BHEKISISA | The cost of caring: Zithulele’s Ben Gaunt, one year later

In 2022, after a decade of service, Ben Gaunt, who led a team who transformed Zithulele Hospital in the Eastern Cape from a struggling public health facility into a poster child of excellence, left the facility. The drama, which followed the appointment of a controversial CEO was well publicised. We spoke to Gaunt one year later.

When I spoke to Gaunt in late July it was exactly a year since he’d left his dream job — a forerunner to him, his wife Taryn and their children Joshua, Grace, Elijah and Abenathi departing the Wild Coast village of Zithulele under considerable duress.

Ben and Taryn had worked in Zithulele Hospital, about 100km from Mthatha, since 2005 (respectively as clinical manager and medical officer in charge of paediatrics), helping to transform it from an understaffed and somewhat dysfunctional 55-bed facility into a celebrated 150-bed hospital with a multidisciplinary clinical team of 40 people. 

In 2022, the hospital became mired in scandal and chaos and the Gaunts and several other senior Zithulele clinicians reluctantly left or resigned. The dramas were well publicised, and the sense you had as an armchair onlooker was of a precious island of functionality slipping into a sea of dysfunction. 

For many of the role players, including the Gaunts, this was a damaging, distressing time.

Speaking from their new home in Port Alfred, overlooking the Kowie River, Gaunt mentions how, in Xhosa bereavement culture, widows wear mourning clothes for a year and this is followed by the ritual taking off and burning of those clothes, often attended by the slaughter of a goat or sheep.

“A few things have happened in the past week or two that have led me to think it is time to burn the clothes, as it were — I can't be in a grieving, unforgiving posture forever, that's not healthy,” he said, adding he viewed the Bhekisisa-initiated interview as an opportunity “to start letting go”.

“Instead of dwelling on negativity and bad I would rather focus on the lessons Zithulele taught us and how these can be applied, not only in my own life, but more broadly, including in the public health system,” says Gaunt, who remains in the employ of the Eastern Cape health department, today as its clinical medicolegal adviser.

“God had told me my life work lay in rural medicine.”

For Gaunt’s testimony to make fullest sense, however, it is necessary to examine the recent past and his own journey in healthcare.

Gaunt was born in Zimbabwe, then Rhodesia, in 1975, and at the age of three moved with his parents and younger sister to Cape Town, where he enjoyed “a typical kind of middle-class white South African upbringing”. He attended Westerford High School in Newlands, where one of his friends was Karl le Roux, with whom Gaunt would one day work side by side at Zithulele Hospital.

“We played first team hockey together and had many conversations about how to save the world,” Gaunt says. 

“My parents, I suppose, were liberal white South Africans. They were not activists, but they've always been generous and open-handed in their engagement with society, and I think this posture rubbed off on me,” says Gaunt, who has an open, youthful face and a quick-draw smile. 

The church was a significant part of this upbringing. “My mother became one of few women to be ordained in the Presbyterian Church,” says Gaunt, who studied medicine at the University of Cape Town and in his second year met the woman he would marry, Taryn Brown, the daughter of church ministers from KwaZulu-Natal. 

In the same year he experienced a vision for his future — “a strong feeling that God had told me my life work lay in rural medicine”.

On a personal research trip he and Brown (they married in 1998) made to Bethesda Hospital in the Lebombo mountains in northern KwaZulu-Natal, Gaunt was struck that one of the doctors was able to return home at teatime and play cricket with his son in the garden: “I thought: that's quality of life.”

Gaunt would later experience this benefit of rural practice himself. “If I am gone from home for a whole day, my children are like, ‘Where have you been?’” 

Almost on cue, his daughter Grace, 17, enters the room to ask a question about baking ingredients. “Grace is the family baker. It’s Elijah’s birthday tomorrow, he’s turning 15,” says Gaunt, beaming, and Grace waves at the Zoom screen we’re communicating through. 

The family Gaunt is familiar from a memoir Gaunt published in 2020 called Hope, a Goat and a Hospital, an account of starting and growing a family in a deeply rural village in a former Bantustan while running and developing a hospital. 

The book has a place among the more compelling medical memoirs written by doctors who have practised on the continent, and I’m not surprised to learn he is a non-fiction nut, especially medical memoir (“I read fiction for the first time in 2021 when I contracted hepatitis A”, he says).

The helplessness of South Africa's HIV denialism

When Gaunt graduated in 1999, he was not yet aware that Zithulele existed. He interned at New Somerset Hospital, overlooking the V&A Waterfront in Cape Town, before moving with Taryn to Empangeni in northern KwaZulu-Natal where they both worked as junior doctors in Ngwelezana Hospital, “a sprawling complex with open passageways and cavernous, old Nightingale-style wards”.

“What I took away from there was probably five years or even 10 years’ clinical experience compressed into two. We used to do mad things simply because we had to, and we could pull it off because the one consultant and couple of senior medical officers that each department had were dedicated to their patients, and also to being there to support us juniors having a go,” says Gaunt, who tries to remember that lesson when working with junior doctors.

“You can swim in really deep water if you know that there is someone to save you if you start drowning.”

