Traffic at the main intersection leading to Paardekraal, a township outside Rustenburg, is quieter than usual, given South Africa’s ongoing Covid-19 restrictions. But on a late winter’s day, a cluster of people who are gathered on the pavement refuse to be silent.
It is an impromptu protest, but an important one. They are responding to news that on that morning the body of a young woman was found dumped in the township. The protestors believe she was also sexually assaulted.
The protestors shout and sing from behind their masks. They wave placards for the muted traffic, for passersby and the handful of police who watch on.
In the thick of the protest is a Doctors Without Borders minibus. It is with the PA system inside the humanitarian medical organisation’s vehicle that protestors are calling out their demands – for the killing of women and children to stop, and for the police to act.
“We have to be here to support the community. People are complaining that such things keep happening, but the police aren’t doing anything for them,” says Molefe Motsilenyane, who works for Doctors Without Borders as a psychological first aider and driver. He and his colleagues join in the protests, dancing and chanting.
For Nwabisa Thwesha, organising a gathering in lockdown risks the police clamping down on them, but she and the other angry protesters do not care. Thwesha lives in Paardekraal and says the violence and killing of women and children are unacceptable and unabated.
“We can’t blame Covid-19 for this, this GBV [gender-based violence] stuff was happening long before. Every few days you hear these stories. It’s like the bushes are eating us women and still women are not being taken seriously. We must come here to protest,” she says, waving her hand towards the open veld and shrubs on the outskirts of Paardekraal.
At night, without electricity, proper pathways and the reality of high crime in the area, she says these become terrains of terror, especially if you’re a woman.
Five impactful years
For five years Doctors Without Borders has had a strong presence in the Bojanala district, building infrastructure and support networks for rape and domestic abuse survivors. It set up its operations off the back of a study it conducted and published in 2015.
The study findings were damning, showing that among the 800 women in the district surveyed at the time, one in four reported having been raped. Access to care and resources for care was also found to be pitiful.
Doctors Without Borders services in the Bojanala district have been centred on the establishment of four Kgomotso Care Centres, each equipped to give a rape victim medical, emotional and psychological support. Besides having a registered counsellor and social worker on hand, there is also a forensic nurse to collect evidence that will stand up in court. They also help facilitate the reporting of the crime to the police if the victim wants to.
Community outreach also became an important pillar over the past five years. It includes support for patient transport, helping to raise awareness about violence against women and children, conducting surveys for reports and deeper investigation into rape and violence in the community, and strengthening referral pathways that include those that lead back to the care centres.
But now Doctors Without Borders is leaving the province.
In line with the humanitarian medical nongovernmental organisation’s model of operations worldwide, it responds to emergencies and helps fill a gap in medical healthcare while partnering with local authorities.
Sometimes it builds infrastructure, like in Bojanala, and employs local teams to staff its projects or deploys staff from its international offices. The aim is always to build up to something, make it sustainable and then to hand it over to the local authority.
The Bojanala exit has come in a year of Covid-19. It has meant that, even in winding down, Doctors Without Borders has had to change gears.
Its resources have been diverted to set up Covid-19 screening and testing. At one point it employed a nurse on a temporary contract to do the swab testing that was not happening in the district.
Kgaladi Mphahlele is a professional nurse and was part of the Doctors Without Borders response team until the end of September. These teams have been stationed outside clinics and hospitals, screening, sanitising and collecting information for tracking purposes in recent months.
The organisation also set up portable hand washing stations at taxi ranks throughout the district.
Months into South Africa’s Covid-19 lockdown, however, much of this has been vandalised. Mphahlele points this out on a spot-check visit to the taxi rank. It is also noticeable that mask-wearing is not being enforced and taxis do not operate with windows open.
Mphahlele says the North West has never been ready for a worst-case scenario of Covid-19, it just got lucky with low infection rates.
“There was all this talk about getting field hospitals ready in lockdown, but we only have the mine hospitals that were handed over to [the health department] and we don’t know what equipment or staff they have there.
“Complaints from healthcare workers who don’t have PPE [personal protective equipment] and PPE corruption is our daily bread here. Thank goodness our numbers in the province are low. We are not ready for a big outbreak in the province,” says Mphahlele.
