The barefoot soldiers of a public health care system that doesn’t seem to care

By Nomatter Ndebele

For the past 17 years, 55-year old Doris Ntuli has worked as a community caregiver (CCG) in the community of Sweetwaters, in Pietermaritzburg, Durban. In that time Ntuli has only received a pay increase of R300 (US$20). Her total monthly income is R1500 (US$95).

Tireless: Doris Ntuli
Tireless: Doris Ntuli

That one increase was all she’s ever been given. Other than that she and her colleagues work without support or resources in a hostile environment and one which provides little help to the people of the communities they serve.

In 2001, the KwaZulu-Natal province launched Operation Sukuma Sakhe, a social health care model that offers an integrated approach to both social and health-care services. The model puts one community caregiver (or community health worker, as it is generally known in South Africa) in charge of 60 households in order to oversee their health as well as their socio-economic wellbeing.

Care givers report to a “war room” with representatives from various social development departments including Home Affairs, Agriculture, Human Settlements, Health and Social Development. Here they are expected to report any issues affecting their allocated households to the relevant departments, who are then required to intervene, either by going back to the specific household or sending whatever is needed back with CCG.

What should be a strict and formal process however, hardly ever happens. On some days, department representatives don’t show up, and care givers say that not once have they received responses to cases written up in the report books in their absence.

This is one of the reasons CCGs, who are a vital part of the primary health care system, have lost credibility in the community. They never seem to deliver on their promises.

Seven years ago, for instance, on one of her rounds, Doris came across a quadriplegic blind man, who was living in an outside room and fending for himself. Although his family lived with him, they did very little to take care of the man. Doris told the family that she would report the matter and ensure that a wheel chair was delivered to the man.

“For seven years, I went back and forth to that war room to report the matter, but I received no help. I eventually stopped going back to the house because I was so ashamed,” says Doris.

The man died before any assistance came.

For two years now, Doris has left reports at the war room, detailing a case of an improperly sealed sewerage access point.

“It’s not safe. It’s just a big dark hole and if a child falls into that pit, they will be gone.”

To this day, the sewage access point remains open and no one from the war room has responded in any way. Doris admits that she is close to giving up on the matter. Clearly, nobody cares.

Although CCGs are employed as an extra hand for the departments of health and social services, they are met with much resistance. Nurses in the local clinics look down on them, viewing them as uneducated and providing very little support for the work they do.

Over the past six years, civil society has pushed for the government to recognise community health workers as legitimate aides of the public health care system, and calling for them to be formally employed and given the support they need to do their jobs.

Simanga Sithebe, a representative from Sinani, an organisation that works closely with CCGs in eThekwini, says that one of the biggest issues CCGs face is a lack of resources. They have no travel allowance and are not compensated for any expenses.

“They often pay out of pocket to provide patients with money for trips to the hospital or clinic,” said Sithebe.

CCGs are also forced to work with few or no materials. Often, Doris will get a bag of nappies and nothing else – no gloves, no TB masks – but she is expected to do her rounds regardless.

“The nurses tell me that they only have enough stock for themselves, and that we haven’t been budgeted for,” said Doris.

“Even people who clean the streets have a uniform. They have boots, but I walk up and down this community everyday in my sandals until they break,” she adds.

Sithebe explained that dysfunctional administrative processes have an impact on the work of these community health workers. The renewal of contracts is not a well-managed process and CCGs can wait for up to two months to find out whether their contracts will be renewed.

Despite the fact that CCGs are contracted by the KwaZulu-Natal Department of Health on one- or two-year contracts, they receive no benefits at all.

“If I die tomorrow, these children you see here won’t even have 20c to their name” says Ntuli.

For years, the CCGs in Durban have been promised better opportunities, but very few have materialised. When Doris started, she was told that she could be eligible for nursing training. This hasn’t happened, and in the 17 years that she has worked, only two other CCGs she knows have received training.

Doris, and many other CCGs in Durban have tried to have their grievances heard. Their peaceful marches and heartfelt pleas have gone unnoticed.

“I am supposedly working for the department, but not once have I seen a representative come and address our issues. For years they have ignored us,” said Doris.

At the beginning of May this year CCGs in Sweetwaters decided to take drastic action.

Doris joined a group of CCGs who staged a shut down at the local clinic. The group arrived early in the morning and locked the gates of the clinic, denying patients and staff access. It was only after this act of civil disobedience, that the CCGs were promised a response.

