My friends and I have this joke among ourselves. We say that medical school is like slavery. But then we say, it’s actually WORSE than slavery, because we PAY to work ridiculous hours in ridiculous conditions. As you can see it’s kind of more of a tragedy, but we’ve chosen to make it a joke. For our sanity’s sake.
So in light of that you might be surprised to find that my overwhelming feeling towards the Miguel Desroches case is not a good one.
Here’s a quick rundown of Community Service Years (also known as ComServe or Zuma Years*):
All South African healthcare practitioners have to complete a compulsory year of community service in a public, usually rural, setting. Allied healthcare workers do this year straight after graduation, pharmacists after first completing a year of internship, and doctors after completing two years of internship.
If they do not complete said year, they will not be recognised by the HPCSA, and cannot practice in South Africa.
Here is a disclaimer: I don’t know this doctor. Some of my colleagues know and have worked with him, and say that he is a real swell guy, with really good arguments. At any rate, those good points do not come across in the article above, mostly because it vilifies the parties involved to excess.
First: Working Conditions
This is the part where I think Desroches has a good point, albeit an incorrect approach.
Truth: junior doctors do work way too much unpaid overtime. There is really good article explaining that here. That is one of the things I look forward to least: because I know how hard it is to put one’s foot down and refuse to work unpaid overtime. As the most junior doctor at an institution, it’s pretty impossible to put your foot down about ANYTHING.
But firstly, that case belongs in the Labour Court. Not in the Constitutional Court (at least, not yet).
And even before it goes to the Labour Court, there needs to be proof that due process has been followed to air grievances – that the correct channels were followed, and that they failed. You can’t just take an employer to court before following the internal procedure in an attempt to resolve the problem! Now that would be wasting tax payers’ money.
JUDASA (Junior Doctors’ Association of South Africa) is supposed to speak for all young doctors. I’m pretty disappointed that they are not taking this to Labour Court, instead of this one doctor, who seems to think he should speak for the profession.
I don’t blame him for wanting to speak for us. I know what it’s like getting annoyed because NOBODY’S DOING ANYTHING about a situation! I just can’t help thinking that there should be a way of involving us, and making it a group thing.
As for JUDASA not doing anything: it IS an association run mostly by junior doctors. The association doesn’t have too much clout when you plot it against a Head of Department or some famous professor.
Second: Community Service being Unethical
As for ComServe, Desroches seems to make a good point about the justifiability and humanity of a forced community service. The earlier article, by Erasmus, also has a good explanation of forced labour by the International Labour Organisation.
Essentially, for labour to be forced, it must be coerced and involuntary. The coercion in this case is that doctors may NOT practice in South Africa if they do not complete the year. The involuntariness comes down to the fact that by far the majority of placement sites are in rural and under-resourced hospitals, and are really not a pleasure for young doctors to work in.
I’ll skip over the obvious, “But you KNEW this when you decided to study medicine!” because that’s pretty flawed even though it is kind of true.
Here is why I don’t think that the compulsory Community Service year is unconstitutional or unethical:
Medicine and Health Sciences are HEAVILY subsidised by the South African government. Our class was once told that, if not for subsidies, our tuition fees would be double what they are. And what they are is ALREADY a lot of money.
Internship is our chance to learn more. It is essentially part of your studies, but at least a paid part (finally). Community Service is also salaried, but now that we are “more experienced”, this is our turn to give back. To return the favour for the heavy subsidies that were paid for our studies.
Is it really fair to have all those resources poured into your qualification, and then by the end of it, you just up and leave to private sector or worse, abroad? It means the country ultimately loses out. I can see the attraction in those options, I really can, but maybe you owe the country just a little bit before taking to the hills.
It is true that the reason ComServes are required is because public health is in a shambles and nobody wants to work at the rural sites, despite rural allowances. So it’s true that this is a bit of a forceful solution to the problem, and that the Department of Health really should be finding a more sustainable solution (because maybe after a year of being the only doctor at a deeply rural site, you would never ever ever want to go back into rural medicine, even if as a student you were interested in it).
So, frankly, I don’t see ComServe being declared as unconstitutional anytime soon. And, frankly, I don’t WANT it to be. I’ve just been to a deeply rural hospital, and it’s one of the better ones, and it was HARD. I know ComServe is going to be hard. But I also know it is going to be a year of intensive learning. And I want to serve my country, for the taxpayers’ money that went into my studies. (Read this article by a doctor about why she is grateful for her ComServe. Guys, that piece makes me excited!)
The only possible solution I see to this, is that allowance will be made for doctors who refuse to do community service, to pay their studies in FULL – i.e. not be subsidised by the government in any way. I’m sure there is a small handful of people willing to do that. I’m not sure what their career prospects will look like, though, because I suspect that prospective employers would like their doctors to have that year of intensive experience.
Third: “Unfair” Placements
This part is hard. It’s also the part about the article that annoyed me most because it sounds really bitter, and maybe Desroches isn’t even bitter. Journalism has its own biases. Anyways. We all want to be placed at the “nicer” hospitals. We all want to be near our families and near the nice big cities. The fact of the matter is, some places are way more popular than others. If you WILL apply ONLY to sites in the Western Cape, there is a pretty good chance that you won’t get any of them, and that the government will place you in a place of their own choosing.
That is why most students know that you should be aware of nice places outside of your preferred city, and apply to at least one of those. It is a method I plan to use when I apply this year.
I’ve had quite some interaction with people involved with placements of junior doctors (mostly because I’m good at networking and getting involved in places). And this I know: placement officials try REALLY hard to place junior doctors somewhere that is good for them. They try especially hard not to uproot people who are married with children. And then they look at other factors too. But sometimes, especially with super-popular places like Cape Town, they just can’t give everyone their first or second or third choice.
And that’s reality. It’s a reality I have to deal with too. And it’s probably a reality I will want to kick and scream and cry against if I don’t get MY preferred placement.
But what do you do? Surely we cannot expect every single person who requests a Cape Town placement to get it, while rural sites go severely understaffed?
I don’t know guys. It’s hard, right?
1. Desroches is really brave to challenge the system. I can say that I am impressed by that, because so many medical students and junior doctors just ACCEPT unfairness, and sit back and complain without DOING anything.
2. His complaints about working conditions are valid, but that case should be formally logged with the Department of Health and if unresolved, go to the Labour Court – then taken from there. If you are a South African lawyer or otherwise well-versed in Law and don’t agree with my assessment, I really would value your feedback.
3. I strongly disagree with Delroche’s take on Community Service. However, I hope that he will speak at my campus soon, and that I can hear his argument from him, rather than through the pen of a journalist.
4. I welcome any feedback and criticism – constructive, and keep it clean, please. Disagreement is welcomed.
1. “Doctor Challenges HPCSA ‘Slavery'”, Angelique Serrao, The Star, 30 January 2014, http://www.iol.co.za/news/crime-courts/doctor-challenges-hpcsa-slavery-1.1639369#.UuvcdRC1ZcQ
2. Slaves of the State – Medical Internship and Community Service in South Africa, Nicolette Erasmus, The South African Medical Journal, Vol 102 No 8 (2012), http://www.samj.org.za/index.php/samj/article/view/5987/4343
3. “I’ll always be grateful for my Zuma Year”, Karen Milford, 31 January 2014, https://medium.com/p/8013b9a8b060
*Named after Nkosazana Dlamini-Zuma, Minister of Health at the time of implementation, and not, according to popular belief, after President Jacob Zuma.