Before coming to Afica I was troubled by this point. If I was prepared to donate 6 months of my time to the cause then how should it best be spent when looked at from the point of view of the patients. In short, should I go to Africa and do the work there or alternatively should I stay in the UK, live in a tent in field whilst working extra hours in a UK hospital but sending all the money to someone I trusted in Africa. The thinking was that although the former would be something I would prefer to do for myself perhaps the potential receipients of my 6 months labour would prefer the latter and maybe that was what I should actually do.
While it hasn't taken me all year to work this out I now realise that without a shaddow of doubt the right thing to do is to come and do the work here. As I have eluded to before in these posts it is the shortage of human rather than financial resources that is the biggest problem most of the time.
I'm therefore left wondering if there shouldn't be a shift in thinking regarding the financial needs of hospitals like ours. I will stick to the doctor situation for now although the same could be applied to most other groups. There are 8 doctors working here of whom 5 are foreign, 1 is here as a part of compulsary service and only 2 are South Africans who are here by clear choice. There are 140,000 patients under our care and we are in the middle of an HIV/TB pandemic so the ratios are in no-ones favour. The bottom line is that rural African hospitals can't rely on do-gooder foreign doctors like me in the long-term . I'm personnally very happy with the terms and conditions here (except the lack of hot water!) but I'm not talking about me. For sure a limited amount could be done by tightening compulsary service rules for South African doctors but the reality is that large numbers of staff will only want to come here if the living conditions are excellent and to put it bluntly the salaries are very high.
Significant funds have indeed been chanelled towards improving staff living standards but I can imagine that it would be extremely controversial to direct extra resources towards higher salaries. What I would say is 'look at it from the patients' perpective'- would they rather have a bunch of extra doctors and nurses and rehab. staff etc. or more expensive pieces of equipment that no-one knows how to use or get fixed when they are broken? I think the answer is clear but I suspect the change is very unlikely to happen. Perhaps I should go back to the UK and live in my tent and use the money to fund extra salaries after all!
Wednesday, 30 July 2008
Saturday, 19 July 2008
Cleaner hospitals
Before I left the UK I remember that 'Cleaner Hospitals' had become a new political catch phrase, along with 'tougher on crime' and 'small class sizes' etc. I also remember when the previous government privatised hospital cleaning in the UK. As I recall they basically sacked all the cleaners on Friday and by Monday same people were hired by the new cleaning companies but were paid less money, it was one of those great advertisements for the motivational attributes of the open market.
Well, the Eastern Cape government can now claim to be ahead of the UK government on both counts. Until recently the hospital was cleaned by a group of generally older women who mopped the floors with various degrees of enthusiasm and kept it reasonably clean. However, someone somewhere decided to contract out the hospital cleaning to a private firm. So one day a whole new army of cleaning staff clad in heavy grey uniforms weilding yellow signs with flashing lights on top started patrolling the corridors. There are so many of them that it can be an obstacle course getting from one ward to another but the place is looking pretty spick and span. I don't think people have to worry too much about hospital super-bugs around here anymore- so one up for the Eastern Cape.
The killer move however is that instead of sacking the old ladies or making them carry yellow signs with flashing lights they just continued to employ them. They have been farmed out to some of the peripheral wards in droves, they now seem to have even more time for gossip and seem to be loving it. This means that since privatisation we effectively now have two complete teams of hospital cleaners working on the same hospital at the same time and no-one has been sacked or had their pay cut. Now why didn't the UK government think of that?
Well, the Eastern Cape government can now claim to be ahead of the UK government on both counts. Until recently the hospital was cleaned by a group of generally older women who mopped the floors with various degrees of enthusiasm and kept it reasonably clean. However, someone somewhere decided to contract out the hospital cleaning to a private firm. So one day a whole new army of cleaning staff clad in heavy grey uniforms weilding yellow signs with flashing lights on top started patrolling the corridors. There are so many of them that it can be an obstacle course getting from one ward to another but the place is looking pretty spick and span. I don't think people have to worry too much about hospital super-bugs around here anymore- so one up for the Eastern Cape.
