From the issue dated December 17, 1999

South Africa Forces New M.D.'s to Do a Year's Public Service

Although some see the mandate as 'conscription,' most say the experience makes them better doctors


Acornhoek, South Africa

When Ebrahim Patel makes his regular visits to the Hluvukani Clinic in a remote part of South Africa, he is greeted by beaming nurses and a queue of people waiting patiently on benches in the shade of an umbrella thorn tree. They all are happy to see a doctor.

Previously, the clinic was staffed only by nurses. That changed this year, when South Africa put into effect a new requirement for everyone who completes medical training and wants to practice in this country -- a full 12 months of community-service work. This follows six years of training plus a one-year internship. Those who refuse to perform such service cannot register to practice in South Africa. Dr. Patel is among the first group of physicians required to spend a year working at understaffed state hospitals, mostly in remote parts of the country. Although he is based at Tintswalo Hospital here, his duties include regular visits to the Hluvukani Clinic, about 25 miles east of Acornhoek on the border of Kruger National Park, South Africa's largest game reserve.

The clinic has no running water, so Dr. Patel must rinse his hands with alcohol between patients. He has not been able to obtain quinine or other antimalaria drugs because Tintswalo Hospital has run out of such supplies. Yet on this day he quietly goes about examining a stream of patients, including a woman who has just suffered a miscarriage and a man with active tuberculosis. As Dr. Patel examines each patient, he diligently instructs a group of student nurses about the various conditions as he diagnoses them.

Dr. Patel was among 10 doctors from four medical schools who were assigned to Tintswalo. Last year, when the 450-bed hospital treated 55,000 patients, it had only eight doctors and six interns. The community-service doctors have eased the workload and enabled the hospital to assign physicians to some of its 14 outlying clinics, like the one at Hluvukani.

"These young doctors have been an oxygen cylinder to someone who was suffocating," says Boyale Bofoya, principal medical officer in charge of surgery at Tintswalo Hospital.

The service requirement was first proposed by the South African government as a form of practical training that would improve the skills of young doctors -- and improve services at rural hospitals with limited resources. Medical students protested, pointing out that the credentials of South African physicians were readily accepted in countries like Britain and Canada. Despite calls for more consultation, Parliament adopted legislation making community service compulsory.

More than 1,000 young doctors who completed internships in 1998 have spent this year in community-service work at hospitals across the country. They are completing their assignments this month.

Trained in city hospitals, most of the physicians had little choice about the rural hospitals to which they were assigned. Some of the doctors, both blacks and whites, strongly opposed having to work without adequate supervision in remote and occasionally dangerous areas, including some densely populated black settlements established under apartheid.

But observers say the issue is not viewed as a racial one. "I've seen disgruntled conscripts across the board, irrespective of race, sex, religion, or whether they are rich or poor," says Malikah van der Schyff, co-chair of the Junior Doctors Association, which has lobbied for the rights of medical graduates.

Timo Xolani Freeth, a former officer of the Health Sciences Students Council at the University of Cape Town's medical school, says students there support the program. "Our stand was that community service was a good idea, but that the government had been quite dictatorial in imposing the requirement," he says.

Mr. Freeth, a white, third-year medical student, says that, at first, the idea of community service was not really embraced by either black or white students, who are now represented in roughly equal numbers at most of the country's medical schools. Some white students, he says, had "behaved like spoiled brats" about their assignments and seemed more concerned about delayed career plans than about health care in the country's black townships and rural areas. But he says the mood among medical students has shifted this year, as reports come back from graduates now in the field.

"People are knuckling down and accepting the reality," he says. "They see the needs and the benefits. You can make a serious difference in areas where there is poor infrastructure and huge infectious-disease rates."

Catherine Musto, who now heads the health-students council at Cape Town's medical school, says the service requirement is "a way of putting back into the country what South Africa has put into our education."

Ms. Musto also says that many students were worried that they would be paid "peanuts" during their community service, but have since learned that the pay for such assignments is not out of line with starting salaries in the field.

The community-service rule was applauded by staff members and patients at overextended rural hospitals. It also was supported in principle by many academics, who recognized the desperate need for trained professionals in the country's rural areas, and who felt that medical graduates would benefit from more practical experience. Young doctors here are not required to serve a hospital residency before becoming general practitioners, as physicians are in the United States.

