Have Your Cake and Eat it Too

While the first day was immensely stressful, my South African PI (principal investigator) Dr. Makin would make the next week or so run a lot more smoothly. I had initially rushed to get a car because I thought I would need to get to Kalafong hospital (out in Atteridgeville one of the largest former townships of Pretoria) the next day and by myself. However, it would turn out that I wouldn’t even need a car for about a week. Dr. Makin drove me to the hospital and showed me the quickest route to get there. She also took me around to run errands and get settled: cell phone, internet, groceries, etc.

The other reason why I wouldn’t need a car to get to Kalafong hospital initially was because of the government workers strike. This led to complete chaos among government services but was especially detrimental in the health care sector. All nurses and cleaning staff were employed by the government. They were part of the unions (representing 1.3 million workers in SA) demanding some 8.6% increase in salaries. Once they left, the public hospitals essentially shut down.

Even in the U.S. I feel we often undervalue nursing staff (and ancillary staff). It generally comes with the territory of training as a physician. We complain that the nurses have better hours, better relative payscales, and better benefits. On top of that we lament their constant incompetence and complain when we are woken up in the middle of the night for trivial reasons. It’s like a rite of passage in medicine; if you don’t have anything better to do, complain about the nurses. However, we often understate the fact that if all the nurses decided to walk out of the hospital (for whatever reason), the hospital would have a tough time operating.

In South Africa, this is magnified even further. Many health care facilities are essentially run by nurses. For example, most routine deliveries (even in the city and its surrounding areas) occur in clinics or midwife-operated-units (MOUs) without any supervising physician. Kalafong which happens to be a “tertiary” care center generally only receives complicated deliveries. Even here most deliveries are conducted without an obstetrician present, though the care of all patients is overseen by a medical team.

SA Medical Hierarchy

Consultant = Attending (completed specialization)

Registrar = Resident (specialist in-training)

Medical Officer (MO) = completed intern year(s) and community service years

Intern = first year after qualifying (2 years of internship now required for new graduates)

Qualified doctor = completed medical school

*All physicians must complete 2 years of internship as well as 2 years of community service after qualifying before they can apply for specialization

Now back to the strike situation...so when South Africans decide to strike, they really mean it. I remember when I was in SA 2 years ago there was a mini-strike and even that one brought the country to a halt. This strike (though I wouldn’t know it at the time) would last 3-4 weeks, and would be a harrowing time for all involved.

“A strike culture

Strikes are an almost yearly occurrence in South Africa, and have become part of the culture for a nation ruled by a liberation movement – the African National Congress of Nelson Mandela – that enjoys strong support from labor unions.

There is even a “strike season,” in which everyone from police officers to electric utility workers to members of the country’s Army march in protest for higher wages."

--Africa Monitor, 8/18/2010

The first day of the strike also happened to be the first day that I was attempting to drive to Kalafong hospital on my own. You can see Kalafong from the main road (Church Street) as a sprawling flat compound of buildings that seems to envelop the countryside. From far away it reminded me of a child playing marbles who sweeps his arms out to capture his bounty. I couldn’t help but think that once you go in this place you might not come back out. I was told later that the former ‘white’ hospitals (i.e. Pretoria West) were ‘fancy’ and built upwards with many floors and elevators, while the ‘black’ hospitals were built as flat expanses.

As I approached the main entrance of the building, I noticed stalled traffic (more than usual) and obvious commotion ahead. There was a mass of people singing and dancing in the street, and interestingly they didn’t sound happy. It looked like it would be tough trying to get into the hospital. Luckily, just as I was contemplating my next move, Dr. Makin called me. She sounded frantic and told me to turn around right away if I was on my way. I wanted to say, “Well, it’s a little late for that,” but I held my tongue. I listened intently as she told me that the research assistants on our team were barricaded inside the research building as strikers were trying to force themselves into the building. It turns out that not only were the workers going on strike, they were going to make sure that no one else was going to work (whether they were employed by the government or not).