Their drastic action was a means to an end, but she and others knew that it will quite likely further strain relations between themselves and staff at the facility.

“We have never had a good working relationship with the sister at the clinic, and after this, I know things will be even worse. But what could we do?”

In spite of all these problems, Operation Sukuma Sakhe is hailed as one of the best primary care health care approaches and is supposed to act as the model on which all other provinces will base their systems.

There is a lot of work to be done in terms of supporting the people who drive the operation. For many people in far-flung rural areas, CCGs are their only line of connection to the public health care system and to social services.

It is not enough to theoretically empower CCGs without providing necessary resources for them to carry out their work.

“Bring your pubic hair” – healers and quacks continue to thrive in KwaZulu-Natal

By Nomatter Ndebele

In KwaZulu-Natal, according to reports from the Human Sciences Research Council, there are 1.8 million people who are HIV positive. Of those, 1.1 million are on the antiretroviral programme. Yet, despite making great strides in the fight against HIV, the streets of KZN are still full of non-medical “healers” who prey on sick, desperate and vulnerable people desperate to be cured of HIV. Nomatter Ndebele visits two “healers” with thriving businesses.

Prayers and pubic hairs

Doctor Sawa’s two-room consultation office is on the 7th floor of an office building in Durban’s CBD. A few blocks from his office, a young woman is handing out pamphlets detailing his expertise, which includes bringing back lost lovers and curing HIV.

When I arrive, Sawa invites us to sit down and disappears behind a curtain into another room. Every so often, there’s a rattle coming from behind the door. After five minutes, he asks me to take my shoes off and come into the consultation room.

Kim Cools’ compound on Inanda dam, where he is preparing rooms for hundreds of volunteers he believes will come and stay
Kim Cools’ compound on Inanda dam, where he is preparing rooms for hundreds of volunteers he believes will come and stay

The walls of the room are draped in leopard-print material, and there is a large wooden pole in the middle of the room. The only light comes from a single candle, casting shadows on the animal-print walls. In one corner there is a grass shrine with a small, cave-like opening. At the other end of the room is a table with empty baby-food jars and Vaseline tubs containing different coloured powders and substances.

When the doctor leans forward, there are beads of sweat dripping down his youthful face.

“Did you bring what I told you to” he asks, referring to the R350 consultation fee. He instructs me to drop the money into a grass bowl, close my eyes and pray. When I open my eyes again, the money is gone.

The consultation begins. Sawa studiously writes down key information. I say I am 24 and was diagnosed with HIV three months ago.

“Do you believe in Amakhosi amakhulu (the ancestors), sister, and do you thandaza (pray)?”

Because that is what I need to be healed, to pray, speak to the ancestors, and to drink his prescribed muti.

The consultation lasts about 45 minutes. Most of it is dedicated to us praying out loud that my ancestors cure me, and while we pray the “doctor” shakes his rattle loudly near my head, and prays “Mbirimbiri, Makhosi amakhulu, Dube, Dube, Dube.”

After speaking to my ancestors, he tells me that I need to be patient as the treatment could take up to a month. He also tells me that I need to come back the following week.

“Bring samples of your pubic hair, so that we can speak to the ancestors again.”

He gives me a green powdered muti bundled in newspaper. I will have to bath in this to cleanse myself of HIV.

“Make sure you call me every time before you bath, so that I can pray on this side,” he tells me.

He tells me to cut down on drinking, that my partner and I can have sex, but that in a week or so – when he gives us the go ahead – we won’t have to use condoms anymore. He also says I never have to go back to the clinic because in about a month, I will be cleansed of HIV.

In the meantime, all I must do is pray, bath, be strong, co-operate and always answer his calls.

Of conspiracy theories and “healing” juice

Kim Cools has striking blue eyes. Next to his right eye is a puss-filled wound.

“I had a little cancer thing here, so I took a razor and sliced it off,” he explains.

There is no such thing as HIV, he later declares.

“If I inject myself with HIV-positive blood, how come it doesn’t affect me? It’s simple. If you read the books, there is no HIV,” he says.

Even so, he has a cure for this “non-existent thing called HIV”.

