This is Part Five of a five-part series on health care in South Africa's Eastern Cape province
Continue to Parts: 1 / 2 / 3 / 4 / 5
For almost two decades, Theodora Motlhabane sold fruit from a tiny tumbledown table near the entrance of Zithulele Hospital in Oliver Tambo District in South Africa's Eastern Cape province.
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She never went to school. She couldn't read and write. She never earned much. But the little money she scraped together selling apples, bananas and oranges – sometimes in driving icy rain, scorching heat and pounding wind - helped to put her last born son, Thembinkosi, through high school.
And it kept Theodora's dream alive – that one day, he would also wear a white coat, a stethoscope and a hospital ID card, just like the doctors she saw every day at Zithulele ... That one day her clever little boy, who had shown such great potential at school, would ensure that the Motlhabane family lived in a proper house and not a mud hut. And that they'd have running water from taps to drink and to wash with instead of dirty stream water, and toilets instead of buckets. And that they'd be able to afford meat every so often, instead of the thin porridge they ate almost every night.
But, when Thembinkosi Motlhabane (33) strode through the gates of Zithulele Hospital on a hot January day last year, as a qualified medical doctor, it was past the ghost of his beloved mother.
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"All her hopes have come true, but she never lived to see it happen," he told VOA.
Like many other people in the isolated district, where infectious diseases are rampant but access to healthcare is severely limited, Motlhabane's mother died young … In 1996, when she was 51, when he was a teenager in high school, her weather beaten skin wrinkled to a degree far beyond its age.
Motlhabane said his mother was the "special reason" why he chose to work at Zithulele Hospital.
"I used to hear about it because my mother used to sell fruits at the gates of this hospital when we were still growing up. So she used to talk about this place. For me to come and work here, it was just my curiosity to come and see the place where my mum was working," he commented.
He added, "The doctors here were always nice to my mother. When we were hungry at home, they would give her food for us. I thought I would come back here to give something back to them…"
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From Xhosa to Spanish
In 2000, after achieving excellent results in mathematics and science in his final year of high school, the South African government gave Motlhabane a bursary to study medicine in Cuba.
Its public health system is internationally respected, while South Africa's is maligned as one of the worst in the developing world.
Motlhabane's journey to fulfill his mother's vision began at Villa Clara University in the Latin American country's central Sancti Spiritus province. He described his initial time in Cuba as "confusing" and a "big shock."
He laughed while recalling, "When I sat in that lecture hall for the first time and the professor started speaking in Spanish, welcoming the new students, I could not understand a single thing. I had a big lump in my throat."
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The young Xhosa man who had previously never left his home province spent his first four months in Cuba learning rudimentary Spanish "all day, every day." It was tough, and Motlhabane made slow progress. He acknowledged, "Really, in the beginning, I felt like giving up and I was depressed and often would think, 'How can I ever be a doctor if I can't even learn basic Spanish?'"
But, it was "sink or swim," said Motlhabane, and for the next eight months he diligently learned Spanish medical terms, before beginning medical school proper in 2001.
His lectures and textbooks were "one hundred percent" in Spanish, he said. "To study subjects like physiology and anatomy in Spanish, when some of us didn't even know these terms in our home languages, was very interesting!"
He acknowledged that he and his fellow South African students failed some tests in the beginning, "mainly because of the language problem. But as time went on, we started passing like everyone else."
The Cuban example
Motlhabane spent almost a decade in Cuba, which has given him in-depth knowledge about health in the country. He's adamant that South Africa and other African nations can learn a lot about how to operate a successful public health sector from the Latin Americans.
The basis of Cuba's healthcare system is enshrined in the country's constitution. The relevant section reads, "Everyone has the right to health protection and care. The state guarantees this right by providing free medical and hospital care by means of…policlinics, hospitals, preventative and specialized treatment centers; by providing free dental care…regular medical examinations, general vaccinations and other measures to prevent the outbreak of disease."
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Motlhabane described Cuba's health system as "really well planned" and highly organized. "Their system is based on what they call 'family medicine.' It is organized in a fashion (so) that there is a doctor who is assigned to look after a certain number of people, less than 200, in a certain area."
He said this allows Cuban doctors to know their patients intimately, and so they "very rarely miss problems" with them. "He records them; he knows who is sick and who is not sick. And he knows how many are born in that area in a period of time. So he sees them regularly, even if they are not sick."
Motlhabane elaborated, "Cuba's doctors also know everything about their patients' home lives, social problems; private problems. They keep meticulous records about every small detail that could have a negative influence on a particular patient's state of health, so that if a problem occurs, they are able to act from a point of great knowledge to help that patient."
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He said this intimacy between doctors and patients "simply doesn't exist" in South Africa's overburdened public healthcare system, where the doctor to patient ration can be as low as three doctors to 100,000 patients.
In contrast, Cuba's doctor to patient ratio is almost 60 doctors per 10,000 people.
Where South Africa fails
Motlhabane branded Cuba's state health field "very specialized," a factor he's convinced contributes greatly to the country's low disease death rate.
"They have many specialists in specific health fields, unlike here in South Africa where there's a great shortage of specialists," he emphasized. "So if you go to a hospital, you know you're going to be attended by a physician or by a surgeon – which does not happen here in our country because we don't have personnel."
