Women in health: “No one taught me how to treat a sick system,” says leading young Professor
In high school, a guidance councillor told Salome Maswime that she would never be accepted at medical school. Undeterred, in 2001, Maswime successfully enrolled for an MBChB (Bachelor of Medicine, Bachelor of Surgery) at the University of KwaZulu-Natal (UKZN). Today an obstetrician and gynaecologist, a professor and head of Global Surgery at the University of Cape Town (UCT), and President of the South African Clinician Scientists Society, Maswime is a beacon of excellence and a role-model to many.
Inside her office at the tertiary hospital Groote Schuur, Maswime laughs to deflect from the gravity of a point she is bringing across. In a field that’s predominantly white and male, she is often the only black woman in a room and at 40, often the youngest. In addition, she feels the eyes of many, many hopeful young black women on her, looking up at her success for inspiration. Being a pioneer brings pressure, says Maswime, as you are not only succeeding for yourself.
“I love doing what I do,” she says. “But I recognise the responsibility and the weight of what I’m holding. It’s not purely wake up and go to work. Some people really look up to you and need you to succeed so they know that they have a chance, too.”
Tilting a palm in front of her, she adds, “I once wrote in my personal reflections [in her journal] – when you don’t have a choice but to win.” She also posted this thought on her Instagram account.
On July 12, Maswime delivered her inaugural lecture as a full professor. Looking on was her father, theology professor Phillip Moila, her mother Patricia Moila, her husband, Gundo Maswime, a lecturer in civil engineering – also at UCT, their sons Farai and Taurai, and her mother-in-law, Grace Maswime.
In her talk, she noted that while caesarean sections are the most widely performed surgery in the world, African women are fifty times more likely to die from the procedure or resultant infections than women in high-income countries. This was the finding of research she conducted along with colleagues, involving 3 792 patients at 183 hospitals across 22 countries.
I love doing what I do. But I recognise the responsibility and the weight of what I’m holding. It’s not purely wake up and go to work. Some people really look up to you and need you to succeed so they know that they have a chance, too.
The next day, Maswime won the National Science and Technology Forum’s (NSTF) SA Medical Research Council clinician-scientist award at a ceremony popularly known as South Africa’s “Science Oscars”.
— Salome Maswime (@MrsMaswime) August 10, 2023
‘A preventable death’
In her office, Maswime is speaking over a potted Anthurium, a gift from a student. She singles out a defining moment in her career when she was 24, during her community service at a district hospital in rural KwaZulu-Natal. For the first time, she experienced a patient succumbing to surgery complications on her watch – a preventable death.
“About five months into the community service, I was doing about two to three cesareans a day and most of the patients were absolutely fine. But suddenly, after that good swing, in the same week, two patients died,” she says.
“The first patient had an anaesthetic complication during her caesarean section. And it’s quite a common complication, so immediately all the doctors are called into the theatre and they did what they could. But then the patient had to be ventilated and sent to the next level of care, which was in Pietermaritzburg 72 kilometres away. And so the decision was made. Because of the distance, let’s get her airlifted to the hospital rather than putting her in an ambulance. But then the helicopter arrived eight hours later, and the patient died just before it arrived. So literally it was like, we had a complication, we managed it, but in waiting for her to be moved to a hospital with an ICU… it was a preventable death, you know?”
Patients [die] for other reasons that are beyond our control. The system is sick, but at medical school, no one taught me how to treat a sick system…
The incident left her severely traumatised and her mind racing with questions. Was it her? Did she lack the skills? Meanwhile, the young doctor had done everything she could. In time, Maswime realised that a failing public healthcare system was at fault, a system shaped by politics, economics, and geography.
“I had to sit and reflect on what just happened and why? Maybe if I had known more, maybe if there had been more specialists… But what didn’t click for me at the time was that the problem wasn’t us, it was the system. Patients [die] for other reasons that are beyond our control. The system is sick, but at medical school, no one taught me how to treat a sick system…”
In the following years, while treating individual patients at the Chris Hani Baragwanath Academic Hospital in Soweto, inside Maswime, a yearning grew to bring healing on a larger, systemic level; to continue her education into the underlying causes of negative outcomes for mothers and neonates in childbirth.
In 2017, at the University of the Witwatersrand, she completed her PhD, looking at reducing maternal deaths from caesarean section-related bleeding at 15 hospitals across Gauteng.
The next year, during a post-doc fellowship at the Harvard Medical School in Boston, in the United States, she was first introduced to an emerging multi-disciplinary field that aligned with her own passions – global surgery.