Now the government is considering extending the requirement to graduates in other disciplines. The Department of Justice recently issued a paper proposing that all law students perform 200 hours of community service to be eligible for a degree and, after graduating, complete six months of compulsory service.

Max Price, dean of the health-sciences faculty at the University of Witwatersrand, in Johannesburg, favors compulsory community service and would like to see it broadened to include all university graduates. But he criticized the hasty way in which the plan was put into effect.

On the positive side, he says, more than 500 young doctors were placed in rural hospitals, some of which previously had no staff physicians. Communities served by these hospitals now have medical care "of a much better quality" than ever before.

On the minus side, Dr. Price says that, because the state could not finance more posts at rural hospitals, it assigned some community-service doctors to urban hospitals that already were adequately staffed. This involved taking contract positions away from experienced foreign doctors, many of whom lost jobs and work permits resulting in "huge hardship."

Dr. van der Schyff, of the Junior Doctors Association, says that the group supports community service "as long as its implementation is safe and it involves consultation with junior doctors." But many medical graduates, she says, still regard the program as "sheer conscription." Of the 1,182 interns who were subject to community service this year, 140 declined to participate. Some went overseas to start their careers while others deferred their community service.

Driving to Tintswalo Hospital from a nearby airport, one crosses a serene landscape with giraffes and wart hogs grazing behind the tall fences of private game reserves. But 15 miles farther down the road, one enters the tightly packed settlements where tens of thousands of black people were forcibly resettled under apartheid, and most now eke out a living farming tiny plots of land. The young doctors assigned to such places mainly deal with illnesses like malaria, human immunodeficiency virus, gastroenteritis, and many other diseases often associated with poverty.

Dr. Patel at first felt that it was unfair to be forced into community service. "We've been uprooted and sent here," he says. "I wanted to be in Gauteng, but I was told there were no posts available there." He expected Tintswalo Hospital to be "really bad," but was pleasantly surprised by the conditions. "We have electricity and, most times, water," he says. "The most frustrating thing is the lack of supervision. In difficult cases, there is no consultation to support our diagnosis."

Conditions at Tintswalo are better than at most rural hospitals, mainly because it has close links to the University of Witwatersrand's health-sciences faculty.

Ntumba Mutamba, head of obstetrics and gynecology at Tintswalo, says the service program is "excellent" and is supported by the public. "For doctors who have just finished their internship, it can offer a lot," he says, adding that the benefits are not only medical in nature but also cultural, humanitarian, intellectual, and social. He hopes some of the conscripts will decide to practice in rural areas.

Donovan Kreutzer, a graduate of the University of Pretoria, says that when he heard he was going to have to do community service, "I felt as if someone was trying to con me out of my life." Now, however, he says working at Tintswalo "is great." He has had the chance to perform some surgeries on his own that he would not have had an opportunity to do in an urban hospital.

However, he is concerned about the lack of equipment and supplies. "We run out of medicine," he says. "We run out of drip sacks for intravenous fluids, we even run out of oxygen in the operating theater."

He is also frustrated by the superstitions of patients. "You get those who insist they have been bewitched and want us to give them a tablet" to stop the curse.

Kim Gottfert, a graduate of the University of Witwatersrand and spokeswoman for the community-service conscripts at Tintswalo Hospital, admits that, weeks ago, they all had "begun counting the days" until their service was completed this month. But she speaks in very positive terms about her experiences here. She describes Tintswalo as "an amazing place" where senior doctors are very willing to teach and share their knowledge.

"What we achieve with what we have is truly amazing," says Dr. Gottfert. "We have to make do with what is available. You can't necessarily rely on fancy tests here, so you learn to trust your clinical examinations."

Stephen Reid, director of the Center for Health and Social Studies at the University of Natal, has just completed a study of some 60 medical conscripts in three of the country's poorest provinces. He says the results show profound differences in attitude among the young physicians, depending on conditions in the hospitals where they serve. A minority of conscripts are "desperately unhappy," because they work in primitive conditions and lack support and opportunities for learning. Others are "ecstatic" about the experience, which has given them the satisfaction of doing a job that needed to be done.

On the basis of the study, Dr. Reid has recommended ways to improve the program, including giving medical graduates more say in where they are placed.