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At the heart of general practice since 1960

How working in South Africa reinvigorated my love for medicine

When Dr Michael Laurino went to work in an HIV programme in South Africa he was reconsidering his decision to become a GP. Three years later, he's using the skillls he learnt abroad, back home

After a rather chequered career in general practice ranging from years of locum work, through salaried positions, two partnerships a Masters degree in Psychotherapy, I was beginning to regard myself as a bit of a failed state! Whilst ricocheting from one unsuccessful working relationship to another I would find myself once again feeling frustrated, bored and singularly uninspired.  It really was time for a change. But what other options were there for a GP in mid-life within the world of work other than to continue to see patients and prescribe what seemed like endless amounts of paracetamol and antibiotics?

 

It was with a heavy heart and not a small sense of futility that I took myself along to the BMA careers fair conveniently located down the road from where I was living at the time. I had no idea what I was looking for but hoped to be inspired. It was here that I first encountered (AHP) Africa Health Placements, an organisation aiming to support and enhance healthcare services in Africa. They were actively recruiting doctors and other health care professionals to work in a variety of salaried public sector posts mainly in rural areas. I was briefed on various opportunities and strongly encouraged to apply.

I had never previously considered working abroad and Africa had always seemed a rather unfamiliar continent for such a debut. South Africa was a country I knew very little about.

I returned to my work as a GP and continued to see my patients, each for ten minutes in batches of twenty, dispensing warmth, empathy, medication and sensible advice. The boredom intensified, I was not sleeping, I began smoking, I felt stressed and irritable. I was losing weight and I really could no longer see the point of any of it. I was miserable, unfulfilled and directionless. What's more I hadn't enjoyed a successful personal relationship for almost two years and my friendships were no longer hitting the spot. I was heading for a mid-life crisis.

So I decided to take the plunge and submitted my application to AHP. After a telephone interview I was offered a post at a rural provincial hospital in KwaZulu-Natal as a Principle Medical Officer. The process of application was relatively straight forward and took around three months to complete. I was required to submit applications to the South African Department of Health, to the HPCSA (the South African equivalent of the GMC) to obtain an appropriate work permit, submit applications to the Foreign Workforce programme of South Africa and obtain confirmation of my qualifications via theECFMG International Credentials Services(EICS). AHP helped me to navigate the process via their operations in the UK and South Africa.

Culture shock

September in Durban was not quite how I'd imagined. The light was intense and the views from my guest house in the Berea, a residential suburb high on the hills over-looking the Indian Ocean, were breathtaking. A far cry indeed from the wet, grey streets I had left behind!

After a day of rest I attended a two day workshop on HIV, TB and STI treatment run by the South African Foundation for Professional Development and then made my way in-land to the small provincial town of Estcourt where I was to be based for the year.

On my first day I was shown around the various hospital departments and by midday, and rather alarmingly, I was deemed fit to begin work. My first role was to work in the busy casualty department where I was immediately pointed towards rows of emaciated men, many of whom were in the advanced stages of HIV disease. The casualty department provided services for a population of around 500,000 patients, mainly Zulu people from the surrounding countryside. My knowledge of the Zulu language was poor and I initially relied on my nursing colleagues for interpretation.

I had never worked in a casualty department before and my 20 years of general practice in London had not equipped me for such an experience. I had certainly never encountered cases of malnutrition or advanced HIV. My South African colleagues were fantastic and incredibly competent and were happy to educate me as I endeavoured to learn all the various complexities of medicine in a resource challenged- and high HIV prevalence-setting. In KwaZulu-Natal the prevalence of HIV was around 30%. In the country as a whole there are currently 5.7 million people living with HIV. Many of the children presenting to the hospital were HIV positive, mostly with symptoms of malnutrition, chronic diarrhoea, wasting, pneumonia or TB. The mothers were either sick or had died themselves from HIV infection and so children were often cared for by grandparents or siblings, the intermediate generation having been decimated by the virus.

After a week in the casualty department I was placed on the paediatric ward where I managed a ward of around sixty children, the majority of whom were HIV positive and were suffering from acute or chronic gastroenteritis, TB or malnutrition. I quickly learned how to cannulate veins, perform lumbar punctures and manage severe infection, dehydration and malnutrition. As soon as they were clinically stable the children were initiated on antiretroviral (ARV) medication and discharged to the ARV clinic for follow-up.

Making progress

After four months on the paediatric ward I was moved to the adult general  medical wards where again the majority of patients were suffering from HIV and unmanaged chronic conditions such as diabetes, hypertension or heart failure. I became confident in my diagnosis and treatment of PCP and Cryptococcal meningitis as well as TB and Kaposi Sarcoma all of which seemed to respond surprisingly well to specific treatments together with antiretroviral medication.

The main structural issues appeared to be poorly resourced primary care services coupled with a crippling burden of HIV disease. Though there were many primary health care centres these clinics were all nurse lead and the nurses were required to manage all acute and chronic conditions in addition to preventative interventions and full obstetric care. Many of the clinics were in remote and often mountainous terrain, so access to centralised hospital services was an issue for most patients both in terms of transport and cost. In the spirit of NHS de-centralisation we arranged for all hospital doctors to visit each clinic for one day a week to both support the nursing teams bringing care closer to where the patients lived and at the same time reducing unnecessary and costly attendance at the hospital. This was a successful and popular intervention which later evolved into a vehicle by which patients could be initiated and maintained on ARVs at their local primary care clinic without having to travel long distances to the hospital.

After a year I was promoted to Chief Medical Officer and was charged with the running of the hospital ARV clinic. The clinic looked after over 7,000 men, women and children, all of whom were on regular ARV treatment. The work mainly involved initiating and maintaining patients on ARV medication, monitoring their response to treatment and identifying poor adherence and medication failure. The South African Department of Health guidelines were clear and pragmatic and at that time were recommending one of two primary ARV regimens for all patients. In 2008 the ARV regimens were based on drugs which are no longer used in the UK. These drugs were infamous for their unacceptable side effects, however they were effective in suppressing viral replication, resulting in reduced disease progression and limited HIV transmission - both of which were worthy objectives. In 2009 the national guidelines were updated and now patients are maintained on much more user-friendly regimens with fewer side effects. The clinic also spearheaded the PMTCT campaign (Prevention of Mother To Child Transmission) thus preventing the transmission of HIV in utero and during breast feeding through the use of ARV medication for both mother and child.

We were practicing HIV medicine on an industrial scale with resources and human capital suited to a much smaller enterprise. On one occasion during a public sector strike, pickets were stationed at the hospital gates preventing access to both staff and patients. The strike was a potential disaster for the ARV programme. Every day without ARV medication meant increasing HIV resistance and eventual medication failure. This in turn would lead to disease progression and the catastrophic effects of drug resistant virus spreading throughout the community. Somehow we managed to negotiate with the strikers for patients to collect their ARV medication remotely without actually entering the hospital premises. This way the strikers would not lose face and the patients would continue to receive their drugs. During the two week strike around 200 patients a day were managed in this way. There was no possibility of examining patients or checking CD4 counts or viral loads for efficacy but at least this way patients could continue their medication without the threat of drug resistance until the strike was over.

Taking the experience home

After three years in South Africa I decided to return to the UK not only to be nearer my friends and family but also to see whether there was a way in which I could use the expertise I had gained abroad in my work in London. The hopelessness which preceded my journey to Africa has become a distant memory. In my final year I was lucky enough to meet my partner Ben and we have now been married for almost six months! Life is good and the future looks bright. Would I go back? Yes! Would I recommend it to someone considering a career break? Absolutely!

For more information visit: http://www.ahp.org.za/

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