8th ANNUAL CONFERENCE
Rural Health Team Towards Quality And Empowerment

Highlights from the 2004 RuDASA conference

Limpopo Province gave us a warm welcome - literally and figuratively! It was good to see the commitment from the provincial department of health to improve rural health services - the meeting was addressed by both the HOD, Dr Manzini, and the MEC, Mr Sekoati.

Dr Manzini started her speech with a story, which captured everyone's attention. The story was about a young rural woman who ended up in a wheelchair due to failures at different points in the health care system. She used the story to illustrate the challenges in rural areas - cultural practices that clash with human rights, long cues at clinics, staff who do not have time to listen to patients, health workers not working as a team, and community service doctors having to work unsupervised. She invited RuDASA to work with the government to improve the lives of rural people. "You are the foot soldiers without whom the battle against poverty will never be won."

The MEC focused on government policies intended to improve health care. He discussed community service, the scarce skills and rural allowances, the new agreement with the UK on a "Code of Practice on the Ethical Recruitment of Health Workers" as well as the recruitment of doctors from Iran. He emphasised that Government would like to engage in dialogue and collaboration with stakeholders such as RuDASA.

Other plenary speakers included the Secretary General of SAMA, Dr Moji Mogare, and Prof. Molehe, who discussed telemedicine. There was a major focus on HIV, with discussions on how to run an ARV clinic in a resource poor area. This is very different from the RuDASA conference in Queenstown in 2000, when Dr Costa Gazi told of his struggle to get access to Niverapine for pregnant women, and where most presentations on HIV focused on treating opportunistic infections. This time the presenters emphasised the importance of treating patients at community based facilities after the initial stabilisation of ARV treatment. There was very active participation from the audience where doctors from all over South Africa shared their experience of ARV treatment in rural areas.

With poverty being such a major problem in rural areas, it was encouraging to listen to John de Wit, who runs an NGO called "Small Enterprise Foundation". They largely work with impoverished women and assist them with small loans in order to start small businesses. Presently they have 23 000 clients and work largely in the Limpopo Province. The principle of their work with the poor is that they believe firmly that poor people are not unintelligent or lazy, but that they have no access to resources. With the necessary resources many of them have the potential to achieve success. It was really refreshing to hear what can be done and not only hear about all the problems we face working in rural areas where poverty is rife.

Fiona Nicolson told the story of how the Thohoyandou Victim Empowerment Centre was started, and how many women and children they treat following abuse. She said that they had learnt an important lesson in the process: you have to have all the stakeholders on board, but not on the board of the NGO! What had happened was that the police were represented on the board, but when the police did not investigate a case of child abuse properly, the representative found it difficult to confront his colleagues at the police station.

Dr Riana Bornman, from the Department of Urology, University of Pretoria, did a presentation that reflected on the challenges and opportunities of research in rural areas. She was part of a major MRC project on the effects of chemicals in the environment, such as DDT, on birth defects, specifically looking at urogenital defects. There is a concern about that in the area in Venda where the study was done (Vhembe district), since there is a relatively high incidence of these defects. Thus the dangers of chemicals in the environment in rural areas is significant. However, probably more significant was the extent to which she was enthused by the challenges of doing such research in rural areas; there was growth and learning through working together with people in the community and understanding the difficulties that people in these communities live under, and through the relationships that were developed between her and local colleagues and community members she worked with. Thus the research moved from a simple academic exercise to an enriching cultural and emotional experience.

Professor Steve Reid presented the research he has been doing on the impact of the new rural allowance on short-term career choices of health professionals. Although subjective responses and changing groups make it difficult to make definitive conclusions, it is clear, on the one hand, that finances are not the major reason for peoples' career choices and other factors are equally or more important; such as job satisfaction, career pathways, and study opportunities. On the other hand finances were considered important in the decision-making process by about 25% of respondents, and thus the rural allowances have the potential to have a major impact on staffing levels.

Dr Will Mapham from Madwaleni Hospital in the Eastern Cape (former Transkei area) spoke about his experience as a community service doctor. He gave an inspiring presentation of what he and his colleagues were doing to try to get the hospital running again. He was very positive about his community service and really thankful for the opportunity, which provided an encouraging perspective. As part of this, he has involved himself in exposing medical students at UCT and Stellenbosch to rural medicine through placement at this hospital. It was a really inspiring example of what a doctor with a positive attitude, commitment and energy can do to turn a situation around.

Dr Andrew Ross from the University of KwaZulu-Natal presented his research on why community service officers (CSOs) choose to remain in district hospitals in KwaZulu-Natal, Eastern Cape and Limpopo Province. Very few community service doctors do in fact remain after their community service year; only 16% of the community service doctors, dentists and pharmacists indicated that they were willing to remain in their hospitals. Of these, about half do in fact stay on. CSOs are more likely to stay if they are allocated in the Eastern Cape and Limpopo, if they are Black, and if they originally come from a rural area. According to the CSOs, community service provides excellent professional experience, good learning opportunities and personal development opportunities, but there are problems with lack of equipment, physical factors such as accommodation, social isolation and lack of support. There is a need for a comprehensive strategy to assist community service officers.

Dr Elizabeth Weiss, one of the few psychiatrists in Limpopo Province, discussed the psychiatric sequelae of taboo sex, and witchcraft and mental health. She made the audience aware of the fact that psychiatric illnesses precipitated by cultural beliefs is a widely described phenomenon. Termination of pregnancy is now a new cause of sexual taboo. The message of the discussion was that doctors should be aware of the influence of cultural background on patients. Transgression of any sexual taboo could cause anxiety and depression, and this will rather present in the general OPD than in psychiatric OPD. The discussion on witchcraft alerted the audience as to who many fall victim to such allegations. This is not uncommon and is a serious situation to be acted upon in a rural community. Marginalised people such as old and senile people frequently are at risk.

This was a truly rural conference, with local delicacies such as locusts and mopanie worms on the menu. Participants were also treated to traditional dancing at the dinner. Dr Ntodeni Ndwamato was elected as the new RuDASA Chairperson, with Dr Bernhard Gaede as vice-chair. Thanks to the organising committee for an excellent conference!