Like clinicians across the public service at the turn of the century, the Gaunts witnessed the ravages of an HIV epidemic about which he could do very little because the country’s then president (Thabo Mbeki) and his health minister (Manto Tshabalala-Msimang) did not believe HIV caused Aids and ensured patients across the country were denied access to life-saving treatment.

“In the paediatric ward there was only piped oxygen accessible against one wall and we called the line of cots ‘death row’. Often, we turned adults away because there was little point admitting them when we could do so little to help,” Gaunt recalls, and after a reflective pause says, “mostly I am not a ‘when we’ [according to the Dictionary of South African English, 'when we' is a derogatory term for one who speaks of any place or occasion with what is seen as excessive nostalgia]. 

“When we were welcoming young doctors to Zithulele years later,” says Gaunt, laughing at the unintended word play, “I would say, ‘there are no holy cows here, if there is a better way of doing something, let’s do it'.”

How Gaunt’s decade of service started at Zithulele

After Gaunt began to show signs of burnout at Ngwelezana, the couple decided to resign and take jobs in New Zealand. “We enjoyed ourselves and recovered thoroughly but remained convinced that our calling was to rural Africa,” he says. Upon returning to South Africa, he demonstrated the seriousness of his intent by taking a job in obstetrics in Empangeni, “an important piece in the puzzle of rural preparation. It makes for much of the after-hours work at a rural hospital”.

The couple planned to add experience in HIV medicine to their preparation, as antiretroviral treatment (ARVs) had finally become available, but found themselves quite suddenly in the rural Eastern Cape exploring an opportunity to work at Madwaleni Hospital. Ultimately, the authorities offered posts at Zithulele and the Gaunts accepted. When they first arrived in July 2005, they found a hospital beset by challenges.

In his memoir, Gaunt recalls how “the pharmacy was out of stock of many essential items and was run by untrained staff. Medical equipment, including essentials such as laryngoscopes, was either broken or missing, and the “high protein diet” from the kitchen consisted of plain bread and mielie pap. Services were run down and minimalist; many patients who should have been treatable at a district hospital had to be sent to the referral hospital in Mthatha.”

Righting some of these issues required an extraordinary personal investment. 

The Gaunts were frequently at the hospital for 36 hours at a time, and in one of their first new year periods, Gaunt was on call for seven nights out of eight — “on duty for 186 out of 201 hours”. 

In time, things would become less relentless. The arrival of doctor friends Karl and Sally le Roux in 2006 helped spread the load and in 2007 three new doctors doing community service, two pharmacists, two occupational therapists, a physiotherapist, social worker and a dentist joined the team. 

The hospital was developing what Gaunt calls a “sticky core — people who came and stuck”, enabling a shift from a survival mindset “to a mental space where it was possible to plan for the expansion and improvement of hospital services”.

The two most important questions to ask a patient 

Gaunt’s operational mantra was “a little bit better each day”, and it wasn’t long before the area’s healthcare picture began to look up. 

In 2005, 745 women gave birth in the hospital — within a decade this had risen to more than 2,000 births annually, reflecting increasing trust in their services. In the paediatric ward, in-hospital mortality decreased more than five-fold. A growing ARV programme meant people had stronger immune systems and were less susceptible to TB. Hospital services and the broader community were being supported by NGOs, including the Jabulani Rural Health Foundation founded by the Gaunts and Le Rouxs.

“I've often been asked, ‘What made the difference at Zithulele?’ The first answer I give is ‘commitment to our patients’, which went with a deep conviction that people living in rural areas deserve the same services as urban people. 

Far too often in the public sector there is a commitment to the pay cheque at the end of the month,” says Gaunt, adding “it’s easy to forget that going to hospital is a particularly big life event for patients, especially if there is something severely wrong, yet it can so easily be just another day at the office for healthcare workers who see a lot of sick and dying people. So it’s about finding the balance between being clinical and dispassionate, and really seeing the person in front of you.”

Gaunt believes there are two questions anyone who wants to understand a rural patient cannot fail to ask: “’Where do you live?” and “how did you get here today?”

He illustrates the importance of these questions in his memoir with the story of an old man he met in the surgical outpatient queue at Ngwelezana Hospital, who was late for his appointment, which was the previous day.

“He apologised profusely, explaining a swollen river had prevented him walking to where he caught the taxi to take him to his rural hospital, where he caught the midnight bus to arrive at Ngwelezana by 5am to get his folder and wait in my queue until 9am. 

“I was flabbergasted. And I made sure he had his surgery that day. Had I not listened to his story, I may have rebooked him, maybe even berated him for missing his date.”

The healing power of holding a stillborn baby

Gaunt is clearly a person of action. You can see it in his facial expressions and quick gestures, but he is also by default introspective and reflective, a man who, in his own words, is “very conscious that I wear rose-tinted glasses and it is just a question of what shade of rose-tinted glasses am I wearing at any particular time”. 

At Zithulele, he came to depend on people he refers to as “cultural bridges” to understand what was happening around him “because we were ignorant”. 

He and Taryn sought out people “who didn't treat us with suspicion or who weren't wearing their hurts on their sleeve, to engage with us and help us to slowly understand this deeply rural, traditional, political culture”.