The killer move however is that instead of sacking the old ladies or making them carry yellow signs with flashing lights they just continued to employ them. They have been farmed out to some of the peripheral wards in droves, they now seem to have even more time for gossip and seem to be loving it. This means that since privatisation we effectively now have two complete teams of hospital cleaners working on the same hospital at the same time and no-one has been sacked or had their pay cut. Now why didn't the UK government think of that?
Sunday, 29 June 2008
Learned helplessness
If you seperate a predatory fish from some prey fish with some clear perspex the fish will initially keep knocking into the perspex to try to get to the food, after a while it will give up trying and just swim around and ignore them. The interesting part is that if you remove the perspex the predatory fish will continue to ignore the prey and will not make further attempts to catch them, this effect is so extreme that the predatory fish will actually die of starvation before it tries again to catch the prey again- hence the fish has learned helplessness.
Life in the Transkei can sometimes feel like the life of the predatory fish. For example I've developed learned helplessness towards accessing various tests for my patients. I have tried hard to access CT scans through the government hospital but have had virtually no success and had essentially given up.
What I've learned is that just as in the fish story it is a dangerous mindset to slip into because you just never know when the perspex has been lifted. It often takes the fresh approach of a new member of staff to spur you into action and in my experience you can get some great results when this happens. For example, I've recently learned by chance of a new approach to the CT scan problem that may well work and it has spurred me on to revisit some other obstacles that I had previously abandoned.
Life in the Transkei can sometimes feel like the life of the predatory fish. For example I've developed learned helplessness towards accessing various tests for my patients. I have tried hard to access CT scans through the government hospital but have had virtually no success and had essentially given up.
What I've learned is that just as in the fish story it is a dangerous mindset to slip into because you just never know when the perspex has been lifted. It often takes the fresh approach of a new member of staff to spur you into action and in my experience you can get some great results when this happens. For example, I've recently learned by chance of a new approach to the CT scan problem that may well work and it has spurred me on to revisit some other obstacles that I had previously abandoned.
Tuesday, 17 June 2008
Bumblebees
I remember learning that while most animals behave to get as much done for a given amount of energy expenditure (maximise benefit/energy cost) this isn't true of bumblebees. They behave in such a way as to get the most done per unit time (maximise benefit/time cost). This is because after a determined length of time they essentially 'wear-out' and die. I've noticed something similar in human resource poor medicine which I wanted to share.
In high human resource settings doctors are generally encouraged to make decisions based on health cost vs benefits. Prescribe a certain drug to enough patients and the adverse side-effects will be out-weighed by the improved quality and quantity of life (health benefits > health costs). When human resources become limited the doctor is often faced with a different question. Is it worth me spending a certain amount of time on an intervention for a given benefit to the patients (maximise health benefit / unit of doctor time). There are a whole bunch of initiatives I would like to start including aspects of preventative medicine and intensive care of the critically ill. The question is not whether there is a cost vs benefit advantage to the patients but given that time is very limited, which of these interventions should I choose to do at the expense of the others. Basically you need to have a much greater understanding of how much something works and not just that it works at all. Financial resources must be considered in both settings but where I'm working financial cost comes into it less than you might think.
I have something else in common with the bumblebee because the only other thing I remember learning about bumblebees is that according to the laws of aerodynamics it is impossible for them to fly!
In high human resource settings doctors are generally encouraged to make decisions based on health cost vs benefits. Prescribe a certain drug to enough patients and the adverse side-effects will be out-weighed by the improved quality and quantity of life (health benefits > health costs). When human resources become limited the doctor is often faced with a different question. Is it worth me spending a certain amount of time on an intervention for a given benefit to the patients (maximise health benefit / unit of doctor time). There are a whole bunch of initiatives I would like to start including aspects of preventative medicine and intensive care of the critically ill. The question is not whether there is a cost vs benefit advantage to the patients but given that time is very limited, which of these interventions should I choose to do at the expense of the others. Basically you need to have a much greater understanding of how much something works and not just that it works at all. Financial resources must be considered in both settings but where I'm working financial cost comes into it less than you might think.
