South Africa–bound

A place of need

It was not easy to choose the most suitable place to go. In Africa there are thousands of paid and unpaid work opportunities for doctors—some in government health departments and others in non-governmental organizations. Family physicians are often most in demand because they have a range of skills to contribute. My wife, Margo, and I wanted to work in an area of need, but where local infrastructure was adequate. There is no point being able to diagnose disease without the resources to treat it. We were prepared to live under basic conditions and could accept some risk, but we did not want to be in a war zone. Because of our language limitations, we needed to choose a country where English was one of the official languages. After examining many fascinating opportunities, we settled on a 6-month post with Edzimkulu, an Edmonton-based charity that works in the KwaZulu-Natal province of South Africa.

The hillside village of Ndawana

We all know that HIV has been a public health, social, and economic disaster for Africa, particularly sub-Saharan Africa. In Western society, HIV commonly affects homosexuals and intravenous drug users. To a large extent, education, prevention, and treatment programs have been successful in limiting its spread. The course of HIV has been much different in Africa. There the spread of HIV is mainly through heterosexual contact. Prevention programs have failed to have a satisfactory effect. The number of people infected is staggering. In KwaZulu-Natal, 39% of women seeking prenatal care carry the virus. Life expectancy in South Africa has dropped from 65 to 42 years of age. It is common for young adults to die, leaving behind orphans in the thousands. Many children are raised by aunts, grandmothers, and even teenage siblings.

Progress in the battle against HIV in South Africa was severely hampered during the late 1990s: the Prime Minister and his Minister of Health expressed the conviction that AIDS was not caused by a virus, but was simply a result of poor economic conditions and poor nutrition. Nothing constructive was done to deal with the problem. It was not until 2004 that the government finally acknowledged its responsibility to provide proper therapy for its affected citizens. Another problem was that the multinational drug companies producing the necessary drugs refused to provide them at prices that African countries could afford. It required a long period of sustained lobbying by a variety of stakeholders before the drug companies relented. Drug companies now allow factories in China and India to produce generic versions of older HIV drugs, and make them available inexpensively in Africa.

Dr Mawdsley teaching at an HIV workshop in Ndawana

There has been tremendous progress since the anti-retroviral therapy rollout finally began 5 years ago. Of the 5.7 million South Africans known to be infected with HIV, approximately 60% are now using treatment. This is an amazing logistical accomplishment, considering the buildup in infrastructure and staff required. A shortage of doctors is always a problem.

Learn, practise, and experience

For a family physician who had had only a handful of patients with HIV in the past, I had much to learn. There were several good handbooks available, as well as plenty of information on the Internet. My first week on the job was spent with 2 busy British doctors at a nearby hospital. Then my wife and I attended a 3-day HIV course in Durban. Initially, I worked in partnership with another doctor 1 day a week and by myself the other days. Within a month, I had enough experience to feel comfortable. I worked in 3 local antiretroviral therapy clinics: Ndawana, Underberg, and Pholela. Patients receiving treatment totaled more than 1500. Newcomers would visit me for their medical assessment and initial prescription of medication. Thereafter they were followed up by the nursing staff. I would see them again if there were adverse effects to treatment, signs of drug failure, or evidence of a new opportunistic infection. It was heartwarming to see how well most of them did. After the first 3 to 6 months, mortality dropped to approximately 2% per year.

It was remarkably fulfilling work. In Canada I have not often been in a position to offer lifesaving treatment to parents of young children, whose greatest hope is to live long enough to see their children through school. Somehow, working as a volunteer made things less complicated and more rewarding. I certainly recommend the experience.

My wife’s work was also fulfilling. At the clinic in Ndawana, she helped streamline the laboratory work process, set up a paper-based patient tracking system, and established weekly in-service training for the clinic staff. Her other projects included assisting with a Child Health Survey and an HIV Awareness Day.

Of course, South Africa offers many attractions unrelated to work. We spent many days hiking high in the nearby mountains. There are game parks and glittering cities. There is a richly diverse art and music scene. Restaurants are inexpensive, and a bottle of good South African wine can be had for less than $4!

There is one patient I will never forget. She was in hospital for several weeks, at first desperately unwell, then slowly recovering. Eventually the day came when she became strong enough to be discharged. She was, of course, pleased. She put on a fresh dress and gathered her few belongings. Before leaving, however, she took time to stroll through the wards, singing prayers for the others, that they too would get well and be able to return home to their families.