Most of the stories I will tell are hearsay but from individuals directly involved (and reliable sources, of course): Our research assistants were able to get out relatively unscathed. However, not everyone was so lucky. The first day of the strike at Kalafong some members of the mob broke into one of the theatres (aka operating rooms, ORs) wielding machetes and guns and forced everyone out, including the surgeons who were already scrubbed (sterilized). The patient was left on the table already anesthetized, though apparently he hadn’t been cut open yet. All the students I spoke to said they were also forced out of the wards by the strikers. No physicians were left to care for the patients. Resistance was futile. If you didn’t leave on your own accord, you were carried out. One of the nurses who tried to enter the hospital compound by car was recognized by the mob, pulled from her car, and dragged through the streets.

“And there have been widespread incidents of workers who did not strike. Strikers marauded through a major Durban hospital, brandishing whips and threatening doctors and nurses. In Johannesburg, women in the final stages of labor and even a man with a severed hand were turned away from public hospitals, while fragile newborns had to be moved to private hospitals from wards barren of nurses.

After many such reports, the government set up special courts to deal quickly with strike-related violence.

A nurse working at a public hospital in the city of Pietermaritzburg was stabbed in the shoulder by three assailants whose faces were covered, said Chris Maxon, a spokesman for the provincial health department. And a nurse who works at the largest public hospital in Johannesburg is in intensive care after being attacked in Soweto.”

--New York Times, 9/6/2010

http://www.nytimes.com/2010/09/07/world/africa/07safrica.html

Within a few days, a large military force was called into action at Kalafong. It was safe to return, though a few harrowing moments were felt each day as you slowed to enter and exit the compound. If you looked the wrong way or someone mistook you for someone else, you could easily become the next victim. A few weeks into the strike I heard gunshots as I was exiting the compound. I didn’t slow down to see where they might have been coming from. Though my driving was improving, I certainly wasn’t stall-free yet and I wasn’t willing to take any chances. Even within the compound there was still an uneasy feeling walking about the hospital. I felt on edge every time I had to pass a soldier carrying an automatic weapon or shotgun through the narrow corridors of the hospital.

I heard gunshots again one day when I was on the labor ward. They sounded close by. As I came out of the operating room, people were a bit more talkative but otherwise there weren’t any signs of commotion. People were acting like hearing gunshots in the hospital was an everyday experience. Later I would hear the story. Apparently some guys robbed a store adjacent to the hospital and then thought it would be a good idea to jump the fence into the hospital compound. Of course the military forces stationed at the hospital responded and a shootout ensued. I don’t believe anyone was injured in this incident.

A few weeks later, another nurse who was well known and had continued to work during the strike, had her house burned down with all of her belongings. As we were travelling to the various clinics and hospitals in the outskirts I began to hear more troubling stories. I heard one such story when I went to visit Laudium hospital with Sister (title for a nurse) Rachel K and Sister Rachel M. These retired nurses were now research assistants who took me under their wing and treated me like a grandson. This was about a week into the strike and there were still people singing and dancing and blocking the entrance of the small hospital. When we went to the labor unit we found only a single nurse (the Sister-in-Charge) and a brave nursing student left to run the entire department. The nurse told us about her struggle to continue working in the face of angry co-workers and other government employees. While she grappled with this issue, she said she was willing to sacrifice her own personal safety to help take care of her patients. It was very powerful to see real-life heroes in action.

Meanwhile, the healthcare situation of the nation was becoming dire. Court injunctions demanding essential personnel return to hospitals were going unheeded. And in actuality, care of patients was being impeded and leading to untold numbers of deaths in an already resource-poor setting. Stories in newspapers highlighted how entire wards were left unattended and how abandoned infants were left to die because there were not enough people to feed or hold them. Even with military personnel in place, the strikers were finding ways to meddle in unconscionable ways. The Laudium nurse mentioned above told a story of how she had been at the hospital the previous weekend at night, again alone. When the police and military left for the day they locked all the gates with heavy duty chains to keep the strikers out. During the course of the night she had a patient that became unstable and required transfer to Kalafong for a c-section. However, when the ambulance arrived to transport her, the guards found that the locks/chains at the main gate had been filled with glue and other debris. The strikers had decided that if they were not going to be allowed in then they were going to make sure that no one else could get out. So there was no way for the ambulance to get in and no way for the patient to get out. The military forces had to be called in to cut the chains because the locks were unworkable. In an obstetrical emergency where every minute literally counts, this would be too much to overcome. By the time the chains were cut and the patient could be transferred to Kalafong, it was too late. The patient and the fetus expired en route.

