AIDS overload in a mining town
The impact of HIV/AIDS on Rustenburg Provincial Hospital has been enormous. Well over half of all patients display the symptoms of AIDS while two-thirds of those tested for the virus last year were HIV positive.
Patients in wards and at out-patients are visibly sick. Emaciated people walk around the hospital. Subdued coughs come from skinny bodies underneath the covers in the wards.
Situated in the heart of North West mining territory, the 352-bed hospital is almost always full to capacity, admitting over 2 000 patients and treating over 8 300 outpatients every month.
Tuberculosis and pneumonia, both closely associated with HIV, are the most common sicknesses.
Catherine Monamodi, sister in charge of the 30-bed female medical ward, says there are always patients waiting for beds.
‘Once a patient is discharged or is transferred, already that bed has a patient,’ says Monamodi.
She concedes that some patients may be discharged too early as a result of the pressure, but adds that the establishment of a ‘step-down’ ward that offers a lower level of care has helped to take patients that are better but not yet fit to go home.
‘You know, because of this mine, because of the HIV, most of our patients are very sick,’ says Monamodi.
Her biggest challenge is a shortage of staff.
‘In a medical ward, patients will be very sick. You have to turn this patient. You have to feed that patient. You have to help that patient to the bath or to the toilet, such basic things. We need nurses who can render that.
‘But in the afternoon, it will be two assistant nurses, one enrolled nurse and one professional nurse with 30 very sick patients who need total basic care.’
But there is a moratorium on new posts because of R10-million over-expenditure, admits CEO Mampeta Bolokoe.
The over-expenditure relates mostly to posts that were initially covered by a conditional grant but are no longer covered and to employing doctors who had worked at the hospital and wanted to be retained, she says.
‘We have not been able to attract doctors for a long time, and for the first time there were doctors who wanted to be retained. So, when medical doctors became available we then had to create extra 10 posts for doctors.’
But despite the shortages, says Monamodi, staff were much more demoralised before Bolokoe was appointed two and a half years ago.
A former nurse, Bolokoe treats health workers with respect and introduced renovations such as painting the wards, says Monamodi.
‘You know, as nurses we spend most of our time in this setting. You’ll be working from 7am to 7 in the evening. So, it’s very important for us to be happy where we are.’
The hospital was the first site in the region to offer antiretroviral treatment in April 2004. It is now monitoring over 6 000 HIV positive patients, 3 300 of whom are on ARV medication.
Just after 10am, there are about 50 patients in the waiting area of the Wellness Clinic. Most of them speak in subdued tones, while others are glued to the television sets.
Like the rest of the hospital, the HIV/AIDS programme is understaffed. It has three doctors, four registered nurses (one of whom is on temporary disability) and three enrolled nurses.
‘We are aware that the vacancy rate (in the Wellness Clinic) is about 50%,’ says Bolokoe. ‘We think the team is performing very well with so little largely because they love what they’re doing.’
The programme offers HIV counselling, treatment readiness training, and ARVs. It also has prevention of mother to child HIV transmission services, and nutritional training.
It offers ARV drugs to rape survivors and support services for patients with TB and other opportunistic infections.
Sister Rebecca Diphoko, assistant director of the comprehensive AIDS programme says about 60 new patients come to the clinic every day.
‘Patients who are stable that have been on treatment for six months and above, and that can supervise themselves in terms of taking the treatment, we are down-referring to the clinics. The clinics supervise and monitor them for six months so that we can get a relief. They come back to us after six months for review.
‘The down referral is a major achievement for us. We’ve started it two months ago, but we’ve already referred 220 patients to the clinics. We are already seeing its fruit right now because by 7 o’clock, the clinic is already full but at least now we can breathe.’
Budgetary constraints are a problem as the programme only has money for salaries, not equipment or training.
Despite the challenges, Diphoko is positive: ‘We’ve managed to keep the morale of the staff high irrespective of the given situation. They don’t absent themselves often unless it’s a serious condition.’
Morale is boosted by the patients themselves.
‘On a daily basis you hear a patients saying: ‘You know, I was dying. I was bed-ridden. My muscles were wasted, but look at me right now. I’ve improved. I can walk. I can do whatever for myself. I’m back to work’. That encourages you to come to work. At least you are saving a life on a daily basis.’
While the programme is going well, it has put a heavy burden on the pharmacy department which has to dispense the ARVs.
‘We are experiencing larger and larger numbers of patients due to the HIV programme,’ says Wilheminah Lekganyane, the pharmacy manager.
‘We are now starting to refer down to clinics which are nearer the patients’ homes, but it’s still a burden on the hospital. We don’t have a district hospital around here. So, Rustenburg Provincial Hospital is serving as a referral hospital and also, as a district hospital. So, all the patients that are not going to the clinics are actually coming here.’
Pharmacy stock controller Farana Cassiem says the pharmacy dispenses to some 350 outpatients alone every day, and the four or five pharmacists on duty every day dish out about 2 500 to 3 000 items.
‘The pharmacy is closed officially at 4pm but at outpatients department if there are patients waiting there we wait until we dispense medication to all the patients before we close the doors. And it can be up to 8pm,’ says Cassiem.
The outpatients department is also under pressure, with seven professional nurses and one enrolled nurse who has been booked off work for three months, and four nursing assistants, to see to around 350 patients a day.
Patients start queuing up at 5am for doors that will open only at 7am.
Sister Hessie Behrend, unit manager for Out-Patients Department, describes the staffing situation as ‘a bit of a nightmare’.
Six nurses have been transferred or resigned in the past few months, yet the OPD offers 17 specialist services as well as dealing with general medical patients.
‘We only have one nurse to (each) specific service that we are rendering here,’ says Behrend. ‘Like, today, we’ve got Poly Clinic. Poly means we see all conditions that have not been sorted out properly. In that clinic we’ve got four doctors. We normally allocate one nurse to work with those four doctors, including having to take the patient’s vital signs, before they go and see the doctors.
‘We’ve also got the surgical out-patients. We normally have about six doctors there. We still have to allocate one nurse to help all those six doctors.
‘We’ve got the medical out-patients where we treat hypertensives, diabetes, asthma. In that clinic we have to have two nurses. One will be helping the doctors and one will be taking the vital signs as well as having to keep a record of the patients that come here.’
Behrend says she has written to management to explain that the department is under strain and is waiting for them to respond.
She needs another eight nurses and five assistant nurses to run a proper service.
While Bolokoe concedes that outpatients is ‘under pressure in terms of the growing population’, she believes that better organisation and the employment of assistants to take over clerical work could alleviate this.
‘I can tell you that Friday, for example, does not have patients,’ she says.
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