South African medics fight rural 'call-up'

Students are outraged over government proposals to send them to the neediest areas for two years, reports Mary Braid

Just 14 weeks before graduation, and with lucrative private practice shimmering seductively into view, South Africa's trainee doctors have suffered a collective cardiac arrest.

The Interim National Medical Council has announced improvements in a medic's education - an extra two years' vocational training on top of the statutory six-year degree and one-year internship.

Student doctors are outraged. They have denounced the extra "training" - to be served not in state-of-the-art city hospitals, once reserved for whites, but in deprived rural communities and townships - as a sham.

Coming so soon after the notion of community service was floated and promptly thwarted, they insist it is the self-same compulsory call-up, unconvincingly disguised.

"It is conscription," said one angry final-year student. "The government is trying to solve a long-term problem with an instantaneous solution." The notion of "training" in rural hospitals, where conditions were appalling, was ludicrous. Clinics were grossly understaffed and lacking even basic drugs and equipment, he said. In most cases there would be no senior staff around to pass on any expertise, and no equipment with which to demonstrate.

His concerns are shared by Professor Graham Mitchell, vice-dean of the faculty of health sciences at Johannesburg's prestigious Witwatersrand University who believes the plan is senseless until a training infrastructure is in place. The government, he said, must improve hospital conditions to attract senior doctors before junior staff could be trained. Rather than compulsory service right after graduation, "you can hardly blame a junior doctor for going to a London hospital for six months to clear a pounds 6,000 loan".

This weekend, health ministers insisted the change was aimed at improving training and simply brought South Africa into line with countries such as Britain. But they admitted that the new proposal had a community-service spin-off.

Such is the crisis in South African healthcare that it needs every bit of help that can be engineered. Apartheid created obscene inequalities, with blacks dying for want of basic health facilities in the townships and rural areas, sometimes within sight of world-class hospitals capable of carrying out heart transplants but open only to whites. Hospitals such as the massive Baragwanath, which serves Soweto, remain woefully short of doctors. In Benoni hospital east of Johannesburg 45 doctors serve two million people, and the example is not extreme.

A few months ago, the government tried to ease the crisis by recruiting more than 100 doctors from Cuba, and another 300 are expected to arrive soon. But nationally there are 2,000 vacant posts, and the shortage is increasing as white doctors emigrate to escape crime and economic uncertainty.

This month the government introduced pay rises of 50 to 80 per cent for doctors in an effort to stem the flow abroad and into private practice, but staffing levels are just one headache. A recent government audit revealed that 8bn rand (pounds 1.1bn) would be required just to bring existing hospitals up to scratch.

With so much to tackle, junior doctors fear they are being unfairly singled out as the weakest target. Newly-qualified practitioners will apparently not be registered until they have undergone the extra training. Dr Kerrin Begg, chairman of the Junior Doctors' Association, says she has nothing against community service if it is clearly required from the start, rather than being sprung on graduates. Making service compulsory, she argues, will breed dangerous resentment.

Perhaps it takes a revolutionary consciousness to make the necessary sacrifice. While Kevin Pillay, president of Witwatersrand University's Medical Students' Council, claims the move will encourage South African doctors to go abroad, incoming Cuban recruits speak the old-fashioned language of vocation and international solidarity. They celebrate something many South Africans continue to ignore: that a political and social revolution - albeit negotiated - has taken place.

"I worked in Zambia for two years from 1988, and during that time I learnt about South Africa and its people's struggle against apartheid," said Dr George Curbello, a Cuban arrival. "I wished to be part of that struggle. Even when I went back home I never forgot about South Africa." He was delighted by the changes in 1994, and eager to serve when South Africa reached a governmental agreement with Cuba which allowed Cuban doctors to work here for three years.

Like Dr Curbello, Dr Maria Cordies left her family behind to come to South Africa. For both, that was the hardest part. But Dr Cordies says: "For me the medical profession is a calling. I can serve in any country where my services are needed."

The South African public seems to take a similar line. While some students insist their taxes are repayment enough for the public subsidy of their education, many ordinary people seem rather taken with moves to tether doctors who in the past have been keener to serve the communities of Montreal and London than those closer to home.

The idea is beginning to gain momentum; in the national debate now under way, no one is safe. Student architects, engineers, dentists - even arts and drama undergraduates - are being urged to put something back into the community. This call-up may yet prove more controversial than the old South Africa's compulsory military service.