Life or Death Gamble to Access Healthcare in South Africa

BULUNGULA, SOUTH AFRICA —  This is Part Five of a five-part series Continue to Parts: 1 / 2 / 3 / 4 / 5
The ferryman’s muscles strained and rippled and he clenched his teeth as he rowed his boat across the wide and muddy river in Bulungula district in South Africa’s Eastern Cape province. A salty breeze blew from the nearby Indian Ocean, periodically threatening to tear a wide-brimmed red hat from his head.

“Honestly, I don’t know how this thing stays afloat,” commented Sam Partington, an American medical student volunteering at an NGO in the area, and one of the vessel’s passengers on an overcast, muggy summer’s morning.

Water seeped through cracks that had been repaired repeatedly in the boat’s fiberglass floor. Broken planks provided seating for occupants. The ferryman’s oars were tree branches to which flat pieces of wood had been nailed.

“You don’t even have to have a fear of water, but when you’re in a canoe like [this]…it’s scary,” said Partington while perched precariously on the back of the surging boat.




​For the impoverished people of the region, accessing healthcare is literally a gamble with death. The only clinic that’s within reach on foot is across the Xhora River.

“It’s frightening in that boat, especially when the weather is bad. If I end up in the water my children and I will drown because I can’t swim,” said Buselwa Senyuko [23], smiling broadly on a mud flat after making a successful ferry crossing that had cost her seven rand [about 60 US cents].

Like most Bulungula residents, she can’t swim. Like most, she has to risk her life to get medical attention at the state-run Nkanya Clinic – the only healthcare facility for many miles around.

“I must go to the nurses today because I’ve got chest pains and I’m coughing so bad that I sometimes cough the blood. And it’s getting worse,” Senyuko explained, hacking hoarsely into a dishcloth she held in front of her mouth.

She added, “My baby daughter is now also coughing but I wasn’t strong enough to carry her all the way…”

Senyuko traveled with Bongesi Gashe [28], who was suffering from a football injury – “a hip problem” - and what he called “a serious personal issue.”

Intense effort

VOA accompanied Senyuko, Gashe and Partington on their journey. They sweated up steep hills, and on footpaths above deep ravines. A fall would have meant certain serious injury, and possibly death. They stumbled down roads strewn with sharp rocks and across slushy fields, past women making mud bricks, and through a dense, moist forest that echoed with the croaking of frogs.

“This is where one of my friends was raped a few months ago,” said Senyuko nonchalantly, as she entered a clearing in a clump of tall trees.

The party reached the clinic after two hours of intense physical effort.

“I’m a fit young man and I’m tired from today’s journey. And I’m healthy. So I can’t imagine what it would be like if you were sick with TB [tuberculosis] or a really bad disease and then having to go through that journey; it would just be incredible,” said Partington.

A therapist at the clinic, Azel de Villiers, explained that it’s often grandmothers who bring their ill grandchildren to the facility.

“Even the lucky ones who have money for transport aren’t so lucky,” she said. “Old magogos [grannies] carry their 10 year old CP [cerebral palsy] grandchildren on their back up a massive hill to get to a taxi, sit in the back of a single cab bakkie [pick up] with 11 people in the back, and then they have to travel on a dirt road to the hospital. It’s actually awful thinking about that.”

Partington reflected on his NGO’s recent visit to a particularly remote part of Bulungula.

“We visited a couple of people that live out in the valleys, where you have to literally climb through a forest to get to their huts. To think of being a mama or a grandma carrying a ten year old child on your back that far, it’s just unbelievable. It makes you realize how strong people have to be here in order to get to their [medical] treatment.”

“You know when it’s a rainy day you’re not going to have any patients. The taxis can’t get to the houses; they [the people] can’t walk in the rain; it’s too muddy. It’s actually just too dangerous to go anywhere when it’s raining [here],” said de Villiers.

In a part of the world dominated by extreme poverty, where few people are formally employed, she’s never certain of having patients. Most people here survive on government child support grants of 280 rand, or US$33, per child per month.

“That money must be used to feed a whole family – a big family. I’ve seen 17 people living in a small hut here, all depending on money from a few grants…You can’t expect them to use that money for transport to come for a half an hour [therapy] session and not feed their family for a day,” said de Villiers.

‘They end up dying…’

According to Partington, poverty and the great effort needed to get to distant clinics are the major reasons why so many South Africans don’t take medication properly, or don’t take it at all, for serious infectious diseases.

“We spoke to a person who had TB, so he was taking TB medication which he had to take for six months. The clinic would only give him two weeks’ supply of drugs at a time. So every two weeks for six months he would have to walk for about eight hours a day to the clinic and back for his TB medication,” he said.

The American medical student added, “You know when you first hear about all these people defaulting on their treatment you think, ‘Oh well what’s their problem? It’s easy to take pills, you know.’ But then you realize – it’s not always because they don’t want to or they’re ignorant; it’s because they simply can’t.”

Health manager at the local Bulungula Incubator NGO, Nomzingisi Hopisi, said many residents are either too poor, or too ill, to access the clinic.

“The situation is especially bad for people with HIV,” she explained. “If they are on treatment, they end up defaulting their treatment…Others they end up dying because of not getting access from health services.”

A young mother’s struggle

After Senyuko and Gashe entered Nkanya Clinic, they took their places in the queues of people waiting to be examined by nurses. Like many such facilities in South Africa’s isolated rural areas, which are enduring chronic shortages of health workers, the facility is not staffed by a doctor.