I have something else in common with the bumblebee because the only other thing I remember learning about bumblebees is that according to the laws of aerodynamics it is impossible for them to fly!
Tuesday, 3 June 2008
The similarities
It is easy to get caught up in all the differences and oddities you are likely to encounter when you move to a new culture. What I hadn't given a thought to were all the similarities that I would find. Steven Pinker talks about the fact that in all cultures people tell stories, recite peotry, sing, dance, decorate surfaces and perform rituals but isn't it the differences in the stories and the rituals that people generally find interesting in other cultures?
What I'm talking about are the things that appear to be all but identical. I'm not surprised that young men love football and drink as much beer as they can afford but it's easy to forget, when people appear engrossed in a daily struggle to survive and bring up children, that there is always time for gossip for example. The old women standing beside the road may have no shoes and smoke long wooden pipes but if you eavesdropped I'm absolutely sure you would hear the same conversation that could be heard the world over about who doesn't keep their house clean and who's husband has run off with a younger model.
The way women look after their children also seems so similar to me. The absolute amount of money floating around might be different but children still nag for a few cents for sweets and mothers still seem to resist for a while but eventually give way for 'a bit of peace and quiet'. Flirting is another thing. A bit of harmless flirting with slightly older nurses seems to get you just as far on the wards here as it does in the UK.
What I'm talking about are the things that appear to be all but identical. I'm not surprised that young men love football and drink as much beer as they can afford but it's easy to forget, when people appear engrossed in a daily struggle to survive and bring up children, that there is always time for gossip for example. The old women standing beside the road may have no shoes and smoke long wooden pipes but if you eavesdropped I'm absolutely sure you would hear the same conversation that could be heard the world over about who doesn't keep their house clean and who's husband has run off with a younger model.
The way women look after their children also seems so similar to me. The absolute amount of money floating around might be different but children still nag for a few cents for sweets and mothers still seem to resist for a while but eventually give way for 'a bit of peace and quiet'. Flirting is another thing. A bit of harmless flirting with slightly older nurses seems to get you just as far on the wards here as it does in the UK.
Saturday, 3 May 2008
It's the little differences
When you move to a place like the Transkei it is pretty obvious that you are going to encounter areas where your own culture is at odds with the local culture. After all it’s one of the reasons for visiting a different culture in the first place. What is interesting then is not that you find differences at all but exactly which things are different and also which things are surprisingly similar.
The latest difference I have encountered is in the attitude to exercise. My naïve view of Africa, based on the seemingly endless supply of talented distance runners from East Africa, was of children running 10km to and from school every day and perhaps a few talented adults out on the roads training. I couldn’t have been more wrong.
I go running after work often wired up to an iPod and sometimes with a head torch, thankfully no-one can see that I also have a chest strap under my shirt measuring my heart rate. To begin with I quite enjoyed the small trail of children joining me on the roads. However, the only things I notice now are the old women who, when they spot me coming, start jogging in a caricature of accentuated strides, swinging arms and a mocking giggle. Worse are the groups of young women who simply burst into fits of laughter as I go by.
When you think about it for a minute of course it’s a completely crazy pastime. They all know that I have a car and a housekeeper and could quite easily sit on my veranda sipping cool beer after work. Instead I choose change my clothes and then to run off in a seemingly random direction only to turn around at an arbitrary point and run all the way back, sometimes I do all this in the rain and the pitch dark. I don’t actually go anywhere useful, meet anyone or collect anything. I just get tired, hot and sweaty for no obvious reason at all.
Worse than running is cycling, sometimes I take a bike to a peripheral clinic and rather than drive home in a nice comfortable 4x4 I put on a yellow helmet and some strange shoes and huff and puff my way home on a bicycle instead. To someone who would walk 10km because they don't have a few Rand for public transport this clearly seems like a crazy decision.
If they knew that one of the reasons I did all this was actually to lose weight it would be the last straw. In this area you can reliably predict the income of an individual by measuring around their waist and most people spend more than half or their income on food the idea of deliberately losing weight remains completely foreign. I can't wait to tell them about those crazy foreigners who eat as much as they can only to then pay a doctor to suck all the fat out of their belly so they can start eating again.
