Ukwanda, the isiXhosa word for "grow," encapsulates the mission of Stellenbosch University's Ukwanda Centre for Rural Health: nurturing healthcare in rural communities. At the centre's annual community partnership event in Worcester, Spotlight discovered how future healthcare professionals are stepping up to address the unique challenges of rural populations.
It's a warm spring day in Worcester, roughly one and a half hours north of Cape Town. There's a vibrant atmosphere as the large auditorium at Stellenbosch University's satellite campus in the town fills up with students studying medicine, dietetics, occupational therapy, physiotherapy, and speech-language and hearing therapy.
The Ukwanda Centre for Rural Health (CRH), set up by the university more than 20 years ago, is hosting its annual community partnership event - and students are showcasing the healthcare projects they've been working on.
In one presentation, two final-year medical students share a troubling discovery from the past year at Caledon Hospital. Muhammad Gaffoor and Naaila Khan found a high number of undiagnosed diabetes cases in the Theewaterskloof area of the Western Cape's Overberg region. Some of these patients had already developed severe complications, including amputations, cardiovascular events, and Diabetic Ketoacidosis (DKA) -- a serious condition caused by a dangerous build-up of ketones in the body.
"What's concerning is that, for a significant number of patients, this was their index (first) presentation as diabetics - and currently, there are limited resources to do screening," says Khan.
Theewaterskloof, home to 140 000 people, is the most populous area in the Overberg district, accounting for nearly 40% of the district's population. Khan and Gaffoor estimate that only 34% of people with diabetes in the subdistrict have been diagnosed.
In another presentation, a team of fourth-year medical students share their experience working in Zwelethemba, an informal settlement near Worcester with alarmingly high TB rates. They worked with the Empilisweni Clinic to enhance TB contact tracing and symptom screening by helping implement a new screening tool.
KILLER DISEASE | For a disease that we can cure, #TB still claims far, far too many lives in South Africa and still makes far too many people sick.
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The students explain that, through surveys and interviews with NGOs and healthcare workers, they identified substance abuse and food insecurity as major barriers to treatment adherence. To address this, they secured funding from local businesses to support a local NPO's meal programme for people with chronic conditions. They also ran campaigns to encourage patients in the area to stay on their TB treatment.
"Right from the start, we identified areas needing improvement in the community's existing contact tracing and screening efforts. We believe that, through meaningful collaborations with community-based workers in TB, we've helped to make significant improvements," says student Jeeyoo Kim. "We've now handed the project over back to the community."
Training for rural healthcare
The students presenting their work in Worcester are just the latest in a long line of young healthcare workers who have received specialised rural health training. After the University established the Ukwanda Centre in 2002, the centre launched South Africa's first Rural Clinical School in Worcester in 2011. An initial focus on medical students was later expanded to include other healthcare workers. Today, students in the programme are trained in a range of rural regional hospitals and clinics in the Western Cape and Northern Cape.
"Instead of doing their clinical rotations in Tygerberg Hospital - where they've traditionally done their final year - they have the option of doing it in rural locations where they are exposed to rural training, with the hope that they will return to rural environments," Dr Francois Coetzee tells Spotlight.
Coetzee is the Acting Head of the Division for Rural Health at the University of Stellenbosch.
"The needs in rural environments vary across towns as well as provinces but one thing that is universal is that there's a shortage of healthcare practitioners in most rural environments and this is not only doctors but also health sciences practitioners", he says. But since people living in rural environments don't have the same level of access to care, it will take more than merely deploying more healthcare workers to improve rural health, he adds.
'Blessed are the flexible for they shall not break'
Coetzee says healthcare workers in rural environments require unique skills.
"Typically, healthcare teams in rural environments are small and closely knit, and everyone is dependent on one another. This means the physiotherapist is supporting the doctor and the doctor is helping the occupational therapist, for example. There is assistance across disciplines - and relationships are key. As a person, you have to be able to work in a team.
"Secondly, it's vital to have an appetite for learning - learning new skills and learning about new people and cultures. Together with that, is that clinicians often end up in a space where they are called to be involved in the care of a patient that requires a higher level of skill than they are comfortable with in terms of their scope of practise or experience.
"So you need to be reasonably comfortable with being out of your comfort zone so that you are sometimes called to step up your game and do something you haven't done before and to do it with minimal supervision and minimal support and sometimes be guided over the telephone.
"Another key aspect is that clinicians working in rural environments need to be able to problem solve and adjust as often the resources are not the same as in urban environments - equipment might be lacking or it might be broken - or just not available and then you need to problem solve or think creatively or find alternatives and those that are champions of rural health, typically are excellent at this.
"I learnt a saying which goes: 'blessed are the flexible for they shall not break' and that's definitely true for those working in rural environments," he says.
Looking ahead, Coetzee hopes that by 2027, nearly 150 of the university's 300 annual medical students will participate in the rural training programme. "We see this as a big step towards addressing a real need," he says, adding: "In 2011, we placed six students in rural settings. Now, we place 40 out of 300 students in rural locations, so the numbers are growing."
Farm clinics
Meanwhile, back in the presentation hall in Worcester, post-graduate student in rural health Dr Frikkie Strauss, who works as a general practitioner, is presenting a proposal for farm clinics in the Clanwilliam area. His work is an example of a project that has gone beyond training and seems set to help boost healthcare services in one rural area.
"A system diagnosis showed that our local town PHC (primary healthcare) clinic is totally overloaded due to a huge influx of migrant workers that settled in informal settlements in the town. Analyzing the numbers revealed that about 20 - 25% of patients attending the clinic come from farms in the vast area surrounding Clanwilliam," says Strauss.
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"It's often difficult for farmworkers to reach town because of damaged roads, so they don't often come to the clinic. Sometimes, if they come to the clinic, they are told it is full and they must come the next day," he explains. Added to this, although the area is served by a mobile clinic every six weeks, Strauss says sometimes the vehicle for this service is not available, or the roads are inaccessible, or there are staff shortages.
Thus the idea to create six farm health clinics was borne. Strauss says it could reduce the number of patients accessing the Clanwilliam primary healthcare clinic by 20% and "hopefully reduce congestion at the clinic and reduce clinic overflow".
Speaking to Spotlight a few weeks after his presentation, Strauss says the provincial health department bought into the idea immediately and are on board with implementation and ongoing running of the project. "The department's existing mobile clinic system, which normally visited a farm every six weeks, has adjusted its programme to visit these farm clinics - so that the rotation will eventually be less than two weeks," he says.
"We are busy getting the system in place. At the moment, the staff on the mobile clinics are telling the people on the farms, 'we will be on this farm, on this date, and your slot is between one and two o'clock,' for instance. It means we don't waste farmers' and farmworkers' time and money; and they don't waste a whole day. This whole system is much better all round - and can only improve," he says.
Ultimately, he says the service will mean "a more dignified service", adding: "It will be less costly for both patients and the Department of Health, there will be better compliance, it will be more convenient for patients, and there will be less pressure on the town clinic with better services to the town population."
