George Veliotes, M.D., has trained, practiced, taught and managed for 25 years in the world's largest inpatient facility, 3,205-bed Chris Hani Baragwanath Hospital in Johannesburg.
"Those of us who have been here for a long time say you either have to be mad, bad or religious to stay at Baragwanath," says Veliotes, who currently serves as one of the public hospital's eight administrators. The hospital borders the legendary township of Soweto, which was the site of some of South Africa's most memorable anti-apartheid rebellions.
Practicing medicine, providing care and overseeing operations are hectic, and sometimes overwhelming, tasks for the management team.
The massive 173-acre Baragwanath campus comprises nearly 100 buildings and employs 7,500 people. It was built in 1941 by the British, who needed a place to treat wounded soldiers during World War II. The hospital has the look and feel of a military facility, complete with one-story barracks and tunnel-like corridors connecting many of the buildings.
Instead of ailing soldiers, however, today's patients are the sick, injured and dying people of a nation undergoing radical social and political change.
Baragwanath is the main source of healthcare for an estimated 3 million people, many living in shanties and shacks, others trying to scratch out a middle-class life.
Resources are short -- the hospital operates with an annual budget of about $100 million -- while the list of medical challenges is immense. HIV, tuberculosis and hepatitis are rampant. Weekend nights find the noisy trauma center overtaxed with victims of violence, car accidents and substance abuse. Some 70 babies are born each day in the hospital, and a recent study showed about one of every five new mothers is HIV positive. If a newborn weighs less than 2.2 pounds, no extraordinary measures are taken to save the baby.
This "let nature take its course" approach is just one way in which the South African healthcare system deals with its finite resources. Ben van der Veen, a senior consultant to the hospital's intensive-care unit, calls it "a crisis-to-crisis" management style.
Most of the patients are crowded into wards with 31 to 65 beds each. Emergency room patients and their families appear to outnumber caregivers 10 to 1. Lighting is dim, but it's not difficult to spot places where paint is peeling off the walls. None of the patient areas are air-conditioned.
Theft of supplies and equipment is an ongoing problem. Even though two security forces patrol inside and outside the facility, hospital officials say cases of violence are on the rise.
Labor disputes also confront the facility's management.
"Most of our workers are unionized, and many of the labor leaders are militant," Veliotes says.
He admits that some of the labor unrest is due to job vacancies remaining unfilled, missing supplies, linen shortages, and other factors that affect efficiency and patient care.
Veliotes pines for a pain clinic, an expansion of the ICU and better research tools for the clinical staff. But he understands the economic reality of a new government struggling to succeed and a healthcare system teetering on the brink of overload.
To help ease the pain, Baragwanath officials pray for financial angels. So far, several U.S. firms and the Japanese government have answered their cries.
Minneapolis-based Medtronic helped fund a cardiovascular center, while New Brunswick, N.J.-based Johnson & Johnson bankrolled a state-of-the-art burn center. A contribution from West Point, Pa.-based Merck Sharp & Dohme Research Laboratories helped upgrade an admissions ward and build a new emergency laboratory. The Japanese government donated money for ultrasound equipment for the maternity unit.
Developing a continuum of care also would help ease the strain on Baragwanath and other public hospitals, says Neil Soderlund, a health economics professor at the University of Witwatersrand in Johannesburg.
"The public sector has virtually no long-term-care or step-down units for hospital patients," he says. "Home care is limited, with most of the activity involving AIDS patients."