He came to realise they were also cultural bridges — “most obviously bridges to a different way of understanding health but also, perhaps, to the idea that we can and ideally should be learning from each other and genuinely trying to see each other as individuals and not as stereotypes and categories”.

An illustrative example of this was the question of dealing with stillbirth.

“The prevailing practice among midwives in Zithulele was we don't hold the dead baby, and yet when we unpicked it a lot of people agreed holding the dead baby was probably commonplace around the world for a long time. 

“And we started to understand that the grieving process often requires that a woman who wants to, needs to hold their baby and actually bond with their dead baby. Specific cultures may have specific views on the matter, but each of us in our own culture is an individual with individual needs,” says Gaunt.

To inculcate an attentive, intuitive and caring culture at Zithulele, Gaunt realised it was vital to first recognise the humanity of the carer.

“I think the bureaucracy loses sight of that and expects machine-like outcomes, but people are your greatest asset and you need to look after them, and that includes recognising the importance of things such as mental health,” says Gaunt, who models this by being open about his own mental health.

“I wouldn’t say I have faced serious mental health issues but in my professional life, especially at Zithulele, I definitely felt more and more stretched,” says Gaunt, who was challenged by his wife to take action at a particularly stressful time in 2014.

“She wanted me to start taking antidepressants and I complained that I didn’t meet the criteria for diagnosing depression but I did feel my margins were very thin. 

“I thought, ‘I can always stop’, so I started, and the way I described the effect to my psychologist, who I was eventually also persuaded to see, was that it increased my buffer. I had a bit more capacity to deal with the stresses of work,” he says. He quietly went off his medication in 2017, telling himself if his wife noticed he would go back on them.

“It wasn't three or four days before she was, like, ‘have you stopped taking your medication?’ And we were on holiday at the time. I mean, it wasn’t even a stressful time,” says a chuckling Gaunt.

Mentorship breakfasts: 'People just loved it'

From 2015, mental health and other relevant issues were discussed among “Zithuleleans” at monthly “mentorship breakfasts”.

“Instead of a team ward round on a Friday morning, once a month we cooked breakfast together and every person would speak for a few minutes about whatever mutually agreed question we had posed ourselves: ‘Why did we get into medicine? Can you remember an incident in medical school that shaped your career?’, or ‘What is the role of women in healthcare?’

“And people just loved it, we learnt a lot about each other,” says Gaunt, explaining that interventions such as this “were mostly accidental, stumbled upon”, but they started to add up to a personal view of leadership, “probably best summarised as values-based leadership”.

“As the team started to grow, we realised we are different people with different perspectives. And so we found ourselves needing to sit down and ask, ‘What are our core values?’ 

“We wrote them down as the clinical team and that took quite a long time to seep into the rest of the hospital, because we didn't have the authority or mandate to run that process for everyone else. But in the end they were incredibly useful,” he says, reciting them quickly: “prioritising patient care, multidisciplinary teamwork, respectful relationships, quality care, continual learning and a hopeful attitude”.

Says Gaunt: “I found it such a helpful way of orientating people to the mindset we wanted to bring to our work, because every year, especially in a rural hospital, you have a handful of community service doctors coming and going and if your team is only 15 people to start with, that's a massive turnover.” 

Saying goodbye 

In 2022, the hospital’s new CEO insisted on ways of working that were anathema to the clinical culture the Gaunts, Le Rouxs and others had fostered for so many years.

The confrontation, which centred on the CEO’s insistence that hospital patients be referred by a clinic and not be allowed to simply walk in, and that children with complicated HIV had to be sent to clinics, was given added intensity by accusations of racism, the threat of mass resignations and a community protest or two, to the extent that the CEO was ordered to temporarily transfer; by that time Gaunt had already requested secondment.

Ultimately, to avoid further damage to health and wellbeing, the Gaunts departed.

“I have had plenty of time to reflect and allow the personal resentment side of things to fall away and I keep coming back to the fact that all of us in the public service in South Africa face a decision: are we here to follow the government rules to the letter, even if doing so is morally, ethically and perhaps even practically wrong, or are we here to put people first? 

“Issues in healthcare outstrip our ability to update our policies,” says Gaunt, making an example of drug resistant TB (DR-TB), which, for a long time, was supposed to be managed in hospitals, even though doctors knew DR-TB was transmissible and this approach was contributing to the spread of the disease. To save lives, rural doctors around the country, including at Zithulele, started managing DR-TB in the community.

“In the end, it should be simple — we are here to serve people, but of course it isn’t, and there are many ways of dealing with the frustration that can arise from that,” says Gaunt, admitting he often wonders if he could have stuck it out at Zithulele.

“The fact of the matter is the news cycle moves on, yet patients are still experiencing the same realities. Once you’re out you’re out, and the people who are still working are the ones making the difference.”

Equally, there is a time to move on and Gaunt appears to have made peace with the fact that his moment had arrived. His entire bearing seems to ask the question, where can I help next?”

This story was produced by the Bhekisisa Centre for Health Journalism. Sign up for the newsletter.