Cools, is a long-time dissident who has been in the country since 1995. He has spent all of this time “trying to awaken the people,” he explains. Before Cools came to South Africa, he had been diagnosed with colon cancer and was told he only had four months left to live. It’s 21 years later and Cools sells at least 2 000 bottles a month of the mixture he believes saved his life.

This mixture of ginger, lemon and garlic is now a juice branded “Umlingo” and it is mass produced at a factory in Pinetown, Durban. It is distributed to thousands of people as a cure for HIV, or rather, as a cure for acidic bodies, since there is no such thing as HIV.

“It’s all one big lie,” he says.

According to Cools’ website, he is a health practitioner. He is also a conspiracy theorist: there is no HIV, the moon is a hologram, the earth is flat, and there is a giant wall at the end of the South Pole holding vast tracts of land that “they” (The Matrix), are hiding from us.

Given half a chance, Cools will tell anyone who will listen about the germ theory, which he has “proven over and over again to be untrue”. .

The local clinic bears the brunt of Cools’ theories.

KwaNgcilosi Clinic is a 10 minute drive from Cools’ island plot on Inanda Dam.

The head sister there is reluctant to discuss Kim Cools.

“I want nothing to do with that man,” she says. “He just keeps confusing the patients with his nonsense.”

In spite of his unsightly eye, Cools is likeable. It is easy to see how anyone could get caught up in this friendly man’s theories.

There was a time when the patients at KwaNgcilosi Clinic stopped coming to get their medication altogether.

Even though things are better now, there are still many people who have traded in their ARVs for Umlingo juice.

While the government and the Treatment Action Campaign (TAC) have worked tirelessly to rid the province of pseudo-scientists and traditional healers, Cools and his gang have managed to keep going.

Cools tell us that in 2017, the government will “rollout” Umlingo juice.

“In 2017, in the Durban Metro, there will be a six-month or 12-month programme to see how it can actually expand.”

Cools claims that there are doctors, nurses and ministerial bodyguards who visit his island compound to get bottles of the juice. The compound is secured by a barbed-wire fence and two gates that remain locked at all times. Although confident of his mixture, Cools carries a deep-etched paranoia: “There are lots of people from The Matrix who want to get rid of me,” he says.

He has big plans for the future. He is currently building bunkers on his compound and a large food forest that will feed the hundreds of volunteers he imagines will come and stay on his Island.

Perhaps the scariest aspect of his warped self-assurance is his blatant disregard for South African law.

He says, repeatedly, that “they are allowing us people to stand up, without doing what Europeans would do, which is put us in prison and shut us up.”

Despite ongoing efforts to rid the province of people like Dr Sawa and Kim Cools, a cycle of poverty continues to drive hundreds of desperate people into the arms of pseudo scientists and false traditional healers offering any kind of solution to the HIV/AIDS epidemic.


Fewer children are dying of severe malnutrition, but ignorance continues to kill babies

By Bill Corcoran & Nomatter Ndebele

Severe acute malnutrition (SAM) remains stubbornly entrenched in many of KwaZulu-Natal province’s rural and peri-urban communities, on-the-ground evidence gathered by the Spotlight suggests.

South Africa has made progress over the past 10 years in reducing SAM levels in young children, according to the 2014 Triennial Report of the Committee on Morbidity and Mortality (CoMMiC) in children under five.

Four-year-old Owami Phongolo suffers from moderate malnutrtion. Here she stands in the kitchen of their four-roomed house in KwaSibongile Hostel, Durban
Four-year-old Owami Phongolo suffers from moderate malnutrtion. Here she stands in the kitchen of their four-roomed house in KwaSibongile Hostel, Durban

From 2009 to 2013 all provinces, except the Free State, were able to reduce the incidence of SAM in the general grouping of identified malnutrition cases. Indeed, KwaZulu-Natal reduced its prevalence from 8.6 percent to 3.5 percent of recorded cases.

However, achieving the national SAM target of just 1 percent of all malnutrition cases remains elusive despite government and international interventions.

The World Health Organisation (WHO) defines SAM by a very low weight for height (below -3z scores of the median WHO growth standards), by visible severe wasting, or by the presence of nutritional oedema.

According to the latest CoMMiC report, 28.7 percent of deaths in the under-five age category in KZN had underlying severe malnutrition in 2013. The province also had the third highest in-hospital mortality rate for SAM in children below five years of age, at 16.4 percent.

