Special Hearings — Health Sector Hearings — 1997-06-18

JANET GIDDY: We worked for nine years in a rural hospital from 1986 to 1994.  Steve objected to military service and was allocated to do six years of community service instead.  Our work included a wide variety of clinical duties at the hospital, teaching of primary health care nurses, working as district surgeons and a responsibility for community work in a district of 70 000 people.
 With regards to Human Rights abuses, we would take as a starting point that the right to basic health care is a fundamental human right.  Anything which prevented access to basic health care could be construed as a human rights abuse and we will describe factors which undermined the provision of health care.  We'll also describe situations in which health care available was abusive in some way.
 The first point is the institutional neglect of rural homelands.  The homelands of the apartheid era, largely situated in rural areas were dumping grounds of people.  As doctors we dealt on a daily basis with the ill health and disease suffered by large numbers of mostly illiterate, poor and marginalised people.  This is primarily the reason we've chosen to make this submission to the TRC in order to make known the plight of vast numbers of forgotten people who lived desperately on the edges of extreme poverty in harsh environments and battling with effects of diseases such as malaria, measles, bilharzia, TB, typhoid, aids. The marginalisation of rural people continues to this day and we believe that it is an urgent priority that this be redressed under the new dispensation.
 When I was asked to make this oral submission, I was specifically told to just focus on rural private practice abuses and leave out all the other stuff and in fact I've specifically not done that because I feel like that, it's part of the general attitude that rural health is just a non-issue, it's peripheral, it's not a big priority.  So that's why I'm speaking about my whole submission although I'll try to keep it to 15 minutes.
Inadequate funding of rural health services.
Rural health services have been chronically underfunded relative to equivalent urban facilities because they're conveniently out of sight and out of mind. They received less than half the budget allocations of urban hospitals of equivalent sizes.

THE GEN SHORTAGE OF HEALTH CARE WORKERS: .
A well functioning health team needs to be comprised of a whole range of professionals such as nurses, doctors, therapists, lab technicians, pharmacists and dentists. At no time while we worked at the Bethesda was there ever such a team.  This is problematic for the following reasons:
 In rural areas there are large numbers of people who are disabled and require physiotherapy and occupational therapy for example.  It's an area where the mysterious Msileni(?) joint disease occurs. 
 We only had an occupational therapist for one year in 1993. 
 A dentist visited once a week for six months in the entire time.  Otherwise the only dental care available was provided by the doctors who taught each other to do tooth extractions.  
 There was never a trained pharmacist employed at the hospital.  The laboratory was always short-staffed which had serious implications for the work in an area where there were a large number of epidemic diseases such as malaria, TB, bilharzia, typhoid and others.  
 There was an ongoing shortage of nurses.  This resulted in much of the work which should have been done by professional nurses being done by staff nurses who were compelled by the circumstances to function far beyond their scope of practice.
 The South African Nursing Council would not  have been pleased if they had known about these irregularities but we didn't think they particularly cared what happened.
The shortage of doctors.
 One of the main reasons why rural communities did not have adequate basic health care is that there were not enough doctors working in rural areas.  As we all know there's a severe maldistribution of doctors in South Africa.  The vast majority live and work in urban areas.  The reason for this are  multifactorial.  
 However, we would highlight the following reasons as ones which could have been managed differently.  
 Firstly incentives.  The Department of Health provided inadequate incentives for South African doctors to work in rural areas.  Some doctors employed by State health were given a territorial allowance which was an attempt to compensate them for working in these areas.  Although it sounded reasonable one had to bear in mind the realities of living and working in a rural area.  These doctors had no housing subsidy like colleagues in public sector jobs in urban places.  There were many inconveniences and expenses associated with living in very remote rural areas including bad roads, having to travel far to do shopping, repairs or anything like that.  Unreliable telephones or no telephones for months on end.  Erratic electricity and water supplies. Schooling was problematic for those with children.  There was no access to medical libraries for continuing medical education.
 One could continue this list which serves to illustrate that life in a rural hospital was awkward or inconvenient for people. While a few adventurous doctors accepted the challenge of living in the bush and tried to live as positively and enterprisingly as they could, for most doctors these situational factors were serious disincentives to working in rural areas.  
 The Department of Health could have provided financial incentives to doctors to recruit them to rural areas.  Many young doctors have loans to pay off and travel to other countries specifically to earn more money to pay their debts.  
 The Department of Health could also have thought of other creative alternatives, for example a paid sabbatical leave for any doctor who worked for a fixed period of time under a contract.  There was such a system available to British doctors employed in a rather strange way, but no one else.
 Rural medicine is uniquely stressful and the idea of paid long leave after a number of years of service would be a real encouragement to doctors to commit themselves for longer periods.