Sikiniwe Khumalo tends to 40 patients during a single shift as a nurse at the Helen Joseph Hospital here. That's too many, she says, for her to offer more than basic medical care, and certainly too many to remember all their names.
Mrs. Khumalo's workload is typical of medical personnel here and around Africa, where HIV/AIDS and malnutrition have given doctors and nurses more than they can handle.
Despite this need, however, in a few months, Khumalo, a single mother of two, will pack her bags and leave the country of her birth for England, where she will have a take-home pay three times her salary in South Africa. And friends who have already left say in Britain, she will care for only six patients at a time.
"Basically, it's the money," she says. "I can't make payments here. I've been working for 15 years, but I think I'm not getting the salary I deserve."
Khumalo is not alone. South Africa is experiencing a huge drain on health professionals, many of whom, like Khumalo, are leaving the country for places such as Britain, America, and Australia where pay is higher and working conditions are better.
This comes at a time when the country's already overloaded health system struggles to deal with the increasing burden of AIDS. But overworked and underpaid doctors and nurses are looking for alternatives. They are often helped by international recruiting agencies that many African governments accuse of poaching their much-needed medical staff.
No one knows exactly how many of South Africa's medical professionals, whose training in the country's medical schools is highly respected worldwide, have left the country, since few tell the government they are leaving.
But the South African Medical Association estimates that at least 3,500 of its 26,000 practicing doctors are living abroad. The country's minister of health says that from 1995 to 1999, more than 2,500 nurses applied to have their qualifications verified, which is usually required for nurses to move abroad.
Surveys show that the outward flow is likely only to increase. Nearly 10 percent of doctors surveyed by the South African Medical Journal said they may leave within the next five years, and 1 in 3 new doctors doing their required one-year community service said they plan to emigrate.
"Students sit around and talk about where they want to go when they leave the country," says Christiaan Burger, a medical student at the University of Pretoria and spokesman for a student group protesting the planned addition of an extra year's internship. Mr. Burger and others say that this extra year of service will push more doctors to leave.
South Africa has called on wealthy governments to stop recruiting their medical professionals.
"There is a strong feeling that it is cynical on the part of countries that are better resourced to rely on a constant stream of migrants from countries that pay less," says Jo-Ann Collinge, a spokeswoman for the South Africa's Department of Health. "There should not be a systematic draining from developing countries."
The Commonwealth, a body of 54 former British colonies and territories, has addressed the issue of poaching. Some countries have agreed not to recruit staff directly from the developing world. Britain, however, is currently trying to relieve long waiting lists at hospitals by bringing in doctors from abroad on a temporary basis.
Because the United States does not have a nationalized health system, the US government cannot prohibit US hospitals and universities from recruiting overseas.
Private companies continue to recruit heavily in African countries by advertising in medical journals and even offering rewards for doctors and nurses who provide the names of their colleagues. Even if such practices were banned, there is little that could be done to stop professionals such as Khumalo from approaching placement companies on their own.
Medical groups in South Africa say the country needs to address the homegrown reasons which have to do with more than just pay that are pushing medical professionals to leave.
Neurologist James Temlett worked for 25 years as a doctor at Johannesburg General Hospital and as a medical professor at the nearby University of Witswatersrand. A month ago, he left for Australia, where he now splits his time between a university and a hospital in Adelaide.
Dr. Temlett says he left largely out of disgust with South Africa's HIV/AIDS policies and the government's refusal to recognize the scope of the AIDS pandemic. The government has opposed the use of antiretrovirals for AIDS patients in public hospitals and clinics, citing concerns about cost and the drugs' effectiveness.
"Out of the 40 patients I would see during a shift, two-thirds of them sometimes even as high as three-quarters were suffering from HIV-related diseases," he says. "It's certainly a crime against humanity not to recognize the scope of the problem.... It's tremendously demoralizing [for] the staff."
Despite its struggles to keep its medical staff, South Africa's situation is not nearly as severe as the situation of many of its neighbors.
There are only 400 registered doctors left in all of Zambia, and many of Zimbabwe's medical professionals have left recently because of the increasingly unstable political situation there. At one main hospital in Bulawayo, Zimbabwe's second-largest city, three of the hospital's four surgeons left the country this year. In Kenya's Daily Nation newspaper, the director of medical services said that Kenya has only 600 practicing dentists, an of average 1 for every 69,000 patients.
"The issue of the migration of doctors is an international issue," says Dr. Kgosi Letlape, chair of the South African Medical Association. "The problem has become very widespread. The problem is that being a doctor is no longer economically attractive. Even successful countries are having a hard time training enough doctors."