By Fazila Farouk · 23 Jul 2009
Throughout my encounters with the healthcare system, it's been the doctors that have left a lasting impression on me. I've wanted to say something about them for a long time. Long before the well-publicised doctors' strike started. After all, a visit to the doctor is an intensely personal experience.
The thing that I am most struck by is the number of doctors I have access to.
I am not one of those ill-fated South Africans referred to by the World Health Organisation (WHO) in its 2009 report, where it talks about eight doctors for every 10,000 people in the country.
I'm always overcome by a sense of bewilderment when I read such statistics, largely for the reason that when I walk around my neighbourhood I see no shortage of doctors.
Seriously, there's a doctor running a private practise on virtually every second corner in my neighbourhood with no shortage of SUV-driving moms keeping the practices ticking over nicely.
It's a nice quiet life for professionals to settle into while the kids are still young and going to school, for both doctors and patients.
Perhaps I shouldn't be complaining about the snug position I find myself in in soft suburbia. But, the activist in me has been grappling to make sense of what motivates people to become doctors for years.
In my mind the medical profession is a healing one. I imagine that people who choose to become doctors do so because of a strong sense of compassion for other human beings -- a generous human spirit that moves them to fix broken people, if you like.
And while I may not live in the South Africa described by the WHO, I do work in it and know a few things about it.
I know that the under-five mortality rate for children from poor families is abysmal. I know that HIV/AIDS is destroying poor families and their futures. I know that poor South Africans are dying from treatable diseases because they don't have access to doctors and medicines.
I also know that apartheid put them in this position.
So when I sit across from doctors in my urban utopia, I wonder if they too know the things that I do. I wonder if they care.
Access to healthcare is a critical development concern and people who become doctors receive enormous state subsidies for their training precisely because it is such a crucial sector for our country's overall socio-economic development.
So I do often find myself thinking about whether doctors see a role for themselves contributing to South Africa's development.
Indeed, I wonder if South African doctors see a role for themselves reversing the ravages of apartheid – because that's what its going to take to develop this country to its full potential.
In the early days after 1994, I naively believed that everyone would throw his or her weight behind making our so-called rainbow nation work. The work of doctors would be critical for building a healthy workforce.
But what I was treated to instead was news of the steady exodus of doctors from the public to the private sector.
Gavin Mooney, visiting professor at the University of Cape Town, a leading authority in health economics, observes the inequities in our healthcare system.
He argues, "Currently the split between private and public care is grossly inequitable - over 40% of health care funds are in the medical schemes for about 16% of the population. And yet those in the schemes are on average much healthier - not because of their private care, but because they are rich."
The majority of South Africa’s doctors work in the private sector servicing this narrow class of privileged South Africans.
Lest you think I have no business making such an assertion based on my perambulatory neighbourhood scan, I called the Health Professionals Council of South Africa (HPCSA), the council with whom every single South African doctor has to register by law. Bertha Peters-Scheepers, their senior public relations manager, confirmed that there are "a lot more" doctors working in the private sector than there are in the public sector and provided me with the HPCSA's latest registration figures for July 2009. There are 35,309 practitioners registered with the HPCSA. Of these, a mere 3,905 work in the public sector, while the majority, 31,519 are in "independent practice." That's a shocking 89% of South Africa's doctors working in the private sector.
Worse still, she said that the HPCSA database would be unable to clarify which of the doctors registered in the private sector were still in the country.
But census data collected by the Centre for Global Development (CGD) does paint a better picture of the medical brain drain. A notable 21% of South African doctors practised abroad in 2005, estimates the CGD.
That’s a huge number, but still an improvement on the numbers that fled the country in the early days of our democracy. A study released in 1998 revealed "Almost half the doctors who graduated from one of South Africa's top medical schools (Wits), most of whom are white, work abroad..."
Now most doctors will justify their decision to leave either the country or the public sector by arguing that they enjoy the inalienable individual right to work wherever they please.
I say hogwash to that because of the very particular history of our country and the challenges that this history has bequeathed to it.
South Africa is no ordinary country. We are a country overcoming a crime against humanity – that’s what apartheid is, a crime against humanity. It is given this egregious label because of its devastating impact, which reaches deep into the fibres of affected societies creating systemic injustices with lasting legacies.
We are a nation living such a legacy.
What does this legacy mean for the public health sector? A decade ago, the Truth and Reconciliation Commission (TRC) commissioned research examining "the role that health professionals played in helping or hindering the promotion of human rights during the apartheid period." Physicians for Human Rights conducted the research and produced a report.
Before 1940, blacks (including Coloureds, Indians and Africans) were not even allowed to train to become doctors in South Africa.
A small number of black students were allowed entry into medical schools from the early 1940’s. But Physicians for Human Rights reveal that prospective African doctors were particularly discriminated against with respect to admission.
Just to put some perspective on the gross inequity that our current system has inherited, "Between 1968 and 1977, 88% of all new doctors were white (whose percentage of the population was less than 20%) and 3% were African (who comprised about 70% of the population)" states the report.
These statistics provide an eye opening account of the antecedents that still feed into the misdistribution of personnel in our current healthcare system. But what I found most disturbing was the humiliation suffered by blacks training to become doctors in apartheid South Africa.
