Why Madwaleni is one of the best jobs aroundWhy Madwaleni is one of the best jobs around

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Dr Richard Cooke, after 5 years at Madwaleni, will be moving on in January 2010 and Dr Tom Boyles, after 3 years, is intending to leave Madwaleni in mid 2010 , creating opportunities for two committed individuals to pick up the baton and build on the excellent work that has already been done at the rural hospital.

The hospital closest town in Elliotdale/Xora 30km away while Mthatha is 100km away and East London 220km. The spectacular Wild Coast is only 16km away.
Madwaleni has 180 beds in seven wards with an outpatients department and a best practice HIV wellness and antiretroviral unit. Two wards are medical and surgical adult patients, three are dedicated for adults with HIV/tuberculosis as well as a paediatric ward and maternity unit

“Those concerned that they may be bored outside of work time, living in the middle of nowhere, must know that every evening and weekend is filled with activities, social events and adventures,” said Lynne Wilkinson, who co-ordinated the HIV Wellness and ARV unit for 5 years.

The staffing including doctors and allied health professionals is also unlikely to become problematic going forward as there are a number of initiatives which ensure continued recruitment and replacement of those moving on.

These include:
* relationship with Liverpool school of tropical medicine where British doctors are encouraged to come and gain infectious disease experience. Currently five of the 10 doctors were recruited via this channel.
* relationship with African Health Placements to place foreign doctors at Madwaleni.
* site for family medicine students from Stellenbosch - after doing a month block at Madwaleni, many apply to come and do there community service here. 2 of the 3 that were allocated here for next year, were students here. In fact Madwaleni has a good name at UCT and Stellenbosch and the last 2 years has had more applications for comm service than posts.

Madwaleni also has increased its accommodation for professionals as the Donald Woods Foundation funded four units at the hospital and three in the community.

The HIV programme has tested just over 39 000 people in this area since 2005. The voluntary counselling and testing outreach service has grown with a permanent team comprising of a nurse and five VCT counsellors who set up testing stations in the community throughout the month including at the social welfare grant points on the days that grants are handed out to the community.

This has impacted on community stigma associated with testing and has again highlighted that in many cases it is access and not stigma that prevents people from testing for HIV.

The HIV wellness and ARV programme now has some 4 300 patients of whom about half require and have initiated anti-retroviral therapy.

This service is decentralised to seven peripheral clinics. More than 60% of the patients are managed at the clinics and they only visit Madwaleni once for ART initiation and are then seen at their clinics. The service which they receive at the clinics is fully supported by Madwaleni including the doctor led ARV outreach team.

Much work has gone into the improvement of the HIV and ARV management skills of the nurses at the clinic with a permanent nurse mentor who has been appointed on contract to work with the nurses daily. The nurses have also been given bursaries by the Donald Woods Foundation to complete the Fort Hare Diploma in HIV management. While the doctor led ARV outreach team still attends the ARV clinics at the clinics once a month, the clinics have now started nurse led ARV clinics where they see all the stable patients at their clinics.

Madwaleni has also raised funding to build three community counselling centres at Nkanya, Melitafa and Hobeni (see www.donaldwoodsfoundation.org), These are now used to run the HIV and orphans and vulnerable children (OVC) programmes. They are also used for other programmes at the clinics.

The hospital runs the weekly focused paediatric HIV wellness and ART clinic and a prevention of mother to child transmission (PMTCT) clinic.

Developments here are that:

· more than 50% of the children are also managed at the clinics. In addition, the programme is runnning a paediatric HIV wellness and ART clinic at the biggest clinic, Xora, once a month.

· dual PMTCT therapy is being provided by the clinics.

The health department is also examining the HIV model to see whether it could be replicated in other parts of the Eastern Cape.

Since 2007, Madwaleni has developed and received funding to support two new programmes that work on the same decentralised basis as the HIV programme.

The OVC programme now supports about 1 400 children through a community network of 180 OVC supporters.

The home based care programme has created supported beds in the community and mostly provides families with assistance for caring for palliative care patients and patients that require ongoing rehabilitation.

On the TB front the hospital has obtained funding from Aurum Institute for Health Research for development of the TB programme and TB/HIV integration. Amongst its initiatives in this regard, this has seen sputum collection rooms established at the hospital and clinics.

