Out of Africa: The Medical Exodus

It is 11am and my brother, Cornelius, walks straight to the fridge, grabs a microwave meal and eats it straight from the plastic container. On his way to bed, he unhooks his stethoscope from his neck and flings off his Adidas trainers.

Sensing my temptation to move his grimy shoes, he shouts, “I wouldn’t touch those if I were you,” and then casually calls over his shoulder with a mouthful of noodles, “Two women birthed on those – and that was just today.” I hear him counter my shriek of disgust from his bedroom (where he will sleep for the next nine hours before he has to head back to the hospital for his evening rounds), “Calm down, you can’t get HIV from dried blood”.

Once Cornelius moves to Canada at the end of the year I will miss him but definitely not his bloodied sneakers. But as a recently qualified GP, he (like hundreds of other doctors) will severely be missed in the country’s hospitals.

Since the early 1990s South Africa has experienced “a brain drain” where skilled professionals emigrated in fear of political and economic instability during the democratisation period. Despite the peaceful transition, the brain drain is still an influential factor in the South African economy and service sector. In the medical profession, the country cannot seem to anchor down its highly trained staff. Nurses, physiotherapists, researchers and, most of all, doctors are leaving South Africa at an outstanding speed – more often than not, permanently. According to the Organisation for Economic Cooperation and Development (OECD), a third of South African-trained doctors are practicing abroad (and the most popular alternatives for emigrating doctors are Australia, Canada, France, Germany, the United Kingdom and the United States).

The South African Medical Journal (SAMJ), to which qualified medical professionals in the country are automatically subscribed, has recently revoked overseas advertisers’ right to place job vacancies—the government’s latest attempt to keep doctors in the country. Of my brother’s close colleague-friends, two have already immigrated to Canada, one to Ireland and two more are currently, like him, waiting for their visas to be processed.

Doctors working in government hospitals cannot complain about their salaries (sometimes making more than those in private practice) and yet these “state doctors” argue that they rarely have the opportunity to spend their earnings due to their ferocious hours.

Besides the six tedious years of studying, where from their third year medical students are already active within hospitals and treating patients (including delivering babies almost daily), doctors are forced to complete an additional three years after they graduate where they are “slaves to the state”. They are paid well (a change implemented only in recent years), but they are forced to work about 80 hours a week (sometimes even up to 100 hours a week) in dismal circumstances.

Only after successfully completing the additional three years of exhausting work are they qualified as general practitioners and can then apply to specialise (which again involves long hours) or choose to join a private practice (often at less pay) or again work for the state (with more flexible hours yet mostly very poor working conditions). Cornelius says, “In a country like Canada you can easily earn up to ten times more than in South Africa. I often feel like I was trained in first world medicine but only had access to third world resources. It’s very frustrating!”

He does admit that due to poverty, rural circumstances and ignorance, South African doctors regularly witness fascinating medical phenomena. Owing to the difficulty many patients have in travelling to see a doctor, it is common for patients to postpone hospital visits for months or ignore symptoms and diseases until they have severely advanced. “In South Africa the diseases we see are often only read about in textbooks by most of the world,” says Cornelius.

But he won’t miss the severely understaffed hospitals. In 2007, the OECD estimated that there were only 7.7 doctors per 10, 000 people in South Africa, a meagre figure compared to Australia who had an estimated 27 per 10, 000. Also, working conditions such as the dirty and flea-infested hospitals, where patients are often admitted only to sleep on the floor in the passages, are repelling factors for doctors. A sleeping bag is currently kept in Cornelius’ car because even the doctors at his hospital do not have sleeping facilities when on call.

Working in a township hospital is also dangerous – the location poses a severe security risk for doctors who have to travel in and out of the area, particularly at night. Car hijackings of hospital staff are a reality, and another quite literal bullet that Cornelius has dodged. He says, “I have a colleague who was stabbed to death by a psychiatric patient. And there are reports of female doctors and students who were raped at some hospitals. I think of that, and Canada seems amazing to me.”

Dr Erica Hick, a colleague of Cornelius at Khayelitsha Township Hospital who is also moving to Canada, tells me: “You treat the patients, save their lives, deliver their babies and then they steal your handbag from the tearoom. It’s not unusual to see a patient carrying a knife. I really look forward to not having to sew up so many drunken patients’ stab-wounds.”

