultural Observations
Practicing medicine in a different language was one of the main differences encountered. The local language is Xhosa, and whilst the first language of most doctors was English, none of the locals spoke any English. Working through a translator whilst also having a rapport with the patient was something I found I had to work on and develop during the time. I found it was hard to ensure that aspects of the consultation were not "lost in translation" and that the important information was communicated. It was also fun to learn the basics of the language so that I could have a simple conversation and could ask basic medical questions to patients.
It was fascinating to learn how the local culture is so crucial to understand when practicing medicine here. It was important to understand how most of the locals would usually consult the sangoma (witch doctor) before seeking western medical advice. Often patients will have already been given a variety of traditional medicines, which could make conditions a lot worse, before coming to the hospital. These traditional medicines often played hazard with patient's regular antiretroviral and TB medications and their liver function.
Learning Points, Experiences and Recommendations
During my time at Zithulele I learnt a huge amount about many different medical conditions that I would not be able to experience in the UK. I also had the opportunity to perform many practical procedures: for example lumbar punctures, abscess drainage, suturing, pleural taps, cannulation and venepuncture in children and babies, delivering babies and assisting in theatre. I had the chance to experience real rural African medicine which is an opportunity I may not have again for a while.
I would thoroughly recommend the hospital to any future elective students, especially for anyone who has an interest in rural developing medicine. It is a stunning location with a completely different side of medicine from the UK and with great teaching from some inspiring doctors. There is a wonderful sociable community at the hospital and every evening there was an activity (such as ultimate Frisbee and aerobics) or a social event going on. It is also an extremely welcoming community with lots of projects that you can easily get involved with.
I can't think of any area which I can fault the hospital. In advice for future students I would recommend reading up on HIV and TB before going out and also taking out some medical basics such as a stethoscope, a reusable tourniquet (there are none there) and the oxford handbooks of clinical medicine and clinical specialties. A book worth reading for anyone going to Zithulele is "Three Letter Plague" by Jonny Steinberg. It provides an invaluable insight into many of the social issues and the culture of the area.
Non-Academic Activities
We had many opportunities to travel and explore the local area during our time there. The hospital finished for the weekend at Friday lunchtime providing the chance to travel further afield at weekends. We did a lot of backpacking along the "wild coast" and the "south coast" of South Africa and visiting lots of tourist destinations. I also spend 2 weeks travelling after my 7 weeks at the hospital. During this time I visited the Kruger National Park and travelled up the south coast of Mozambique.