Bojanala district is platinum mining. Concerns were that returning miners would cause localised spikes in infections. By early winter the mines did record increases, but by spring the number of new infections had dropped again.
Mphahlele’s biggest concern is that lockdown restrictions have disrupted regular services for reproductive health and termination of pregnancy. In the early months of lockdown there were reduced services and some facilities closed for weeks at a time. Doctors Without Borders had to increase its assistance to transport patients to facilities and to arrange appointments at the few sites where treatment was still available.
“I get desperate phone calls from women who say they are going to get terminations done in places and ways I know are unsafe, but they can’t wait for appointments that will only happen weeks later or they have no transport money to get to the facilities; it makes you worry,” Mphahlele says.
Wrapping up is hit and miss
Mphahlele is one of the staff members who are wrapping up their contracts with Doctors Without Borders.
“Honestly speaking, I don’t know what’s going to happen when Doctors Without Borders leaves Rustenburg,” he says.
The exit plan for Bojanala district has been in the pipeline for more than a year and the winding down process is expected to be concluded by the first months of next year, with a full handover to the North West health department.
In the textbook model of a handover, the facilities, equipment and services become community assets, which the department inherits and oversees.
Doctors Without Borders staff are redeployed, conclude their contracts, or are retrenched procedurally. Some are also absorbed in the department structures.
But the reality of the handover in the province has so far been hit and miss – raising questions about the health department’s capacity and commitment to continue with the Kgomotso Care Centres in a model that will still deliver a reasonable service.
Tebogo Lekgethwane, North West health department director for media and communications, received Spotlight’s interview request and questions. These were confirmed to be circulated to various department heads who have been directly involved in months of discussions.
However, no one from the department responded to Spotlight’s questions.
Lack of communication, commitment and clear decision-making by the department go against a memorandum of agreement signed between Doctors Without Borders and the department five years ago.
Some doors closing
By the end of September, two of the four care centres had to close their doors without department staff to replace the Doctors Without Borders teams. A month later one of these reopened, but the organisation says indications are that the services at all four are likely to be interrupted or even closed for the foreseeable future once the organisation leaves.
For forensic nurse and Kgomotso Care Centre project medical referent Cecilia Lamola, the inevitable loss of the facilities to the community is a massive blow.
“We at the care centres have focused on a programme that has been about preventative measures and supporting a victim in the long run.
“When the systems are not there or are not well run then people will be violated like it’s a normal thing. We end up creating a violent community and a violent society,” she says.
She says evidence she collected has helped convict perpetrators of rape and abuse.
“When you take evidence and the perpetrator gets arrested and prosecuted, you have played a critical role and given a voice to the justice system,” says Lamola.
She says knowing the community will “not be able to just switch to services run by the health department when we are gone is heartbreaking. It is something that doesn’t gel with me.”
Doctors Without Borders communications manager Sean Christie says their operations in the North West ran for nearly double the initial intended lifespan of the project.
“Doctors Without Borders’ DNA is about emergency response, innovating care and being a catalyst. Budgets are renewed on a year-on-year basis. Something like the projects in the Bojanala district competes against dozens of other initiatives in 67 countries around the world and in places where there is a total gap – absolute zero – in terms of resources or access to care,” he says.
Christie says while the organisation never intends to be in one place permanently, its partnership agreements are meant to ensure continuity of service, replicability and the potential to be scaled up.
He points out a “disjuncture of service and the uptake of service” in the North West Kgomotso Care Centres. It deserves deeper review and reflection, he says.
But it also offers up clues to how people seek (or don’t seek) help for rape or in domestic and cases of violence against women and children. It speaks also to the shame, stigma and distrust of the systems that are in place.
A key positive, though, he says, are the off-shoot projects from Doctors Without Borders’ presence in the province. Another is the schools sex education project that is undertaken by youth counsellors, the networks that have been built and a culture of inclusivity that has bought religious leaders and traditional healers into the room.
“An exit plan and a handover are never about a hard stop.
Doctors Without Borders understands that the reality is that public resources are not the same as they are for an organisation with deeper donor pockets.
“We don’t expect the care centres to be run in the same way when we leave, but we do want there to be something that remains in place. After all, the Kgomotso Care Centre model is something that started from a concept of care the health department itself envisaged. We just helped to implement that,” Christie says.
*This article was produced by Spotlight – health journalism in the public interest.