But it was clean and neat, albeit sparsely furnished in terms of medical equipment.

Thembakazi Mdluli [16] was here with her one year old son, Inam.

“My baby has sores all over the body, especially on the ears. First they look like pimples then they become pus-filled sores,” she said.

Mdluli had carried her baby on her back for almost two hours to the clinic.

“I feel scared because I have to walk through the forest alone. There are rapists in the forest,” she said, almost whispering, as her baby whimpered.

“It was not easy. I tried to hurry because the child is sick. But I am used to the journey because I come here at least once a month for the child’s immunizations,” said the young mother.

Mdluli continued, “It’s difficult being a mother. You have to stop going to school, and you have to come to the clinic every month, whether you like it or not. You have to buy food for the child, even when you don’t have money.”

Sex education ‘taboo’

There were several teenaged girls nursing sick babies in the clinic’s waiting area.

“I have been shocked at the numbers of very young girls who are already sexually active in this part of the world,” said Partington. “It’s surprising to me that they don’t understand the consequences…Pregnancy is just as scary as [contracting] an STD [sexually transmitted disease], perhaps even more scary, in America. But here, it’s not even a second thought. Sometimes they even want to get pregnant so they can get a child grant. That’s completely foreign to me.”

De Villiers said talking about sex in Bulungula is a “big taboo,” despite its prevalence.

“Everyone here is having sex. They generally start having sex from a very young age. You just can’t talk about it,” she maintained. “Parents – they know their children are sexually active but they don’t want to educate their children, they don’t feel it’s their place to educate their children about that. [Children] are not getting the [sex] education at school either. So how are they supposed to know what to do and how to prevent whatever they need to prevent?”

The result, she said, is “massively high rates” of teen pregnancies and sexually transmitted diseases, including HIV.

‘Sometimes I stay silent…’

De Villiers explained that condoms are also “culturally unacceptable” in Bulungula. It’s something she’s determined to overcome – even if only on a small scale.

She’s a speech therapist, but regularly talks to women about the importance of using condoms.

“I never thought I would be teaching about female condoms. And demonstrating [their use]!” she said, laughing, after showing a group of women how to use the devices.

She acknowledged though, “Sometimes I stay silent about stuff that we really should be speaking about here, like abortions…These things are really very important and it’s essential that the people here know about them to be able to make informed choices. So many women here go for backstreet abortions and it causes so much suffering. If we could educate them, we could prevent situations like these…”

No medicines

Like many other public health facilities in South Africa, Nkanya Clinic is often hampered by lack of medicines and other medical supplies.

“I want medicine for the cough and the chest pains. But sometimes this clinic does not have medicine,” said Buselwa Senyuko, while queuing to see a nurse.

Thembakazi Mdluli added, “I sometimes come here and they tell me, ‘There are no immunizations, come back next week’…I feel bad but what can I do? I need my child to be vaccinated.”

Hopisi said the clinic often runs out of antiretroviral [ARV] treatment for HIV-infected patients. “This is extremely dangerous because if the treatment is interrupted, these people get very sick in a very short time and they can become resistant to their ARVs,” she explained.

Partington said, “Sometimes there’ve been cases where [people] actually go to the clinic and instead of getting their TB treatment, they’re given vitamin C supplements.”

De Villiers said there’s such a high prevalence of cerebral palsy in Bulungula because pregnant women can’t get proper medical care.

“We have women giving birth at home and then having complications but then it takes so long for them to get to hospital that the child dies or is born brain damaged, with cerebral palsy,” the therapist said. “We don’t have an ambulance at the hospital, so an ambulance has to come from Mthatha – which is an hour and a half away, at least. If an emergency C-Section needs to be done on a woman, she gets rushed back to Mthatha. All of that time adds up…”

Mdluli was adamant that the government has “forgotten” the people of Bulungula district. “It makes me hurt. I’d like a clinic to be built in my area. I’d like us to have clean running water. But they can’t even provide us with an ambulance…”

No surrender

As a speech therapist, Azel de Villiers traverses medical territory on which she acknowledged “in an ideal world” she would not be trespassing.

She’s sometimes a dietician, trying to help malnourished people. Next, she’s an occupational therapist, teaching coordination to a physically disabled patient. Next, she’s a physiotherapist, giving exercises to strengthen a person’s muscles.

“We’re just so short staffed here that everyone basically has to do everything to help the people; we can’t specialize and we basically have to do one another’s jobs even if it’s not really our field of expertise,” de Villiers said.

Then she has to overcome obstacles unique to very isolated parts of South Africa.

“We get children who are scared of white people, so then you can’t touch or go close to the child. It’s very difficult,” commented de Villiers.

The therapist is clearly under a lot of pressure, and is one of many South African health workers working under adverse conditions – yet refusing to abandon their poor patients.

“When you work with these people every day, and you see how brave they are, how can you be a coward?” she asked. “How can you surrender, when your life is so much easier than theirs?”

But even a health worker as dedicated as de Villiers acknowledged that she can’t endure extreme hardship “forever” – and neither can her patients.

“Sooner or later, things are going to catch up with you if you are not given the proper tools with which to work and you’re going to break. Sooner or later, a situation is going to arise from which a patient cannot recover, if they aren’t given something as simple as a packet of pills, or a basic clinic near their home.”