Health professionals working at Dundee Provincial Hospital in KZN’s Endumeni Municipality cited poverty, a lack of education, laziness, and the use of quack or fake remedies as the reasons most SAM-afflicted children had been admitted to their facility.

Hospital records show that in the 15 months to the end of April 2016, the medical facility’s e-ward, where all SAM cases are treated, admitted 59 young children struggling with the condition, of which five died.

It is unclear how many children with mild-to-moderate levels of SAM attended Dundee Hospital over the same period, as these cases are treated as outpatients, and the information was not accessible to the Spotlight.

High School Students in Dundee buying snacks through the school fence at break time
High School Students in Dundee buying snacks through the school fence at break time

Lungile Tshabalala, a dietician at Dundee Provincial Hospital, explained that in many SAM cases she sees, the patients’ mothers do not understand how to nourish their children properly. They try to feed babies with adult food, she said, as they cannot afford baby formula.

“This shouldn’t be happening,” she said. “There should be people monitoring these kids all the time, rather than just when they are in hospital.”

Tshabalala said that nutrition advisors do not always do a good job of advising patients properly because they are under the directive of supervisors who try to impose their own ideas, which are not always best practice.

When speaking to nurses and mothers in Dundee Provincial Hospital’s e-ward, many interviewees said the widespread use of quack remedies and herbal enemas was a contributing factor to the persistence of malnutrition in local communities.

“If a child has diarrhoea, the mother thinks the herbal treatment will help,” according to Tshabalala.

The mothers on e-ward said that people used such mixtures because they are advised to by older generation family members, or traditional healers. One enema that was said to be widely used comprises shoe polish, toothpaste and soap.

Mathias Mbatha, head of traditional health practitioners in the Dundee area, told the Spotlight that children should never be given a health enema, but that “fake” traditional healers often prescribed it for a variety of ailments, including HIV.

“The biggest problem is the pseudo-traditional healers,” stated Mbatha, “They chop up whatever they can find and just sell it to people on the streets. Sometimes people take enemas without even having them prescribed.”

“There is a move to create an official traditional healers forum to ensure that people consult with legitimate traditional healers,” he added.

It also appeared that many of the mothers who accompanied their children on e-ward were unprepared to deal with motherhood and child rearing.

Nompumelelo Phongolo (37) sits with her daughter Owami during an interview with Spotlight
Nompumelelo Phongolo (37) sits with her daughter Owami during an interview with Spotlight

Nontando Sithole (22), who took her seven-month-old daughter S’nikiwe to see a doctor because she was struggling to breathe, said she had not taken the baby to hospital since she was born because “I was too lazy”.

Mbali Sithole (19) took her 11-month-old daughter Elihle for an assessment at the hospital on April 29 last year because the little girl had diarrhoea and was vomiting. The child was immediately admitted for SAM.

“I thought she was just teething, but she became weak and started to lose weight,” said Sithole.

For Umzinyathi District where Endumeni is located, the provincial department of health’s annual report for 2014/2015 states that 282 young children were admitted to hospital with SAM for the 12-month- period. In total, 35 of these patients died.

For a province-wide view of the problem, the annual report states that 3 880 cases of SAM in children under five were admitted to hospitals in KZN for the period under review, of which 405 proved to be fatal.

In terms of diarrhoea, which in severe cases leads to malnutrition, the number of deaths in the province stands at 30 from 798 cases admitted between 2014 and 2015.

During his April 2016 budget vote speech KZN Health MEC Dr Sibongiseni Dhlomo said that in March 2015 a pilot intervention targeting all households in Zululand District, which has the highest number of malnutrition deaths for children under five in the province, was launched. This was followed by a broader roll out of the initiative across the province.

“The main outcome of the community-based profiling recommended by the model was that children were identified earlier with fewer complications, and thus had better health outcomes.

“There has since been a 22% reduction in deaths related to severe acute malnutrition in the province since the last financial year,” he stated before adding that “all other districts have been encouraged to roll out implementation of the model so that the province perseveres in achieving optimum child health.”

When the KZN Department of Health was approached to contribute to this article, they failed to address any of the questions submitted to the KZN health MEC’s spokesperson, despite being given a number of weeks to respond.

So, whether its latest intervention is viewed by the department of health as a watershed moment strategically, and has the desired impact of driving down the number of SAM deaths to the 1% national target, remains unclear.