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ASHLEY FREEMAN, DENA EL SAYED and MEGAN DEVLIN describe their elective in South Africa.


Imagine yourself, a young medical student, in rural South Africa. You are on a weekend trip to visit the remote Drakensberg National Park with your seasoned tour guide, a native of South Africa. While you are enjoying the exquisite mountain views, your guide begins to experience chest pains. Frightened by the prospect of a heart attack, he looks to you for comfort and a plan. You are two hours from the nearest hospital.
This is a true story of our experience while on an elective in South Africa. An ambulance was able to transport our guide to the nearest rural hospital. The lone junior doctor offered what little help he could, apologising for the lack of an ECG and laboratory facilities. Due to the urgent nature of the presentation, we were left with no other option but to hook up our guide’s IV fluids to the inside of our rental car and drive him back to the city where he could undergo more thorough investigation. While our guide survived the ordeal, the incident was a shocking introduction to the sparse healthcare provided to the people of rural South Africa.

A makeshift ambulance in Kwazulu-Natal.

Rural crisis
In April 2009, we travelled to Pietermaritzburg, within the province of Kwazulu-Natal (KZN), to undertake a three-week elective at Grey’s Hospital. Working in a relatively well equipped tertiary care centre, we observed the unique burdens of a population plagued by HIV/AIDS and tuberculosis. One doctor described “the dubious distinction of being consultant-in-charge of the first female inpatient diagnosed with AIDS in Pietermartizburg”. Unfortunately, within three years, 70% of the occupants of that ward would have HIV/AIDS. This is also now the case in public hospital medical wards throughout the province. However, we were also troubled by the stark differences we had witnessed between urban and rural care. It was evident that the difficulties of rural healthcare go beyond a high disease prevalence and lack of funding. The severe physician shortage in South Africa is creating huge gaps in the system. We found that rural medical staff were very much isolated by a lack of consultant guidance.

A lucky break
Rather serendipitously we met two veteran consultants in internal medicine, Dr RI Caldwell and Dr Jim Muller. They introduced us to their own project, the Red Cross Outreach Programme, which was established to alleviate some of the problems we witnessed on our tour. Funded in part by the province of KZN and the Red Cross Air Mercy Service, the Outreach Programme is responsible for 20 district hospitals serving a population of three million people.

Dr Caldwell preparing for an Outreach visit.

These two heroic men are working with the Outreach Programme to ensure that consultant advice is made available to rural centres despite physician shortage. The goal of the Outreach Programme is to bridge the gap in knowledge and care that exists between tertiary and district hospitals, and to foster an environment of continuing medical education. This is accomplished by ensuring that each district hospital gets a monthly visit from a consultant in each major discipline.
We accompanied Dr Caldwell and Dr Muller on several Outreach trips throughout the elective. Our days began at dawn at an airfield outside of town where we boarded a small propeller plane that would take us to a rural hospital. Each visit was structured, with consultations on difficult or puzzling medical cases, clinical teaching rounds and formal tutorials for medical staff. The consultants even provided their own personal contact details so that they could be contacted in emergencies.
Prior to this outreach programme, the teams were isolated with little or no opportunity for continued learning or consultation on challenging cases. We discovered that many of the staff live on the grounds of the hospital, and are completely dedicated to patient care. The staff were extremely grateful for these visits and described their relief to know that they had support. In rural South Africa, a junior doctor may have to wait weeks for advice, while a junior doctor in Ireland can take comfort in the fact that there is always a senior physician to consult in the case of uncertainty.
The Outreach Programme is a novel approach that succeeds in making specialist advice available to rural medical staff. We feel privileged to have participated in such dedicated efforts to enhance healthcare for a neglected population. Given the opportunity, we recommend that other RCSI students experience the Outreach Programme by applying for the elective through the University of KZN.

Dena El-Sayed with a paediatric patient.

Acknowledgements
We would like to thank Dr RI Caldwell, Dr Jim Muller and the University of Kwa-Zulu Natal for this opportunity.

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