Pediatrics elective at Paarl Provincial Hospital, South Africa
Jillian Lin, a pediatric resident at UBC, spent three months completing a general pediatrics elective at Paarl Hospital in South Africa’s Western Cape.
"When I first arrived at Paarl Provincial Hospital, a publicly funded community hospital in the Western Cape of South Africa, what struck me immediately was the heat. It was mid-December, summer in the southern hemisphere, and temperatures that week
averaged between 30–35°C. The pediatric ward was located on the third floor of a fourstorey
building, and unfortunately the hospital’s air-conditioning system was broken. The
heat accumulated on the ward, and I quickly realized that my small water bottle was not
nearly sufficient for a full day of clinical work.
Paarl Provincial Hospital is a government-funded secondary community hospital that provides care to a large catchment population. It includes a pediatric ward and neonatal intensive care unit, along with several other adult specialist services. Just two streets away, however, stands a private hospital – Mediclinic Paarl Hospital. In contrast to the aging infrastructure of the public hospital, the private facility appeared modern, clean, and closely resembled hospitals in North America. Access to private healthcare in South Africa often depends on employment and insurance coverage, making such care inaccessible for many families. Those who could not afford private healthcare would seek care from the public sector.
Right from the first day, the pediatric team at Paarl welcomed me warmly. My colleagues were incredibly friendly and supportive, helping me navigate the hospital systems and ensuring I felt part of the team. They were very excited that I was there and got me to work right away.
One of the biggest clinical differences I noticed early on was the prevalence of tuberculosis (TB). Almost every day, multiple children admitted to the pediatric ward were undergoing investigations for TB. In Canada, TB is relatively rare and any suspected case, even with low suspicion, is placed in a negative-pressure isolation room, with staU wearing N95 masks and full personal protective equipment. Healthcare workers are routinely fittested for N95 masks. At Paarl Provincial Hospital, the situation was very different. Most pediatric patients were admitted into shared rooms, and while confirmed TB cases were placed in an isolation room, it was not negative pressure. Protective equipment was limited to gloves and N95 masks, and staff typically wore masks only when entering isolation rooms. The realities of infection control had to be balanced against the realities of space and resource constraints.
HIV was another highly prevalent condition. Every child admitted to the pediatric ward underwent routine rapid HIV testing. In South Africa, the burden of HIV remains significant. As of 2022, approximately 8 million people in South Africa, about 13% of the population, were living with HIV, compared with roughly 0.2% of the population in Canada. The overlap between HIV and TB is also profound: more than half of patients with TB in South Africa are co-infected with HIV, and children living with HIV are estimated to be 18– 20 times more likely to develop active TB disease than their HIV-negative peers.
One patient in particular has stayed with me, as their story reflected the complex intersection of HIV, poverty, and health inequity. She was an one-year-old child admitted with severe acute malnutrition, presenting with the classic features of kwashiorkor. The mother was a young migrant from Lesotho who spoke limited English and had struggled to find stable work after entering South Africa without documentation. The child tested positive for HIV on rapid testing, later confirmed with PCR. The mother later disclosed that she had known her own HIV status and that the baby had initially received prophylactic treatment at birth, but the medications had not been continued. The reasons were complex and not entirely clear—possibly a combination of limited access, misunderstanding of treatment, and persistent stigma surrounding HIV. The child’s condition deteriorated
rapidly during the admission. One evening while I was on call, the baby developed
worsening respiratory distress. We initiated CPAP and broadened antibiotics while also
starting treatment for possible TB. By the following day, it became clear that the child would
require intubation and mechanical ventilation. However, this would require transfer to a
tertiary pediatric intensive care unit, and the regional PICU could not accept the patient
due to the extremely poor prognosis associated with severe acute malnutrition and limited
ICU resources. The child passed away the next day. It was a diUicult moment that underscored how resource constraints can shape medical decision-making.
Another memorable experience occurred early in my rotation when the pediatric team was called to the emergency department for a woman in premature labour. She had received no prenatal care and unexpectedly delivered triplets. All three infants were extremely premature and required resuscitation. The hospital had only one neonatal resuscitation station available in the emergency room, but the entire pediatric and emergency team mobilized quickly. My attending physician rapidly assigned roles, identifying the most critical infant while others assisted with airway management, intravenous access, blood draws and preparation of incubators. Despite the chaos, the teamwork was remarkable. We were able to successfully resuscitate all three babies. In that moment, I witnessed the incredible teamwork of the staff, while also being reminded of the difficulties of providing care in this setting.
Unfortunately, two of the infants weighed less than one kilogram. According to local guidelines, these infants were given a “trial of life” without intubation, as long-term ventilatory support for extremely premature infants with those weights was not available. Ultimately, two of the three infants did not survive, while one weighed greater than one
kilogram received ventilatory support and got transferred to a tertiary centre.
These cases also reminded me that outcomes might have been different in Canada
and in private healthcare settings of South Africa, where advanced intensive care resources are more readily available. While seeing patients each day, I frequently reflected on how these cases might unfold in a Canadian hospital, and what factors - resources, systems, and social context - shape the differences in care.
Beyond the clinical learning, there were also unexpected moments. On one occasion, our team was stuck in an elevator while transporting a critically ill child in shock who had just arrived via rooftop medevac. In a confined space with seven adults and one unstable child, and temperatures again exceeding 30°C, we improvised - hanging IV fluids from a nail in the elevator and continuing care while waiting 30 something minutes to be rescued. In another incident, a fire broke out after a garbage bin was set alight, spreading to a nearby vehicle and damaging part of the hospital. Despite the absence of a formal “Code Red” announcement and delayed evacuation orders, staU responded quickly and collaboratively to move patients to safety, and thankfully no one was injured.
Throughout my elective, I also observed the broader social context shaping healthcare. The legacy of apartheid continues to influence socioeconomic disparities in South Africa. Many patients at the hospital were from historically disadvantaged communities or neighbouring countries. The South African National Department of Health mandates free healthcare services for pregnant women and children under six years old regardless of nationality, which helps improve access but also places significant demand on the public healthcare system. Despite these challenges, South African physicians demonstrated remarkable compassion, clinical skills and adaptability. Their training emphasizes hands-on practice, and I was able to participate in many procedures including lumbar punctures, arterial blood sampling, and intravenous insertions.
Beyond the hospital, the Western Cape offered breathtaking natural beauty. I had
the opportunity to explore Cape Town, hike along coastal mountains, visit beautiful
beaches, and go on safari to see wildlife in their natural habitat. The warmth and kindness
of the people I met made the experience even more meaningful.
My elective in South Africa was truly a once-in-a-lifetime experience. It deepened
my appreciation for the resources available in Canada while also expanding my understanding of how medicine is practiced differently in diverse healthcare systems
shaped by culture, history, politics, and population needs. Most importantly, it reinforced
my admiration for healthcare providers who continue to deliver compassionate care under
challenging circumstances."
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