Reflections on a Global Health Fellowship in South Africa

I worked in Tintswalo Hospital in Mpumalanga, north-east South Africa, between February and July 2022. It was a hugely rewarding experience, both within and outside the hospital environment. The placement was organised through Pro Talent and the Tshemba Foundation – a non-profit organisation that arranges medical volunteering opportunities in Mpumalanga.

Tintswalo Hospital is a 350-bed level 1 district hospital with Emergency, Medical, Surgical, Paediatric, Obstetric and Psychiatric wards. There is also a busy outpatient department as well as HIV, TB and eye clinics on site. I primarily worked on the female medical ward, and also helped out in the emergency and outpatient departments. The hospital was predominantly run by “community service” doctors in their third year post-qualification. I was amazed by the breadth of their knowledge and skills, which included anything from manipulating a fracture under sedation, performing emergency C-sections, leading paediatric resuscitations, and providing anaesthetics cover for theatres. There were plenty of opportunities for me to assist in these situations, and I picked up some really useful procedural skills during my time in the hospital.

The Tshemba Foundation provides support in both primary and secondary care settings, and volunteers are encouraged to assist at local primary health clinics as well as Tintswalo Hospital. I therefore divided my time between these two settings, which allowed me to get a broader understanding of the most common conditions affecting the population. There was a significant burden of non-communicable disease in primary care, and it was common to see patients with extremely poorly-controlled hypertension and diabetes, as well as new presentations of end-stage renal failure. Working in the hospital alongside the clinics allowed me to see the other side of this coin, with strokes in particular being common and carrying a poor prognosis. The HIV prevalence in Mpumalanga is approximately 15%, and again I saw both sides of how this is managed in primary and secondary care. I was impressed by how well HIV was managed in the community. The nurses were very knowledgeable and many patients were compliant with ARVs. Sadly, however, a large proportion of inpatients at the hospital had AIDS-defining illnesses. I became familiar with conditions that I had only come across in textbooks, including TB (pulmonary and extrapulmonary), cryptococcal meningitis, PCP and one case of cerebral toxoplasmosis.

Volunteers with Tshemba are encouraged to engage in teaching sessions and/or lead a quality improvement project. Being based on the medical wards, I noticed that a lot of medications were often not prescribed properly or not signed for. I felt there was scope to improve the prescription chart, so designed an updated version. Although I wasn’t there to see the project completed, I have been informed that the new chart is now in use. Other projects included teaching nurses on BLS, improving the triage system in the emergency department and leading a drive for contraception through the family planning clinic at the hospital.

Of course, as expected, there were some challenges associated with working in a rural hospital in sub- Saharan Africa. The nearest referral hospital was a three hour drive away, and patients were usually either not sick enough or too sick to be transferred – that’s if we were able to get through to the right person! Trying to arrange CT scans was similarly frustrating, and often involved speaking to several hospitals who would give conflicting information. Even if the scans could be arranged, the next hurdle or arranging transport then had to be overcome. Aside from these logistical challenges though, the hardest thing for me was to adjust to seeing relatively young patients dying, and the way this was the norm for staff in the hospital. Sadly, the prognosis for patients with advanced HIV was so poor that these patients invariably would not be accepted for transfer to referral hospitals, so it was not uncommon to see patients in their 30s and 40s being “not for resuscitation” – something that would be unthinkable in the UK. I also looked after a number of patients who died of other things where I felt more could and should have been done.

There were some success stories, though, such as helping to arrange a helicopter transfer to a referral hospital (and listening to patients cheering when the heli landed in a nearby field), or seeing a child in a primary health clinic with suspected meningitis and personally taking him to hospital (an ambulance would have taken too long) – it turned out he did have meningitis, and thankfully he made a good recovery.

There was plenty to do outside of the hospital too. As volunteers, we had evenings and weekends off, and made the most of our free time. We lived in beautiful accommodation in a “Big Five” game reserve, where it was possible to see giraffes outside your bedroom window or watch impala drinking from the watering hole while we ate breakfast. I will never forget the magical feeling of falling asleep while listening to a lion roar in the distance, or that slightly-too-close encounter with elephants on the way back from work with another volunteer. Sharing accommodation with fellow volunteers was great, and allowed us to form firm friendships. We had regular braais, and would often cook together or play cards during the frequent periods of load shedding (power cuts). Parkrun, followed by coffee and breakfast, was a regular Saturday morning activity, and I joined a local football team with another volunteer. Living on a game reserve, we also regularly went on game drives, while Kruger National Park was only 45 minutes away. There were also hiking trails and waterfalls to explore around the stunning Blyde River Canyon. Mpumalanga really was full of beauty and variety.

I am so grateful for the opportunity to live and work in South Africa. I became a more confident and resourceful dokotela (doctor), and pushed myself to become more of a leader. I would recommend the Global Health Fellowship to any trainee with an open mind who is looking for a fresh challenge and the chance to do something a little different with their career.