Disquiet on precarious front line

Gauteng community health worker Sisanda Kulima says that when her daughter asked about the coronavirus, she was surprised her mother was not afraid.

“She said to me: ‘But you are working hard mom.’ And I felt so proud because that made me aware that people can see how much I love this job,” Kulima says, her voice buoyant over the phone.

Kulima works at Finetown Clinic, in the south of Johannesburg. The 35-year-old is one of the province’s 9000 community health workers, who are a vital link between vulnerable communities and South Africa’s ailing healthcare system.

They will be on the front line of efforts to combat the spread of the coronavirus in townships across the province — which to date has the highest number of confirmed Covid-19 cases in the country.

Last week Gauteng premier David Makhura called these workers the “troops on the ground”. The province will arm this “huge army” of workers with information about Covid-19 and “what families and households can do”, he said at a press briefing last Wednesday.

But community health workers like Kulima say this was the first time they had heard of what was expected of them during the outbreak.

They started organising themselves — collecting information, printing pamphlets to distribute to communities and coming up with strategies on how to tackle the virus — well before President Cyril Ramaphosa’s late-night declaration of a national state of disaster on March 15.

On Monday, the Gauteng Community Health Workers’ Forum wrote to Gauteng Health MEC Bandile Masuku demanding protective equipment, permanent jobs and the reinstatement of dismissed workers.

The letter notes: “This is not the first time CHWs [community health workers] have been tasked with serving the working class to prevent the spread of infectious pandemics … CHWs have been on the front line of the struggle against HIV/Aids and .. illnesses such as tuberculosis. Many CHWs lost their lives in the service of their communities.”

“From my side, I am not scared,” says Kulima. She repeats the phrase “I am not scared” two more times before continuing her thought. “I would have been scared a very long time ago.”

“I am worried,” she admits, however. Although she isn’t scared to fight the virus head on, Kulima is nevertheless worried that many

community health workers in Gauteng say they do not have the protective gear they need to guard themselves and others against infection.

“If we can have the protective gear, I don’t see how we won’t be able to trace in households. But for now there is a little fear of going into the households and not knowing if you will contract the coronavirus.”

At the beginning of March, the World Health Organisation warned of a “severe and mounting disruption” to the global supply of personal protective equipment like medical masks.

Shortages are leaving doctors, nurses and other front-line workers “dangerously ill-equipped to care for Covid-19 patients”, the WHO said in a statement calling on industry and governments to act quickly to boost supply.

This week, the National Education, Health and Allied Workers’ Union — which represents public healthcare workers — released a statement saying that the necessary protective gear had not “materialised” in their workplaces since March 5, when the first confirmed Covid-19 case was reported in South Africa. “This has caused anxiety and distress amongst workers, especially the critical front-line public services.”

A community health worker based in Ekurhuleni says her clinic has enough gloves and masks. But there are only seven community health workers at that clinic, while others accommodating far more workers do not have enough protective gear to go around, she says.

The Ekurhuleni-based community health worker asked not to be named because she says she has seen the effects of becoming known as an “activist”.

“There are other clinics where there are 50 [community health workers]. They are staying in one room … So they are also clustered in that room and they are supposed to go outside and educate the community about the coronavirus and then come back,” she says.

“What if that person is already sick? Maybe she has the flu and she comes in contact with somebody with coronavirus.”

The Ekurhuleni worker says she and her colleagues were not given training or information about the virus until last weekend. “We just googled the information,” she says.

‘We are on our own’

In Bronkhorstspruit, to the east of Pretoria, Klaas Nakedi says a lot of his work has been around combating fake news about the coronavirus. “We’ve been using social media because a lot of people are using it and there is a lot of fake news. So we are using the platforms to counterattack by spreading researched, valid information on the virus.”

Community health workers spent the past two weeks distributing thousands of pamphlets to people at taxi ranks and in townships.

“There are no resources from the government so we are using the pamphlets to raise awareness within our communities and in so doing minimising the risk of us being infected as well as us infecting the community,” he says.

Nakedi, who has been a community health worker for six years, lives and works in Rethabiseng in Bronkhorstspruit, an area plagued by an ongoing water crisis, with residents complaining that the water is contaminated.

Nakedi is worried about what will happen if the virus takes hold in Rethabiseng.

“Unfortunately, I see, as this is one of the poorest communities, we will be one of those that will be abandoned,” he says. “We have to find our own resources and try to communicate to our people. We are not running away because we are committed public servants … but I think we will be abandoned. We are on our own.”

Nakedi says recognising the inadequate provision of services to poor communities is why he became a health worker in the first place.

“I believe that to see the changes I need to be the change. I am the community,” he says.

“So if I see something that needs to be improved — if I see a gap in the community — I think I should be the first to stand up. I’m the one who knows the crisis beneath the challenges of my community.”

‘I am the community’

Kulima, the community health worker from Finetown, shares this sentiment. “We show love through our work because we never chose it because of money. We chose it because it is a calling,” she says. “And we shall protect the South African people.”

There are 54000 community health workers across the country. These workers are well positioned to understand the healthcare needs of the township and rural communities they serve.

Kulima has lived in Finetown for 25 years. “I grew up here. I am very familiar with this place.”

She says her concern is that many of the people she treats are on medications that suppress their immunity. “Those are the people who are in danger. My worry is if it can get to the point that it gets to our township. At some point, this township will have many people who will die of the coronavirus.”

Like her colleagues, Kulima is undeterred, even in the face of the potentially massive task that lies ahead — and even though the department of health has failed to fulfil its promise to make them permanent.

Recognise us

In November 2018, the minister of health at the time, Aaron Motsoaledi, announced the national department’s plan to “absorb and hire” community health workers. Motsoaledi said the workers, who were earning R3500 a month, would earn R6000 as permanent employees.

But to date these Gauteng workers have not been given permanent contracts.

Recognising the global attrition rates of community health workers, and the role they play in the provision of primary healthcare, the WHO published a set of guidelines for countries to support them.

The WHO guidelines strongly recommended that policymakers ensure that community health workers are remunerated with “a financial package commensurate with the job demands, complexity, number of hours, training and roles that they undertake”.

Kwara Kekana, spokesperson in the office of the health MEC, said training of the community health workers last week.

“The situation is changing rapidly and the department is also adapting and amending its plans as the situation changes.”

The workers will be provided with protective clothing and procurement is continuous, she added.

Kekana said “the discussion with CHWs in Gauteng has been taking place on a continuous basis between the MEC and the advisory committee. We have made a commitment to the committee to update them on every step in the process in Gauteng as we try and resolve some of the issues raised.”

She added: “CHWs are an important part of the health system.”

Kulima says community health workers “will continue to do what is right for the community but the government should also do what is right for us”.

“The problem is now they want to use us, but they don’t want to pay us and they don’t want to recognise us.”

Articel by Mail and Gardian