Sacked - for putting his patients' interests first

Dr Thys von Mollendorff, the Mpumalanga hospital adminstrator who was dismissed on February 22 for gross insubordination, has appealed and warns that he his prepared to fight his case all the way to the Constitutional Court if necessary. His offence was to defy the government's ban on anti-retroviral drugs for rape victims by allowing a local volunteer charity to work in Nelspruit's 250-bed Rob Ferreira hospital.

"If this was only about me, then I'd probably just get on with my life. But it isn't just me. It's about our patients - the region's poorest. If I give up now, I'll be betraying everything we've fought for," he says. "Public hospital patients don't have fancy medical aid. For my patients, HIV/Aids is a death sentence. They're very lucky to be alive 10 years after being infected."

Two years ago Von Mollendorf was called to an emergency case - a four-year-old girl who had been violently gang-raped. Her genitals had been torn by the repeated assaults and were then slashed with a knife.

"It was terrible. I rushed her to theatre and repaired what I could," he remembers. Months later he carried out reconstructive surgery in the hope of giving her a chance at a normal life. "That case was pivotal, but not unusual. Over 9 per cent of all rapes that we see involve children younger than five years. In the end I just had to do something about the sheer numbers of children and women we were seeing," he says.

Unable to win a budget or staff to improve the hospital's existing internal services, Von Mollendorff allowed a local volunteer charity organisation, the Greater Nelspruit Rape Intervention Project (Grip) into Rob Ferreira to provide free counselling, fresh clothes, legal advice and, crucially, free anti-retroviral cocktails of AZT and 3TC. The strategy echoed existing government policy, under which 49 other charities such as Alcoholics Anon- ymous and Life- Line also worked in the hospital.

"Grip moved into a small, unused room, paid to paint and equip it, and for the first time gave rape survivors a safe, private and humane place to be treated." Previously, rape survivors first had to report to police, where they could be kept waiting for hours in bloody clothing to make a statement, he says. The women, mostly rural villagers, then had to walk or hitchhike 3km to Rob Ferreira, where they would wait again for a gap between emergency cases.
"And even when they were examined, it would be in an open casualty ward in front of scores of people. We were effectively traumatising them a second time," he said.

"Grip's improvements were dramatic. The rape survivors were treated immediately. They received intensive private counselling, clean clothes and help with all the legal aspects. Most importantly, he says, the free anti-retroviral drugs Grip supplied within 72 hours of the rape saved at least 100 lives.

Mpumalanga health MEC Sibongile Manana was kept informed of Grip's progress through monthly briefings, reports and news clippings charting growing public support for the initiative. "It was going fantastically, until she suddenly called us in seven months later, in October 2000, and accused us of violating government policy and of using black patients as guinea pigs by giving them scheduled drugs that were poison," says Von Mollendorff.

"We were shocked. She was very aggressive and would not listen to our assurances that procedures had been followed. Four of my top personnel were charged with misconduct along with me, and Manana warned she would personally ensure that we would all be severely punished."

Manana also attempted to evict Grip, twice going to the High Court, but was defeated. She then turned on nursing staff, insisting anti-retroviral drugs were a racist conspiracy designed to undermine and ridicule President Thabo Mbeki. Within weeks of her statements 13 of Rob Ferreira's 46 doctors had resigned, most of them senior staff. "We were 40 per cent understaffed when I was appointed superintendent in 1999. It was a nightmare wading through all the red tape to recruit and appoint decent doctors and then we lost them within weeks," recalls Von Mollendorff.

Manana was eventually forced to drop all charges against him and other hospital staff, and promised there would be "harmonious" relations. "But the intimidation continued, through unions, officials and innuendo. I asked for instructions in writing and for a copy of a written government policy on drugs for rape survivors, but Manana refused," he says. "Then I took a conscious decision that the Constitution, the Hippocratic oath and my patients' best interests would determine the type of treatment."

His refusal to bow to pressure surprised both friends and colleagues. "He's a very quiet person who does not go around making noise and inciting people," says acting Rob Ferreira Hospital superintendent Dr Pat Saffy. The son of a stationmaster, and a deeply religious man, Von Mollendorff dreamed of being a doctor when he was still in primary school and has worked in rural government clinics and hospitals for the past 21 years. "I could work in the private sector and make more money, but my passion is hospitals. You're closer to patients and can make so much more difference where it counts - among the poor."

When he was appointed to the superintendent post at Rob Ferreira, the third largest hospital in Mpumalanga, he thought he could make a real difference just by working hard. "I wanted to replace the antiquated and broken equipment, fill the large number of vacant posts, and improve the quality of medical service," he recalls. "It was a dream that didn't last long." He endured repeated budget crises that led to cuts first in medicine supplies, then water, electricity and even food. "We were operating by torchlight at one stage, and begging neighbouring hospitals for medicines or things like gloves," he recalls.

Manana's continuing skirmishes with Grip eventually saw Dr Von Mollendorff suspended from duty in November 2001 on a range of charges including his alleged failure to get permission to refurbish the Grip's care room and failure to "declare" Grip's payment for paint and other materials.
"It was bizarre. I showed that we had obtained written permission from public works and that no financial benefit accrued to anyone. But the moment I produced that evidence, the charges were changed to insubordination," he says.

At the disciplinary tribunal held in Premier Ndaweni Mahlangu's office, Von Mollendorff was once again refused copies of government policy on anti-retroviral drugs, though he was given copies of the discredited views of HIV/Aids dissidents, including those of Dr David Rasnick. "The chairman of the tribunal told me that I should have been able to read between the lines and should have known not to allow the use of anti-retroviral drugs," he says.

Two weeks later, on February 15, he was found guilty of gross insubordination and on February 22 he was fired. "I was called to meet a government official at a traffic intersection in town and simply handed my dismissal letter. It was a severe blow. I did not expect to lose my life's work on an issue that is a clear-cut ethical matter," said Von Mollendorff, who at 47 should have had many more years of public service. "No politician presumes to tell doctors which medicine to use or not use for any other disease. Why should Aids be different?"

In private, colleagues in Mpumalanga appear to agree. Though few are prepared to speak out publicly, all note that another four doctors have resigned from Rob Ferreira since Von Mollendorff's dismissal. However, 12 ethics and human rights experts, most of them from South African universities have spoken out, describing Manana's actions as "ethically indefensible" and calling on her to reinstate the doctor. In a joint statement they write: "To vicitimise him for having defended the highest principals of his profession, and for standing up for his mostly vulnerable and poor patients, is unjust in terms of all civilised and humane ethical standards."