PERIPHERALIA

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In his book Equanimitas, written in 1904, Sir William Osler 
laments that very few doctors go into public life to help 
advise and manage the delivery of health care.  “As a rule,” he 
says “doctors make bad citizens taking little or no interest in 
civic, state or national politics”.  Most of us do not like leaving 
the comfort zone of clinical medicine and entering the more 
robust arena of medical politics. 

We teach students how to use an asthma inhaler so that the 
lung functions stay normal and explain the management of 
diabetes to achieve normal blood glucose levels. We then 
pack up our bags and go home – job done. There is little space 
in the curriculum to discuss with students the wider issues 
about the real world outside the hospital and clinic walls. 

What can a health worker do to speak out? There are now 
various frameworks for helping to set up equity-driven 
policies and patient advocacy (Voice). There are also systems 
for enabling health care workers to act as agents for change 
that are now being included in medical school curricula as 
well as by the HPCSA (Advocacy for Health). The problem 
is getting through the firewalls and reinforced concrete 
ceilings of the Departments of Health and then upwards to 
the big birds on the upper floor.  

I have now devised a module to be included in the curriculum 
and then a question paper for the final MB examination. 
It is in my new discipline which is called Strategies for the 
Management of Health Care Services, and I have seven 
magnificently subversive questions on the exam paper: 

1.  You are working in a suburban clinic.  You have a patient 
with asthma who is well controlled with a Budesonide 
inhaler, which is the only steroid inhaler on code. Your staff 
nurse informs you that due to supply chain management 
failure they will not be able to supply Budesonide for the 
next three months. After you have calmed down from 
an incandescent rage to a controlled fury, explain your 
further management of this patient and give suggestions 
for additional strategic management systems that could 
be introduced.

2.  You raise this supply management problem with your 
immediate supervisor who informs you that “there is 
very little that can be done about it” so you write to the 
Department of Health but receive no reply. Indicate the 
further actions that you could take in this matter as a 
South African citizen.

3.  It has been reported recently in the press that at Inkosi 
Albert Luthuli hospital, which is a specialist tertiary 
hospital, an operation has taken place to separate 
conjoined twins. The operation took 13 hours and 
involved 23 specialists and was done at great expense. 
Several streets away from the hospital are shack dwellings 
with raw sewerage flowing past the shacks. Malnourished 

children from this area are dying from gastroenteritis. 
Discuss the concept of distributive justice as it applies to 
these two situations.

4.  It is said that there are now about 1500 guidelines 
worldwide for the management of the different diseases 
and conditions of the 21st century. Common ones are 
guidelines for the management of hypertension, diabetes 
and asthma. Statistics SA released figures that show 
that about 13 million of our people are living in extreme 
poverty (that is extreme poverty not just poverty). About 
20–30% of our population does not have full access to 
health care and 10–20% cannot afford the bus fare to 
their local clinic. It has been proposed that an addendum 
is added to clinical guidelines in South Africa to the effect 
that the guidelines only apply to those who have access 
to health care. Discuss the reasons for adding or omitting 
this proposal.

5.  It has been suggested that those hospitals/departments/
clinics that are functioning at substandard levels of care 
display a visible notice outside their facility:

THIS HOSPITAL/DEPARTMENT/CLINIC DOES NOT MEET
THE MINIMUM STANDARDS OF MEDICAL CARE.

This would be similar to the notice in the car park  
that states: 

CARS ARE PARKED AT YOUR OWN RISK.

Discuss the advantages and disadvantages of such notices.

6. The population of South Africa is about 55 million and 
it is projected to increase to 75 million in the next few 
decades. This will cause enormous demand on hospitals, 
clinics and health services. The total budget for health 
services is approximately 188 billion rand, of which less 
than 0.5% is spent on family planning. You would like to 
request that this is increased to 1%.  Give your reasons for 
your request and also the reasons why your request will 
be declined. 

7. Climate scientists warn that it is unlikely that we will reach 
the end of our current century with a habitable planet. 
Discuss.

The first 5 questions are minor details but the last 2 questions 
are the greatest challenges we face in the 21st century.

In fact I am going to make the seventh question compulsory 
for all university students, for all final Bachelor degrees exams 
for all faculties in every university in the world.  The question 
would have to be passed to graduate. 

So question eight is: Would this proposal save the planet?

Chris Ellis is a family physician in Pietermaritzburg, 
KwaZulu-Natal

E mail: cristobalellis@gmail.com

 The Patient who cannot afford the bus 
fare to the clinic