‘The health minister, Aaron Motsoaledi, who last worked as a doctor 16 years ago, stitched up the wounds of at least a dozen stab victims during a night shift at Chris Hani Baragwanath hospital in Soweto on Friday.

He spoke out angrily against strikers for invading a sterilised area of the hospital to toyi-toyi (an apartheid-era protest dance) and, at another hospital, for interfering with an operation on an anaesthetised patient.

"In other words, they were saying: 'Leave this one to die'," Motsoaledi told South Africa's Sunday Times. "You can't have a health worker who is also a killer. A health worker, by definition, must be a person with a very deep conscience who, regardless of how he feels, will never arrive at a decision where they are prepared to kill a human being." '

--The Guardian, 8/23/2010

http://www.guardian.co.uk/world/2010/aug/23/south-africa-public-sector-strike

Every few days there would be an update, an ultimatum for a certain percentage increase in wages, continued balking by the government, and then the strike would continue. Children were no longer in school. They had had about a month off because of the World Cup and were now missing another month. Matric final years (high school seniors) were complaining that they would have inadequate preparation for their qualifying exams. There was one story from Capetown where students were striking and demanding an automatic starting score of 25% on their final exams. There were also threats that the police, traffic controllers, and prison officers would strike as well.

“A strike by 1.3 million South African state workers may descend into “anarchy” if police, traffic and prison officers join the wage dispute tomorrow, the secretary-general of the ruling African National Congress said.”

--Bloomberg, 8/25/10

http://www.bloomberg.com/news/2010-08-25/south-african-strike-to-widen-as-council-workers-plan-walkout-on-aug-27.html

In the labor wards at Kalafong there were very few nurses and care was being diverted. The MOUs and clinics were overwhelmed. Many patients were delivering at home, fearing that there would be violence at the hospitals or that they would receive inadequate care. This led to many complications among patients because of delay in receiving care. On my first day in the antenatal care clinic I saw the results of the stress to the system. There were over 80 patients waiting to be seen and only 2 students and an intern to care for them. And I of course I had no clue what was going on. There was a long corridor with curtains dividing it into “rooms” and a small pathway along the side to walk through. I was thrust into one of these cubicles and a patient promptly walked in through a door on the other side. I was able to hash from the patient (who spoke very little English) that she had been sick the previous week and had been given antibiotics at the clinic. The patient was 26 weeks pregnant and I looked in shock at her medications. She had been given doxycycline. If I remembered anything from my obstetrics rotation back in Boston it was DON’T give tetracyclines (i.e. doxy) to pregnant women because of possible tooth discoloration or bone formation problems in the fetus. Luckily, the patient hadn’t started taking the doxycycline. Her logic was that she thought she was supposed to finish her vitamin supplements first before starting these new tablets. I wasn’t about to argue with her. We prescribed a new antibiotic and sent her on her way. The second patient I saw had severe pre-eclampsia. Her arms and legs were swollen. Her blood pressure was hovering above 180 systolic and she was also having symptoms like headaches, etc. I went to the intern to present the patient and request a transfer to the inpatient ward. However, she stopped me dead in my tracks. There were no available beds for the patient. Her condition was not ‘severe’ enough. I thought to myself, “So this is the kind of day it’s going to be...”

And the situation on the labor ward dictated what happened in the antenatal clinic. Students and physicians alike could be seen cleaning the wards as well as the operating rooms. Supplies were low and at times nonexistent. At one point I remember there being no fluids left. There were no gloves. I saw one nurse hand-suture an episiotomy (cut made to the vagina to aid passage of fetus during delivery) without gloves and the bare needle (small) in her hand. She would thrust the needle deep into layers of muscle and then reach for the tip on the other side and pull through. When the nurse saw my astonished look, she said, “We don’t usually do this, but the times are desperate.”

The strike would end uneventfully after three weeks and it seemed like people went back to work like nothing ever happened. All in all I learned some important lessons, especially that though we like to keep up appearances, our societies are almost always on the verge of chaos.