South Africa does have centres of excellence, but then there are the rural hospitals with very few doctors, access to specialists, travel time, and distance to your referral hospitals… We always say that diseases don’t have borders, but health systems do…
Harvard’s Programme in Global Surgery and Social Change was founded in 2010 with the objective of “advocating for universal access to safe, affordable surgical, anaesthesia, and ob/gyn care when needed”. The programme leans on the teachings of late Harvard medical anthropologist, Professor Paul Farmer, health rights activist and co-founder of the non-profit organisation Partners in Health.
“There are so many worlds within health systems; internationally, across countries, and provinces,” says Maswime. “Some are weak, some are good, some are strong. For example, South Africa does have centres of excellence, but then there are the rural hospitals with very few doctors, access to specialists, travel time, and distance to your referral hospitals… We always say that diseases don’t have borders, but health systems do…”
Maswime quotes former US president Barack Obama as saying, “Change requires more than righteous anger, it requires a programme, and it needs organisation.” This programme, she says, is global surgery.
In 2019, she founded the global surgery division at UCT. Built around social justice as a key principle, the division teaches undergraduate and post-graduate students with links to several departments within the university’s Faculty of Health Sciences.
“We teach about good health outcomes and bad outcomes as a reflection of health systems – the decisions, the resources, the policies – on strengthening surgical systems, on leadership and enabling change because these are not things you get taught in medical school,” she says.
“So my view is that just like human beings, we can make an analogy of health systems being sick or healthy. Or surviving versus thriving. We look at areas of intervention – it may range from shortage of resources, equipment, skills, financing, audit systems, governance – and you have to understand the system and diagnose the challenges, propose solutions.”
We just had a fruitful Research Agenda Meeting! This was the opportunity to discuss our work streams, Ph.D. & MSc student involvement, and align our research and advocacy efforts.
A promising step towards advancing Global Surgery! #ResearchAgenda #MedicalScience #GlobalHealth pic.twitter.com/4I3k2qQEKs
— UCT Global Surgery (@GlobalUct) August 3, 2023
For example, while discussing the problem of lacking specialists at rural healthcare facilities in South Africa, Maswime refers to her own roots in rural Limpopo. She suggests a model where, instead of trying to import doctors from urban centres to rural areas, local governments should invest in bursaries and training of local talent. These doctors, she says, are likely to return home with their skills given the right incentives, due to a sense of belonging in their rural communities.
A life of many firsts
Born the youngest of eight siblings in Botlokwa in Limpopo, Maswime was just eleven months old when her father got a family scholarship to further his theology studies in Chicago. Back in South Africa, he eventually became the interim vice chancellor for the University of Venda – two hours drive outside Polokwane – while her mother worked as a primary school teacher. Maswime recalls a childhood filled with church events and academic functions. In 1994, aged 11, she became the first black pupil at two Afrikaans primary schools in the area.
“In 1994, it was about January, when my father picked me up at school one day and he was like, okay Bergvlam [Primary School] is now taking black students; you’re starting there tomorrow, you’ve been accepted.”
So now when I’m comfortable being in a room that’s lily white, you know, it’s not because I’m experiencing it for the first time – I’ve been in those situations all my life.
Speaking to Spotlight, Maswime pauses slightly to pronounce “Bergvlam”, and then spells out the word. “At Bergvlam, some classes were only in Afrikaans. I mean, it was “Wiskunde”, so you’re having to learn maths in Afrikaans, which you don’t really understand. And some teachers were compassionate about this, and some were not. Six months later, my parents wanted to put me in Soutpansberg (Primary School). First, they had to meet with the governing body to confirm that the school was willing to accept me as their first black student. Soutpansberg did accept me, but asked me not to come to school on the first day because they first needed to inform the kids that a black student would be joining the school.”
Relaying these memories, Maswime laughs. “So now when I’m comfortable being in a room that’s lily white, you know, it’s not because I’m experiencing it for the first time – I’ve been in those situations all my life.”
Inside Maswime’s office, on the wall next to her desk, photographs include one of her shaking hands with former President Jacob Zuma. She was awarded the Trailblazer and Young Achiever award by the President of South Africa in 2017.
Another photograph shows Maswime in a red toga beside her husband and boys on her PhD graduation day. Maswime and Gundo met through the His People church while studying at UKZN. They live in Hout Bay. Academic colleagues might be surprised to learn about Maswime’s creative side. She enjoys writing drama scripts and can play various instruments, including the trumpet and the flugelhorn.
*This article is part of Spotlight’s 2023 Women in Health series – in which we profile remarkable women making a mark in the world of healthcare.