Dr Hick says that the effects of AIDS on families are also devastating and the number of newborns left behind at hospitals is something she cannot bear any longer. “It’s utterly unthinkable, but it happens,” she says. In 2012, the United Nations International Children’s Emergency Fund (Unicef) reported that South Africa has an estimated 3.7 million orphans—of which more than half were orphaned as a result of AIDS. Unicef also projected that there were roughly 150, 000 child-headed households in South Africa.

Cornelius estimates that around 80 per cent of his patients are HIV positive or are living with AIDS. According to Statistics South Africa (StatsSA), approximately 5.26 million people in South Africa are HIV positive. South African doctors certainly don’t flinch at HIV, but Cornelius does consider himself lucky. Unlike many of his colleagues, he hasn’t been forced to use the tedious anti-retroviral medicine in the case of accidental blood contact with HIV-positive patients. The high infection rate of this devastating yet preventable disease definitely plays a role in doctors escaping from the Dark Continent.

The severe poverty and extremely high birth rate are also unattractive for doctors. “In my short time in obs and gynae (obstetrics and gynecology) I have delivered at least 100 babies. And I’ve done at least 100 caesarians,” Cornelius almost boasts.

In 1997, the Choice on Termination of Pregnancy Act was passed, making abortion legal in South Africa. In 2011, StatsSA estimated that over 77, 000 legal abortions were conducted in South Africa, an astounding number that excludes the thousands of illegal abortions many South African women still seek. Cornelius is one of the many doctors who refuse to conduct abortions (a choice doctors are legally entitled to). He adds, “It’s actually a joke how often women come to the hospital and want an abortion, but are too far into their pregnancy. I have witnessed many ugly tantrums when staff informs them that they can’t terminate the pregnancy. And then I just pray for that unwanted baby.”

StatsSA further reported 161, 000 teen pregnancies between 2008 and 2010—some of which were primary schoolgirls. “It is very frustrating seeing such young girls come in pregnant, often not with their first or even second child. And the father is rarely present,” says Cornelius.

Fetal alcohol syndrome is also a battle. In 2012, The Foundation for Alcohol Related Research (FARR) in South Africa estimated that 14 out of 1000 babies were born with fetal alcohol syndrome. “I once delivered a baby where the mother was so drunk, she passed out during labour and missed her child’s arrival in the world. I really wish I didn’t have to witness that,” Cornelius says.

Another influential factor leading to doctors emigrating from South Africa is the lack of fair hiring. The OECD’s 2008 study listed affirmative action as one of the top reasons for doctors emigrating. Since 1998, South African medical schools have also implemented an extensive quota system, reserving placements based on race. Unfortunately, race-based hiring is a reality in the country and it is a real setback for South African medicine, causing many GPs and specialists to leave the country for good.

Cornelius recalls a colleague who applied for a position in her hospital, had excess qualifications and diplomas, years of experience and was recommended by the hospital board for the position. However, regardless of her qualifications and excellent resume, the job was reserved for a black candidate. The person they hired was indeed black, had no relevant experience, no additional qualifications and no references. Cornelius adds, “I remember her telling me that day, she’s packing her bags and moving overseas.”

But for emigrating doctors it isn’t all “common colds and gastro” as Cornelius puts it. The application process is expensive, lengthy and requires written and oral examinations, a difficulty with their extensive working hours. Likewise, the location in their chosen country is mostly very remote. In Australia, the government allocates specific towns for immigrating doctors. Although doctors mostly have some say in their location, the better pay is of course in the remote areas. “The average Canadian hasn’t even heard of the town where I’m moving, Lac La Biche,” he humorously points out, “but I will probably be driving a Porsche – if the snow permits it, that is…” There is a gap for South African doctors in many countries because local doctors prefer living and working in urban areas with more temperate weather.

At the end of the day, overseas hospitals are generally well-staffed, well-equipped, hire fairly and do not pose any direct threats to doctors’ lives. The hours are also often better. Australia, for example, legally capped the number of weekly hours for medical professionals.  Also, HIV, ignorance, stabbings and police-accompanied patients who are handcuffed to their hospital beds are unsurprisingly giving South African doctors good reason to leave. And, of course, being paid in dollars does not compare to the dismal Rand…

“With South African crime, poor working conditions and extreme hours, I think the rest of the world looks very attractive. Plus the Canadian hospital told me I will probably only deliver two babies a year,” Cornelius adds. “Just think how long my trainers will last!”



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