South Africa’s hospital train
Nelson Mandela will be remembered at every level, but not least for his ambitious programme to develop public infrastructure. Where that is not enough, a health train rolls around the country to serve areas that lack the simplest medical services.
Radical attempt to bring healthcare to everybody
To travel west from Johannesburg to the small town of Kathu is to take a journey back in time. The motorways gradually give way to potholed roads, bordered by the veld. The way deteriorates further past the invisible border of the Northern Cape, South Africa’s largest and least populated province. There is another 500km on patchy asphalt through a deserted landscape before the sleepy town of Kathu, population 10,000, in the foothills of the Korannaberg mountains. Along the main street are a shopping centre, shops selling spirits, and luxurious guest lodges, where bored young women sit in the evening, drinking strawberry vodka.
Northern Cape is larger than Germany and has a population of a million: it as “as deserted as it is desert”, as they say here. But one morning this summer, an 18-carriage train carrying ultramodern medical equipment was travelling the line that serves this outer fringe of the Kalahari. It halted in the middle of the grassy plains, at Wincanton station. Posters throughout the region and local radio stations had announced its arrival. “I’ve waited two years for this moment,” said a local woman. The Phelophepa was here.
The Phelophepa (“good health” in the Tswana and Sotho languages) is the result of the South African government’s problems in providing its 50 million citizens with basic social services. “It would be better if our hospitals were in permanent buildings,” said Lynette Coetzee, programme manager for the health train at the Transnet Foundation, part of the state railway operator, which manages and co-funds the project. “The reason our work is in such demand is that something has gone wrong since the end of apartheid.”
At the end of more than four decades of “separate development”, the nation inherited a healthcare system of international renown, but confined to areas where whites lived. To correct this, Nelson Mandela and his successors pursued an ambitious programme of developing public infrastructure. They extended water and electricity networks, and built or renovated 1,600 hospitals, “providing a more equitable distribution of access to care,” said Alex van den Heever, professor of social security systems administration and management at Witwatersrand University. But, he said, “the general quality of healthcare deteriorated considerably,” because of a government programme, launched in 1997, offering (mainly white) doctors and administrators voluntary redundancy to balance out the number of whites and blacks working in public hospitals. “Many professionals moved to the private sector, and in one fell swoop the memory of the system evaporated,” said van den Heever. The replacement appointments made by the governing ANC (African National Congress) were political. “The health sector was held hostage to power games between local party bigwigs. Clientelism and corruption brought the system to its knees.” It also made the Phelophepa indispensable.
A hard life on the rails.
“Since 1994 we have provided primary healthcare to 46,000 South Africans a year,” said Onke Mazibuko, a psychologist in his thirties who has been managing the health train for two years. “Our aim in Wincanton is to treat 1,250 people by the end of the week. It’s a hard life: we get up at 6am, shower for three minutes, then work for eight hours, until we’ve seen the last patient.” Every year he covers 15,000km to help the underprivileged. He works alongside 19 itinerant doctors who supervise a weekly rotation of 40 medical students from the country’s best universities: “It’s their baptism of fire.”
The day after the Phelophepa’s arrival, the ghost station of Wincanton had turned into one of the busiest places in the province. Men and women, young and old, black and coloured, queued to see the medical staff. There were sockets without eyes, limbs damaged by badly treated wounds. It’s not surprising: “The nearest hospital is at Kuruman, 50km away. I have no way of getting there,” said Peter Thonas, there with his seven year old nephew, who had toothache. “Doctors are too expensive,” said Julius Tood, a young man who had hitchhiked from a nearby township. “People are suffering here. Our condition is like the landscape all around us — unchanging.”
In front of the carriage dedicated to general medicine, a doctor diagnosed a case of diabetes, while another measured blood pressure. After diagnosis, patients are directed to specialist carriages. Two carriages house the ophthalmic clinic: where a patient waited for a student to make a pair of glasses for 30 rand ($3). For many South Africans, this is a new experience: “I’ve seen 80-year-old patients who have never had an eye test in their lives,” said Liesbeth Mpharalala, who runs the ophthalmic department.
In the dental clinic, a dozen staff were busy with their patients. “Most of the poor have no dental education. They don’t know how to look after their teeth,” said Muhammad Garu, a dental student in Johannesburg. Lynette Flusk, in her cramped office in the psychology clinic, described the problems: unemployment, trauma from rape, poverty. “Self esteem is not high here. Don’t be fooled by the landscape — horizons are limited.”
‘The need is enormous’.