The latest difference I have encountered is in the attitude to exercise. My naïve view of Africa, based on the seemingly endless supply of talented distance runners from East Africa, was of children running 10km to and from school every day and perhaps a few talented adults out on the roads training. I couldn’t have been more wrong.
I go running after work often wired up to an iPod and sometimes with a head torch, thankfully no-one can see that I also have a chest strap under my shirt measuring my heart rate. To begin with I quite enjoyed the small trail of children joining me on the roads. However, the only things I notice now are the old women who, when they spot me coming, start jogging in a caricature of accentuated strides, swinging arms and a mocking giggle. Worse are the groups of young women who simply burst into fits of laughter as I go by.
When you think about it for a minute of course it’s a completely crazy pastime. They all know that I have a car and a housekeeper and could quite easily sit on my veranda sipping cool beer after work. Instead I choose change my clothes and then to run off in a seemingly random direction only to turn around at an arbitrary point and run all the way back, sometimes I do all this in the rain and the pitch dark. I don’t actually go anywhere useful, meet anyone or collect anything. I just get tired, hot and sweaty for no obvious reason at all.
Worse than running is cycling, sometimes I take a bike to a peripheral clinic and rather than drive home in a nice comfortable 4x4 I put on a yellow helmet and some strange shoes and huff and puff my way home on a bicycle instead. To someone who would walk 10km because they don't have a few Rand for public transport this clearly seems like a crazy decision.
If they knew that one of the reasons I did all this was actually to lose weight it would be the last straw. In this area you can reliably predict the income of an individual by measuring around their waist and most people spend more than half or their income on food the idea of deliberately losing weight remains completely foreign. I can't wait to tell them about those crazy foreigners who eat as much as they can only to then pay a doctor to suck all the fat out of their belly so they can start eating again.
Sunday, 13 April 2008
Frustrations
Up until now I've tried to resist writing anything too negative so I'll try to get it all out in one go. I think the worst frustration is that although there is often money available it often gets spent in ridiculous ways. There are so many expensive pieces of equipment lying around that either no-one knows how to use or are not working and no-one knows how to fix them but when you want something simple and cheap it is not available. For example, someone recently installed a very expensive state of the art piece of anaesthetic equipment in our operating theatre, it must have cost £10,000, yet we have no trained anaesthetist and no specialist surgeon with little hope of either arriving soon. Just recently the head of maternity services spent her budget on an enormous desk and comfy chair that are sitting in her office (I think the chair gets more use than the desk); this is in a department that often has inadequate resuscitation equipment for sick newborn babies. It feels like living in dictatorship when the despot spends the last of the foreign currency on fighter jets rather than grain.
I thought that because South Africa is a middle income country it might be spared some of the corruption found in other African states. However, even in the medical profession there are many stories of doctors who claim full salaries from the government but spend less than half of their time working in the public hosptials and the rest of it working in private practice.
I must balance these frustrations with some of the freedoms that working in this environment gives you compared to working in a First World setting. Paperwork for doctors is generally kept to the minimum required to deliver effective care rather than the excessive amounts required to stand up in court, and similarly it is not necessary to over investigate healthy people for reasons of avoiding litigation rather than because it is what they really need. The bottom line is that wherever you work there will be frustrations, when you move from the Developed to the Developing World you really just swap one set of frustrations for another.
I thought that because South Africa is a middle income country it might be spared some of the corruption found in other African states. However, even in the medical profession there are many stories of doctors who claim full salaries from the government but spend less than half of their time working in the public hosptials and the rest of it working in private practice.
I must balance these frustrations with some of the freedoms that working in this environment gives you compared to working in a First World setting. Paperwork for doctors is generally kept to the minimum required to deliver effective care rather than the excessive amounts required to stand up in court, and similarly it is not necessary to over investigate healthy people for reasons of avoiding litigation rather than because it is what they really need. The bottom line is that wherever you work there will be frustrations, when you move from the Developed to the Developing World you really just swap one set of frustrations for another.
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