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Motlhabane said an indication of the success of Cuba's health system is the country's very high life expectancy rate, with the average citizen living to almost 78 years of age. In South Africa, the average person can expect to live to only about 50 years of age.
Health experts have ascribed South Africa's poor performance in this regard to its high burden of disease – especially HIV, and the generally terrible state of its health sector.
Motlhabane maintained, "What can be learnt first from Cuba is very simple - that to have a good health system you must employ enough doctors. It's no good pouring billions into a health system when your doctors are leaving all the time for greener pastures, or when you aren't training enough doctors. In this scenario, you will be in constant crisis because doctors are the drivers of any health system."
He said public health in South Africa is failing largely because its education system is also "below standard," particularly with regard to the subjects of math and science.
"Most people fail these and so we aren't producing enough doctors. If we want an improved health system in this country, we have to prioritize education," Motlhabane insisted. "The authorities must make sure that South Africans are taught proper mathematics and science, by good teachers. Unfortunately much of the teaching at the moment is bad, which is why children aren't learning these subjects properly. They therefore do badly in exams and so drop out of mathematics and science. They aren't motivated. When this happens, we lose many potential doctors."
Challenges of disease and death
Reflecting on his work so far at Zithulele Hospital, Motlhabane said his greatest challenge has been trying to heal patients suffering from highly infectious diseases that he never saw or even learned about in Cuba.
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Laughing, he explained, "In Cuba as a doctor you mostly deal with chronic diseases like diabetes, hypertension, epilepsy and asthma. So I was really shocked when I returned to South Africa to see all the HIV and all the TB. I saw only one case of TB when I was in Cuba in all my years (there). I didn't have the chance to see any HIV patient there but when I came around here, it was just completely different."
Most of Motlhabane's patients are infected with HIV or TB – and often both.
"If you don't know TB around here, you are just like, 'you don't know anything,' because that is what you are going to see, every day. Same as with HIV – if you don't know it, your medicine is incomplete because that is what you are going to be facing almost every day around here," he said.
Consequently, dealing with a lot of death as a doctor in Oliver Tambo District has also been "beyond traumatic" for Motlhabane.
"When I first got here, I was really upset about all the people who die. Psychologically, I struggled. I still do. Children even die from diarrhea, because they don't get to us in time for us to heal them. Every day people die from TB and AIDS. In Cuba, if a patient dies, it's like headline news. Here in South Africa, death is so common it's the rule, not the exception," he commented.
But Motlhabane insisted he remains dedicated to rural public healthcare and serving people who are as poor as he once was. "It's good to bring health to them, because they can't afford to go to the cities. So it's quite nice to come and work here and you feel like you are doing something for someone. And when you have helped someone, then you feel good," he said.
Doctor exodus
But while Motlhabane maintained he wants to stay in rural public medicine for the rest of his career, most of his doctor compatriots don't feel the same way. Many continue to leave public health, lured by better working conditions and far higher salaries in South Africa's private sector, or in developed countries.
"This makes me feel so bad," said the young doctor, with a sigh. "It doesn't make sense to me why you will go to a place where you are not needed – because most of the countries where they go to are first world countries."
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He added, "Those countries don't have the problems that we have, like HIV and TB and so on, and they have too many doctors, not a great shortage like we have. I don't see the point as a doctor to help people who don't need help – unless money is your motivation and not actual healthcare…"
Motlhabane insisted that practicing medicine is a calling, and shouldn't be only about money. "It's true that there's not much money in practicing medicine in (South Africa's) public sector, and especially in the rural areas. But doctors still make a good living and added to that, they save many, many lives and ultimately make our country a better place," he said. "It saddens me that so few doctors are willing to make a sacrifices in order to make their country a better place."
But he also said the South African government should spend more on ensuring that doctors are attracted to, and remain, in the country's public healthcare system, and especially in its rural regions.
"They could increase allowances to work in the rural areas, and even increase salaries for rural health workers. A lot of…government officials, they're driving nice cars, they live in luxury places. So I believe that this country has got money (to do this). I went to Cuba which is a very poor country but they still have a good health system. So I think government can still do something (to improve healthcare)," he said.
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Haunted
On his way into work at Zithulele Hospital every day, Motlhabane never fails to stop and chat with the women who now sell fruit outside its gates, like his mother once did.
He always finds himself hoping that their sons and daughters, too, are educated and become professionals, so that they're able to rise out of poverty.
"I want to help people around here and to motivate especially the young people that education can make a difference. It doesn't matter where you come from; it doesn't matter what your background is - if you just have a dream and have a vision, then eventually you will fulfill it," he said. "It's very important in life to dream. My life started with my mother's dream for me to become a doctor. Then I started to believe in the same dream…"
And when he enters his surgery in the morning, and is about to see his first patient of the day, Motlhabane always says a quick prayer to his mother, to thank her for her faith in him.
"Throughout my studies, I never surrendered because I had that image of my mother sitting outside the hospital gates, trying to make money for me. Even now, when things disappoint me or when I think I am overworked and I feel that I am not doing enough for my patients, I think of my mother. And I think what a very fortunate person I am, when compared to the hard life she had."
Then he smiled, and softly said, "My mother haunts me … In a good way."
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