In times of unrest, rural communities must be able to trust and access medical facilities.
The tumultuous 2012 and 2013 farm strikes in the Western Cape drew the world’s attention to the poor wages and living conditions of South African farmworkers. But they also highlighted challenges associated with protecting the right to health for communities facing unrest, as well as the safety of health workers whose wellbeing may be on the line.
With health services stretched to the limit and clinics sporadically closing in De Doorns and Ceres to protect their staff, the Western Cape department of health relied on police cars to transport patients and on police stations to act as makeshift health centres.
This fuelled rumours that doctors were reporting patients with strike-related injuries to the police, and that patients were being taken straight from the hospital to jail. As a result, even seriously injured community members were reluctant to access health facilities.
The root of this reluctance can be traced to incidents during the strike, the history of mistrust of health clinics and police under apartheid, and ongoing issues with poor service delivery in farming communities.
The People’s Health Movement of South Africa conducted 25 in-depth interviews with farmworkers from three communities in order to examine these issues.
Although this sample is by no means representative of the entire farmworking population, we unearthed substantial obstacles to accessing healthcare in these rural communities, both during the strike and on an ongoing basis.
One of the most powerful barriers to accessing medical attention was mistrust of medical facilities. During the strike, this mistrust centred on what the Mail & Guardian called a “widespread belief” that doctors were reporting patients with rubber-bullet injuries to the police.
A farmworker and resident of the informal settlement Stofland told the health movement that she wanted to take her friend to the hospital after she was shot with a rubber bullet, but “other people was caught in the hospital [and] went to jail, so we said, ‘no, we can’t take you to the hospital’. We so much wanted to take her, but I also think they would take her … to jail. Because the first people who went to the hospital with injuries ... they didn’t come back.”
Handcuffed to hospital beds
The health movement also encountered first-hand accounts of farmworkers being taken directly from the hospital to jail; being handcuffed to hospital beds and interrogated by police, thereby compromising their treatment; and verbal abuse of patients perceived to have been involved in the strike.
One farmworker who was shot on his way to the pharmacy was surprised to find police officers waiting for him inside the hospital. He spent the following two nights in the police station, before the case was dismissed for a lack of evidence.
Incidents such as this led to the notion that seeking medical care for strike-related injuries could directly lead to detention or criminalisation.
The impact of these incidents was amplified by the collective memory of the apartheid-era practice of police rounding up suspects at hospitals — a practice that was particularly common in rural areas, according to an article by Leslie London, chair and head of the University of Cape Town’s Division of Public Health Medicine.
As one farmworker told the health movement: “In any strike … in the apartheid years … they [the police] always watch out for people who have been shot and who have been beaten … they know that you have to go to hospital, so there is always police who is waiting there.”
Instances of similar events today can reawaken these memories, and instil the idea that hospitals are not safe places for protesting communities.
“I was the guy who always told myself that [the] apartheid years [are] gone, so we are living in a new South Africa,” said the farmworker. “But I don’t see it like that any more.”
Most of the interviewees expressed an underlying discontent with health service delivery, which was heightened by sporadic clinic closures during the strike. Among the most common complaints were inaccessibility because of long distances to health centres, lack of money for transport and excessive waiting times.
In four independent interviews, participants asserted that people had died while waiting to be treated at the clinic. Other reoccurring complaints included verbal abuse, such as health staff shouting and swearing at farmworkers and routine breaches of confidentiality, including staff disclosing people’s HIV statuses or life expectancy.
One farmworker said: “[At] the clinic they like to talk too much outside, too much …. that is why all of us here, we can say exactly: ‘That one has Aids, that one has Aids, that one has Aids ...’ So people do not go for their medicine, because they are too scared to go there. They sit at home because they do not want people to know they are sick.”
These issues raise questions about the acceptability of care and ethical treatment of patients.
The right to health is a responsibility that stretches across sectors. In the case of the farmworkers’ strike, it was not just the responsibility of healthcare workers to ensure that their patients’ care was not compromised by the threat of arrest, it was equally the responsibility of the South African Police Service to distance themselves from medical facilities — not to mention to consider the deleterious health impacts of their wide and indiscriminate use of rubber bullets.
South African health services must also work to address the factors that breed mistrust in the system.
Without progressively working towards ensuring high-quality care, the ongoing dissatisfaction and mistrust of health service delivery in farming communities — made all the worse during times of unrest — will not be resolved.
One constructive action would be to establish and strengthen health committees at each clinic or health centre. These are formal structures designed to encourage community participation and are mandated by the National Health Act.
But although the Act was instated in 2003, many health centres do not have such structures. A 2012 report conducted by Hanne Haricharan of the University of Cape Town’s Learning Network for Health and Human Rights found that only 55% of clinics in the Cape Town metropole have a health committee.
These are a vital part of community participation in health, as they can bring community concerns directly to decision-makers, monitor and evaluate the health centre, and serve as a bridge between the community and the health facility.
This participation is one crucial step towards full realisation of the right to health.
Alysha Aziz is a recipient of a Fulbright scholarship and a volunteer with the People’s Health Movement of South Africa. The movement’s report on access to healthcare during the farm strikes is available on the organisation’s website. Next week we will publish the provincial health department’s response to the People’s Health Movement of South Africa’s survey findings