The rehabiliation department's services are growing and are being rendered from the clinics. The partnership with Malumalele Onward over the last two years has made an incredible difference to the lives of the children with cerebral palsy.

Academic links have been further developed with University of Stellenbosch Family Medicine Department (formal undergraduate training) and the University of Fort Hare (advanced training in HIV for nursing staff). Plans are at an advanced stage to establish Family Medicine post-graduate and mid-level health worker (Clinical Associate) training in conjunction with Walter Sisulu University Faculty of Health Sciences (Mthatha) in 2010.

Research links have also been formed between Madwaleni and the University of Cape Town (HIV research).

Associated training and mentorship links have been established in recent years with such organisations as Saving Mothers Saving Babies, the Foundation of Professional Development (SA), St Christopher’s Hospice (London, UK), Malamulele Outreach (Cerebral Palsy Outreach) and the Owen HIV Clinic at the University of San Diego, California, USA.

Madwaleni has been chosen as one of the new sites under the National health department Hospital Revitalisation programme, with planned allocation of resources under the categories of Organisation training and development, Quality Assurance, Health Technology and Infrastructure, starting in 2010.

For more information on Madwaleni hospital see www.madwaleni.org.

Health-e posed several questions to Cooke and Boyles>

Richard Cook:

1 – What qualities do you think you need to work in your situation as opposed to an urban situation?

An interest in understanding and working with traditional – in this case Xhosa – values and beliefs, a resilience in the face of difficult, isolated working conditions, a realisation that so much can be achieved if no-one is concerned as to who gets the credit, an open-mindedness to the benefits each different health care professional (docs, nurses, physios, OTs, all...) can help bring to the patient and ourselves in a team effort; an understanding of the benefits of task –shifting to counsellors and peer educators who are highly valued resources in their own right; possession of an adventurous spirit to take on the challenge!

2 – I would imagine you would describe your job as satisfying on many levels, why?

The chance to be involved in such a variety of clinical challenges!; the chance to initiate new health programmes at an isolated district hospital where the gains for patients and community are immeasurable in a poorly-resourced rural area; the chance for personal growth outside my comfort zone of privilege and city culture; the chance to learn to speak isiXhosa when ten years ago the thought was a pipe dream; the chance to teach medical students outside their worlds, to try and inspire them to come back later in their careers ; the chance to remember every day that the decision to study medicine at the age of 29 as the best decision I could have made; the chance to work in a beautiful Wild Coast setting where immersion after work and on weekends allows the line to be drawn so well between work and play; the chance to respond and appreciate genuine interest and support from health professionals locally and abroad who perceive we practice “real medicine” here at Madwaleni.

3 – Why are you leaving?

Madwaleni is a different hospital to the one I joined in early 2005. I have a sense that we have established a lot at this hospital, and it is now time to move on. I have been a key person in initating and guiding many different things here, but now much of the “new” that is planned has been initiated - and will be managed – by a broader government and NGO involvement. Quite heady times when it was only a couple of people with very few resources, but the growth and change has been welcomed during these five years. I learned a lot in evolving with those changes, but it’s now time to move on

I am also tired, I need a break and then to take on an energising challenge elsewhere.

Most of all however, I will graduate next week with my Masters in Family Medicine (from the University of Stellenbosch), and it is a good time to move on to where I can focus more on my first love – clinical medicine. The admin and management aspects of my job as a Managing Chief Medical Officer here have taught me a lot, but I need a new environment to work in my new role as a specialist in Family Medicine.

4 – If you have to give the “elevator pitch” to sell Madwaleni to another doctor, what would you say?

Come and be part of a great health team involved in an incredible range of clinical skills, protocols and programmes. Each member of that team – irrespective of seniority - has a say in the development and running of programmes that really make a difference in the lives of underprivileged people. And we get to do this in one of the most beautiful parts of the world on the Wild Coast. Believe it or not, you have the chance to be part/lead this team in providing some of the world’s finest health care in such a deeply rural, unforgiving environment, especially based on perceptions of those wonderful, under-privileged people you provide that help to.

5 – What are the top 3 misconceptions doctors have about working at a hospital such as Madwaleni?

