From Rags to Riches
Building a Regional Paediatric Surgical Service for the Eastern Cape, 1995–2026
Milind Chitnis
Adapted from From Ahmednagar to Africa: A Paediatric Surgeon’s Odyssey of Service, Leadership and Learning.
A leap of faith
My young family’s move to Africa was truly a leap of faith. During my training and early professional life in India, if anyone had told me that I would spend most of my career in South Africa, I would have laughed. When I accepted Colin Lazarus’s offer, my plan was simple: stay for three or four years, gain surgical experience, and return to Pune to give back to my motherland and community. I had no idea that South Africa would become my professional home for more than three decades, or that a small service beginning in February 1995 would grow into an accredited regional department serving children across the Eastern Cape.
Glasgow, Colin Lazarus, and the beginning
The story began before I reached South Africa. Colin Lazarus, then Head of the Surgical Division at Cecilia Makiwane Hospital (CMH), had recognised the need for dedicated paediatric surgical expertise in the region. Already an experienced general surgeon and in his early fifties, he chose to retrain, spending 1993 at the Red Cross War Memorial Children’s Hospital (RCWMCH) in Cape Town and 1994 at the Royal Hospital for Sick Children at Yorkhill in Glasgow, where I met him.
I had already completed my MCh in Paediatric Surgery in Mumbai and was undertaking further training at Yorkhill. Colin was senior to me and generous with his teaching. More importantly, we shared an interest in building services rather than merely occupying posts. South Africa became a democracy in April 1994, and the fragmented health services of the former homelands were beginning to be integrated. Colin returned to the Eastern Cape with a mandate to establish a paediatric surgical service and invited me to join him. I arrived in East London, now KuGompo city, on 31 January 1995. We began working together at CMH the following day.
Building a service that did not yet exist.
I was not joining a mature paediatric surgical department. I was arriving to help build one. The distinction matters. In 1995, wards, theatre lists, intensive care, training posts, referral pathways, and academic routines could not be taken for granted. Many had to be assembled, negotiated, or improvised. The Eastern Cape had inherited deep inequalities from apartheid. Many children came from rural communities where diagnostic resources were limited and transport difficult; some neonates requiring complex surgery still had to travel approximately 1,000 kilometres to RCWMCH in Cape Town.
One of Colin’s earliest and most important decisions was not to create two competing miniature services. CMH in Mdantsane and Frere Hospital in KuGompo city were about twenty-one kilometres apart. Instead of duplicating scarce expertise, we developed a single regional Paediatric Surgery department across both hospitals, leveraging the strengths of each. That model survived repeated administrative changes. It taught me an early lesson in institution-building: organisational charts matter, but clinical services survive through relationships, shared purpose and practical systems that make sense to the people doing the work.
Fig 1: Entrance to the old Cecilia Makiwane Hospital
A return to India — and a decision to stay.
My original intention to return to India did not disappear. After my first three years in South Africa, I resigned and returned to Pune. I joined St John’s Medical College Hospital in Bengaluru as an Assistant Professor in Paediatric Surgery. Still, within weeks, I realised that the post and I were not a good match. I contacted Colin and asked whether I could return. He said yes.
Getting back was harder than deciding to return. I was temporarily without an income, my passport had expired, and South Africa had introduced a moratorium affecting the employment of foreign-qualified doctors. My first visa application was rejected. Colin intervened and explained that I was a previous employee returning after a brief period in India. Eventually, the work permit was granted. We returned in August 1998, and I resumed duty on 1 September. At the time, I interpreted the sequence of events as God’s will for me to work in South Africa. I promised myself that I would remain in this department until retirement. I am grateful that I have been able to keep that promise.
Local solutions to local problems
Specialist paediatric surgery cannot function in isolation. It depends on anaesthesia, intensive care, radiology, pathology, nursing, theatre capacity, and reliable referral systems. In our early years, several of these supports were incomplete or absent, so we built partnerships as carefully as we built the surgical service.
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When specialist paediatric anaesthetic expertise was insufficient in the state sector, private specialist anaesthetists helped with neonatal emergencies and major operations for more than seven years. Frere Hospital initially had no dedicated paediatric intensive care unit, so children requiring intensive care were managed in the adult unit with experienced nurses and paediatric surgical staff; a fully fledged paediatric intensive care unit eventually opened in 2014. When local histopathology services were limited, specimens travelled by courier to RCWMCH. Each solution was imperfect, but each moved forward.