The report states, "During the apartheid years, students in the health sector experienced discriminatory and demeaning treatment. In many cases, health educators served as models of supporting extreme discrimination. Most training institutions that were attached to white hospitals prohibited black trainees from examining and treating white patients. White students, on the other hand, were able to examine and treat all patients. When black students were allowed into the 'European' hospitals, they were often not allowed to wear their white coats or stethoscopes. Black students generally were not allowed to attend professorial ward rounds since they were conducted in white hospitals."
By 1985, 94% of specialists and 83% of all doctors in the country were white. That's not such a long time ago. Doctors who qualified during that time would be in their prime today. I wonder how many of them complained about the way their fellow black students were treated?
Things have changed in post-apartheid South Africa and quota systems have also been introduced to ensure that higher numbers of blacks qualify as doctors. But it's still going to take some time before our new doctors are ready to take on the challenges of our unequal healthcare system, as admission quotas were still being negotiated between historically white medical schools and the Ministry of Health as recently as 2004.
But even as the complexion of medical graduates is changing, the question is, what kind of ethics are these students being taught in post-apartheid South Africa? Do they understand the significance of their role in helping South Africa to achieve its millennium development goals? Do they even know that the Universal Declaration of Human Rights recognizes the human right to health?
They probably don’t. Some of this has to do with their training. Physicians for Human Rights noted in their research for the TRC that with respect to bioethics training, even in post-apartheid South Africa "codes of conduct have not been applied to the health consequences of human rights violations; nor have they been interpreted as a mandate to protect and promote rights as a means of promoting the conditions for health and well-being."
It is doubtful whether the majority of South Africa's doctors even understand the human rights challenges facing this country and the importance of their role in helping to overcome these.
It is revealing that throughout the health-related injustices suffered by South Africa's poor, it has not been the doctors who have taken up their plight. When Thabo Mbeki and Manto Tshabalala-Msimang obstructed the roll out of antiretroviral drugs, it wasn't the doctors who downed their stethoscopes and took to the streets to fight against the injustice; it was organisations of the poor who had to do that for themselves.
This lack of concern for the broader development implications of their work is also exemplified by the behaviour of doctors in the current public sector strikes.
Certainly, their low salaries and awful working conditions appal me too. But while I salute the veteran doctors in our public healthcare system, I question the motives of the young interns who've been at the forefront of the wildcat strikes. I know that they are in the public sector for a short time only because of community service obligations.
I am also deeply troubled by the fact that striking doctors have not made a single suggestion for how to fix our broken public healthcare system beyond proposing financial incentives to retain and attract more doctors.
But at the end of the day, it's the doctors in the private sector that disappoint most in terms of their lack of understanding of the critical role that access to adequate healthcare for all plays in building a developing country.
They would argue that a bungling bureaucracy, low remuneration, inadequate facilities, poor nursing support and far too few doctors to share the workload typify the public sector in South Africa, which makes it too difficult to work in.
They would be absolutely right about that. But, it's not going to improve unless they move across and at least try to make it work. I mean if only 10% of South Africa's doctors work in the public sector, how on earth can anyone expect it to function?
When it comes to the motives of those working in the private healthcare sector, the man of the moment, America’s President Barack Obama, certainly seems to have pegged these properly.
Last month, President Obama spoke to the American Medical Association about healthcare reform. The association is objecting to a national health insurance scheme similar to the one being debated in South Africa, because "many of their physicians benefit from runaway health costs," argues Brook Jarvis of Yes! Magazine.
Critical of their stance, president Obama bluntly told the group that the healthcare system has "taken the pursuit of medicine from a profession - a calling - into a business."
This is exactly what has happened in South Africa too.
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Very, very powerful - now spread the news to all decisions makers...that's what your art is.
Just What the Doctor Ordered!!
Trenchant analysis Fazila!! Thank you.
What Do You Expect?
Why should doctors be different from any other sector of society? Why are they burdened with being "better" than the common man? Already they have sacrificed years of study to become acknowledged professionals, and now you insist that they give up their economic freedom?
If you want to change the behaviour of doctors, change their motivators. Incentivize them to stay in public service.
And while we're at it, why don't YOU go out and get qualified and spend free evenings as a paramedic? Surely it is a SOCIETAL responsibility and society must respond to the changes.
To "tut-tut" doctors is not going to change anything; indeed, if I were a doctor, it would make me bloody mind and virtually _ensure_ that I go "well stuff you all".
A Little Naive, I Fear...
What makes you single out doctors? Why should they be expected to sacrifice for their country if engineers, Home Affairs officials, accountants, teachers, advertising executives and politicians do not do so?
Until such time as our society inculcates a sense of mission into our youngsters, don't expect too much of them! They are bred in a capitalist society which tells them they should not care about their neighbour, but rather make money. And as long as every last politician takes every cent due to him/her in luxury cars, before fulfilling obligations to the poor, why should the rest of us be any different?
I spoke recently to children in a class of black Matrics. One - that's right, one - of them wanted to go into a career which would make life better for her community (it's a science, but she was clear about her motivations). The rest were thinking marketing, PR, I-don't-want-to-work (three were pregnant), a vague 'businessman', "I won't study, I want CASH", security guard, my-mother's-shop... It was so dispiriting. Instead of laying into doctors - who at the very least do do a year of community service, in which they 'give back', unlike, let's say, accountants - why not put your mind to how we can change this prevailing apathy, greed for money and lack of community?