That there is no support from the “outside”. Health professionals do NOT climb in a cupboard on arrival, only to re-emerge into the sunshine to join the real world some later time, those last months/years wasted. NO! This is in fact “where its happening”! The outside links are in place and getting stronger all the time, both clinical and academic

That there is no support from within! Everyone understands that teamwork is everything! Even the most hardened “go-it-aloners” eventually get it. And if the rest of us are working harder coz someone is away on a training course for example, we know the service will improve and each of us will get the chance for training at another time.

That these kind of hospitals are boring places where no fun is ever had! How many other deep rural hospitals can boast of big screen movie nights, poker nights, beach braai parties, talent shows, team trips to the Knysna Marathon/Comrades Marathon/Two Oceans marathon/Midmar Mile/ our own Wild Coast Marathon and a Madwaleni Extreme Facebook Page!!!!?

6 – How important is government support and do you have it at Madwaleni?

Government support is THE important!! Much of the change here in last five years has been around increasing government support. While government is conscious of standardising service delivery in many hospitals, Madwaleni has been encouraged to pilot certain initiatives and programmes, to then enable tested programmes to be rolled out elsewhere in the province. Everyone acknowledges the bureaucracy of government has been slow in these deep rural parts – with a new leadership approach and Madwaleni now part of a new district, this is now visibly changing.

7 – What is you overarching memory of Madwaleni?

There are so many. Its gonna take me years to reflect on everything. It may be the friendliness and warmth of the local Xhosa people. It can be the incredible storms and the sunsets. But the one glaring thing that both warms and frightens me – dependent on which direction I’m looking along the timeline - is that I doubt that I will be able to make such a difference in people lives again.

8 – What sets Madwaleni apart from other rural hospitals?

I just don’t know. anything? I am due to spend some time visiting other rural hospitals early next year in an effort to get an idea. Is it our teamwork? Is it that we are in that privileged place in time where there are improvements in capacity, support and intent when there is so much work still to be done - that will in turn yield so many benefits.

Tom Boyles:

1 – What qualities do you think you need to work in your situation as opposed to an urban situation?

Ability to work unsupervised and make decisions for yourself as there are far fewer Dr's per patient there is less time for group decisions. You need to be able to survive without home comforts at times and it helps if you enjoy beautiful countryside. Most of all you need to work hard and you need to listen to what people tell you because they ususally learnt it the hard way.

2 – I would imagine you would describe your job as satisfying on many levels, why?

On a professional level you are spreading yourself as thinly as possible which means you can impact on far more lives than you could do in an urban setting. You become very reliant on your clinical skills because of the lack of sophisticated and sometimes basic tests and so you feel much more self sufficient in your profession.

On a personnal level it sure beats telling someone at a dinner party that you are an accountant!

3 – Why are you leaving?

After 3 years I have learnt pretty much everything I am going to learn here. Although there is much more to acheive at Madwaleni there is still a lot for me to learn from more experienced doctors in larger hospitals so that is where I am headed for a while at least. There is also the long-term tirdness, when I started a full day clinic in the beginning I would look up at the clock for the first time and it would say 20 past 3, now it says 10 past 9!

4 – If you have to give the “elevator pitch” to sell Madwaleni to another doctor, what would you say?

Aren't you fed up of looking after priviledged people who don't look after themselves and still have unrealistic expectations of a health service. Wouldn't you rather look after people with no priviledges, who see value in you just taking an interest in their wellbeing and who, if you weren't there would probably not see anyone at all.

5 – What are the top 3 misconceptions doctors have about working at a hospital such as Madwaleni?

Very hard for me to say really. They might think it is dangerous or that it is an easy life or that you get bored during your time off. None of which is even vaguely true.

6 – How important is government support and do you have it at Madwaleni?

The only truely sustainable source of support is from government and so it is vital. We do have government support although things can take time to come through. We have donor support but this is to speed things up before government can take over rather than a permanent solution.

7 – What is you overarching memory of Madwaleni?

Wow- so many! The hard graft, the poker evenings, the new friends made, the in-jokes that seem to last forever. The patients that died despite all your efforts and some that didn't.

8 – What sets Madwaleni apart from other rural hospitals?

I wouldn't want to claim that it is different from other hospitals. There are lots of great things happening in rural hospitals in SA and although, there are aspects we are particularly happy with other hosptials would say the same.

Source: health-e News

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