Once patients have been treated, they go to see Elizabeth Mpya and her assistants in the pharmacy. For a few rand, she gives out anti-inflammatories and antibiotics. In the “management” carriage, Mazibuko was writing a report on their activities for the Phelophepa Transnet Foundation. “The need here is enormous, but we won’t be back in Wincanton for at least another two years,” he said with regret. Until then, locals can go to the hospital at Kuruman. “But it’s terrible,” said a patient. “I almost died when I went there to have my baby.” Another option is the community health centre run by Marinda Theron in Deben, a township of 6,000, but “there are too few doctors and the ambulances take ages,” said an Afrikaner nurse who had worked there for 14 years. “And Placido Domingo doesn’t do anything to reduce our workload — even he sends us patients!”
“Placido Domingo” is a traditional healer (he borrowed the opera star’s name) who lives in Deben. In the maze of alleyways lined with corrugated iron huts, his luxury brick house stands out. Two Mercedes C230s are parked discreetly under a canopy. The living room has elegant furniture and a stereo sound system. Our host talked about his love of traditional Tswana music: “I’m recording my second album in Kimberley next week.” But in Deben he is known for other talents. “I identify the curses that may be causing health problems. People here use a lot of curses.” To treat his patients, Domingo (nicknamed “The Witch”) throws 17 lamb bones on the ground, interprets their pattern, then invokes the help of the spirits before prescribing treatments based on lotus flowers and powdered bark. Eighty per cent of South Africans regularly consult one of the 200,000 registered traditional healers. But, our host said, when the Phelophepa comes to town “people from Deben flock there. Traditional and western medicine complement each other.” He does not join them for a check-up.
Yet Mazibuko feels satisfied with what the train achieves: “We treated 135 patients on Monday, and twice that on Tuesday.” Attendance is not guaranteed. “Local state employees are on strike, and the council did not provide any transport for people to get here. Even the water we were promised was not delivered.”
The post-apartheid health record
More than two decades after the end of apartheid, the chaotic state of public services is cruelly detrimental to the health of South Africans: life expectancy is just 53.4 years, 17.8% of the adult population has HIV or Aids and the country is ranked 123rd out of 187 on the Human Development Index. The government has to face these huge challenges with only one doctor for every 4,219 people, one of the lowest ratios on the planet. “Many are leaving the country for better working conditions abroad,” said Mike Waters, the opposition Democratic Alliance’s health spokesman. Northern Cape is particularly badly affected, despite the local government’s vision of “health service excellence for all” — it cannot fill 57% of its vacancies for doctors and 34% of its nursing posts.
“In my town the government has built a brand new hospital, but you won’t find a single doctor inside,” said Isabelle Roberts, who had travelled from Dingleton, 60km away, to be treated on the Phelophepa. With an annual budget of 25m rand ($2.5m), the hospital train has treated nearly 6 million South Africans since 1994, and made more than 20,000 future doctors aware of the challenge of working in a medical wilderness, in a country larger than Italy, France and Germany put together. “I tell my students: try to come back to the train after you graduate,” said Lynette Coetzee. “And many do.”
The Phelophepa also employs 80 full-time and temporary support staff, recruited at the stations. While the doctors are dressing wounds, they are stocking supplies, washing linen, or preparing meals. And there are bored security guards aboard, watching their monitors. “This train is a bit like a submarine,” said Saazi Guzi, in charge of the dental clinic. “We share very personal things. The people around you end up being part of your family.”
Colin Boucher, head of logistics, joined the Phelophepa 18 years ago, and thinks he has done his real family an injustice by staying on the train this long. “I’ve got another 12 years to go, but to be frank I don’t know if I will make it.” Flusk, head of psychology, said: “You are well outside your comfort zone here. The patients are difficult, and you are far from your loved ones. This train can make you or break you.”
Sunday is their day off. Mazibuko, tired after too little sleep, wandered along the tracks in his flip-flops, gazing across the Kalahari. “You can’t imagine what we have seen on this train.” Behind the apparent routine of the work, he likes to remember the diversity of the experiences. “Wherever I am, all I need to do is look out the window, and I will see the same scene: an old woman who has come to have her vision tested, an old man wobbling on his walking stick, a child running around... Every week I will see the same scenes, but each time in a different place.” He recalled his favourites: “A stop at Mossel Bay, in the south, overlooking the Atlantic; a stop at Mooketsi, in Limpopo province, in the foothills of the Hanglip mountains.”
A few carriages further along Mpya the pharmacist also looked out over the veld: “I am an optimist. The next time we come through Wincanton, there will be a good hospital a few kilometres away. When that happens, we won’t be needed... I hope I see that before I die.”