The same philosophy shaped infrastructure. The East London Health Resource Centre, opened in 1998, gave staff and trainees a physical home for learning. For almost two decades, Paediatric Surgery at Frere Hospital had only one-and-a-half days of theatre time each week. A major turning point came when the Carte Blanche Making a Difference Trust funded the refurbishment of a dilapidated theatre area into a dedicated two-theatre paediatric operating suite. I still remember the excitement of its inauguration in September 2014. Buildings matter, but it is people who turn them into places of care.
Eyabantwana: creating our own support structure
Colin and I had long wanted a transparent mechanism to support needs that the provincial Department of Health could not always meet. The immediate spark came from one of our registrars, who cycled approximately 1,000 kilometres from KuGompo city to Cape Town in five days and raised R100,000. In 2012, we established Eyabantwana for the Children Trust as a not-for-profit organisation.
The Trust has helped strengthen infrastructure, equipment, education, and training; refurbish the burns ward; purchase specialised equipment; and support visits by distinguished paediatric surgeons. Those visitors brought more than technical expertise: they connected a small Eastern Cape department with a wider professional world. Fourteen years later, Colin and I take satisfaction in knowing that Eyabantwana has become established in the local community and can continue long after both of us have retired.
Fig 5: Eyabantwana for the Children Trust logo
From service to institution
For me, the clearest sign of transformation was training. The Health Professions Council of South Africa accredited the unit for part of specialist Paediatric Surgery training in 1999 and for the full duration in 2003. Affiliated with iYunivesithi Walter Sisulu, the department became one of South Africa’s accredited Paediatric Surgery training centres. By the later years of my tenure, all eight accredited registrar posts were occupied. Increasingly, our staff reflected the population we served, including many women and doctors from backgrounds historically excluded from specialist medicine. A department should not simply reproduce its founders; it should become broader, stronger, and more representative than they were.
Research and teaching widened our horizons further. We participated in national and international collaborations and published work arising from local clinical problems. During the coronavirus disease 2019 pandemic, monthly online departmental meetings brought national and international experts into our teaching programme and drew participants from across Africa and beyond. My involvement with professional organisations increasingly came to mean less a personal achievement and more a bridge opening doors for the department and its trainees.
What “rags to riches” means to me
Institution-building is usually described in terms of achievements: theatres, accreditation, staff numbers, publications, and programmes. That is necessary, but incomplete. There was a personal cost, too. With age, I have become more willing to acknowledge that commitment can quietly become overcommitment. The determination required to build a service can also consume too much time and energy. I am proud of what we built, but I no longer believe that professional devotion should be measured by how completely work occupies a life.
Across the years, one sentence became shorthand for our departmental philosophy: “In Africa, we do not sit and cry; we find local solutions to local problems.” This never meant accepting inadequate systems. Children in the Eastern Cape deserved the same standards of safety and dignity as children anywhere else. It meant that while advocating for better resources, we could not allow the absence of ideal conditions to become an excuse for paralysis.
The phrase “from rags to riches” therefore does not mean becoming rich in money or resources. It means becoming rich in capability, people, relationships, knowledge, and confidence. Those forms of wealth take years to accumulate and can be lost if not passed on.
What remains when the founders leave?
As I approach the end of my state-sector career in October 2026, my hopes are no longer centred on what I personally might build next. Buildings are only one kind of legacy. The more important test is whether the service continues to grow when the people who began it are no longer in charge. A mature department should train people who can question old habits, improve systems, create new partnerships, and eventually take the institution further than its founders could.
In 1995, Colin and I were trying to create a service that did not yet exist. Thirty-one years later, my task is different: to step back without stepping away from the values that shaped it. There is a season for building institutions and another for entrusting them to others. The operations, wards, theatres, and training posts matter. But the deeper legacy will be the people who carry the work forward and the children, many from communities far from major centres, who can now receive specialist surgical care closer to home.
That, for me, is the real journey from rags to riches.
Adapted and recast from the published article by Milind Chitnis and Jessica Davies, “From Rags to Riches: 1995–2025 Establishment of a Regional Pediatric Surgical Service in Rural South Africa”, Pediatric Surgery in Tropics (2025).
Editorial assistance: ChatGPT (OpenAI) was used to help shorten and polish this article. Responsibility for the content rests with the author.
