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Report: The Farm-worker Strikes of 2012-2013 and the Right to Health

Below is a report issued by the People’s Health Movement South Africa on Farm-worker Strikes of 2012-2013 and the Right to Health. This report was made possible with the help of  Alysha Aziz a Fulbright scholarship recipient and volunteer with the People’s Health Movement South Africa.

Introduction
From roughly August 2012  to late January, 2013, farm-workers in the Western Cape engaged in a tumultuous strike; a historic moment for the sector. The struggle dragged on for multiple months, punctuated by a brief period of failed negotiations in December 2012, then resuming full-force in January 2013. Thestrikes did not end neatly; rather, they ended with a partial victory of a new sectoral determination in February 2013 setting the minimum wage for farm-workers at R105.

This strikes brought to light many challenges associated with health delivery during strikes/ service delivery protests, particularly in underserved areas. Newspapers reported at least three strikers lost their lives[1] and many more injured — chilling news that spoke to the need for emergency medical care. Simultaneously, rumors circulated that doctors and other health officials were reporting patients with strike-related injuries to the police, and taking them straight from the hospital to jail. As a result, community members were reluctant to access health facilities, even if they were severely injured. The barriers to care were heightened when clinics in the De Doorns area and Ceres area closed to protect the safety of the clinic staff.

The purpose of this report is to examine community reluctance to access health facilities, the closure of the clinics, and any other barriers to care that arose during the farm-workers strike of 2012 – 2013. This report will close with recommendations for ensuring access to acceptable medical care during a strike action/service delivery protest. These have been created in the hopes of creating guidelines to protect the right to health of communities in times of protest and upheaval and to equip the PHM-SA with an advocacy tool.

II. Methods

For the purposes of this report, I conducted twenty-five, in-depth, face-to-face, one-on-one semi-structured interviews with farm-workers from three areas: De Doorns, Ceres, and Robertson. All three areas were affected by the strike, and De Doorns and Ceres were both areas in which clinics were closed. While this sample is by no means representative of the entire population of farm-workers, the obstacles to accessing healthcareunearthed by this investigation are still worth noting.

Approximately two-thirds of the interviews were conducted with the help of an Afrikaans interpreter, while remaining third was conducted in English (based on the interviewees comfort level and proficiency in English). Initial respondents were identified by NGO leaders, and subsequent respondents recruited via chain-referral sampling. All participants were over eighteen, and were required to provide written consent after reading (or being read) an information and consent form in either English or Afrikaans.

All interviews were transcribed and analyzed via thematic coding — a process of identifying and analyzing emerging themes in qualitative data. I often refer to data gleaned from interviews and use direct quotes, but to protect confidentiality, no names or identifying characteristics have been used in this report.

III. Physical Barriers: Closure of Clinics

The first barrier to care was the closure of the local clinics, which are typically the first points of care for farm-workers. Midway through January 2013, during the second wave of strikes, the Department of Health temporarily shut down clinics in the De Doorns and Ceres area, due to safety concerns for the clinic staff. According to the Western Cape Minister of Health, Theuns Botha, “We cannot afford to put our health workers who work at these clinics at risk, and so are forced to close the clinics.[2]” In addition, over the course of an informal interview, a clinic staff member highlighted the fact that it was not simply a concern regarding safety at the workplace, but also the safety of the staff’s homes and families, either from police violence or community/strike-related violence.

However, while the health and safety of health-workers must be a chief priority for the Department of Health, a patient’s right to care must be protected with the same dedication. In this case, the closure of the clinics resulted in disruption of treatment for many farm-workers in the affected areas. In the words of one farm-worker:

“It was very bad, it was very bad. People come get their medicines, clinic was closed for 3 weeks, people getting sick, some of them, we go to clinic, we hear the peoples talks, there was no transport, some of the people don’t have money, they stay here in the settlement and they can’t go to hospital.”

Another interviewee said that she worried about the clinic being closed when her child ran a high fever, another worker cited missing doses of her anti-depressants, and several brought up their concern for community members with HIV, TB, or chronic illnesses.

On the other hand, other proactive community members, clinic staff members, and leaders mobilized to protect the health of the community. For example, one well-respected farm-worker was part of an impromptu committee that was “deploying some people to wait for the ambulance when they are coming, and then they give attention to someone else when they heard that people had been shot there, then they went to that farm to see how serious the wound is.” Another outspoken leader met with the nurses to organize medicine for patients with chronic illness (including her diabetic sister, who was in need of insulin) and provide emergency care for the urgently ill. Another religious leader recounted how he went door-to-door delivering medicines with the help of a list of patients and addresses provided by a local nurse. Others mentioned the assistance of Doctors without Borders, medics brought in by various unions, and other volunteers.

Therefore, while access to medical care did not come to a screeching halt, the closing of the clinics did place a burden on the health of the community. This burden seems to have been largely tackled via community mobilization, outside support, and the cooperation of clinic health workers concerned for their community, rather than structured measures put in place by the Department of Health. However, these innovative measures can be drawn upon in creating future guidelines in the case of an emergency medical shutdown. 

IV. Mistrust of Health Facilities

In addition to the inconvenience of the temporary closure of Western Cape farm-workers first point of healthcare, an even more powerful barrier to accessing medical attention was mistrust of medical facilities. During the strike, the mistrust centered around what the Mail and Guardian called a “widespread belief[3] that doctors were reporting patients with rubber bullet injuries to the police. For example, according to a farm-worker and resident of the informal settlement Stofland, after she removed the rubber bullet lodged deep into her fellow farm-worker’s wrist, she instinctively tried to call an ambulance. Then, she thought twice about the consequences of her friend being admitted to the hospital.

“I phoned the ambulance, but after we hear our other people was caught in the hospital, 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 and put her also to jail. Because the first people who went to the hospital with injuries—they didn’t come back.”

This sentiment was echoed multiple times throughout all three areas in which I conducted interviews. Therefore, I traced the origin of the story and interviewed one of the men that many interviewees had cited as an example of why they would not seek care at the hospital.

Interviewee: [We were] in the clinic, maybe for an hour or less, while we were waiting for the ambulance. Then we go to [Worcester] hospital. Ok, they take care of us in hospital, from the hospital we go to the police station where we slept that Wednesday. That Thurs–

Interviewer: So were the police waiting for you outside the hospital?

Interviewee: Uh, not outside—inside!

According to his account, the police found him inside the hospital and escorted both him and another worker to the police station, where they remained for three days and two nights. There case was then dismissed in court due to lack of evidence. However, the news of these two individuals being taken directly from the hospital to the police station spread rapidly.

In addition, other farm-workers reported being treated like criminals in the hospital, with no other “evidence” against them other than then the rubber bullet injuries on their bodies. One young man recounted being shot in the eye with a rubber bullet, and then taken to the Worcester hospital in an ambulance packed with ten other injured people. According to his account, he was handcuffed on the hospital bed by his wrists and ankles, and questioned by the police while receiving treatment. He (quite reasonably) believed this compromised his medical treatment. According to his testimony, another man who was shot in the head was also handcuffed and interrogated while in the hospital. I could not find him for additional testimony, and was informed that he had since become severely mentally ill, could no longer work, and had returned to his hometown in the Eastern Cape. A 1991 article grappling with apartheid-era ethical questions pertaining to the management of civil unrest issues addresses this very issue, stating, “Where the conditions under which the patient is held as prisoner interfere with their medical care (eg: shackling to the bed), the attending doctor is obliged to insist on the removal of such interference.[4]” However, according to the interviewee’s testimony, their attending doctor(s) did not fulfill this obligation.

It was incidents like this that informed the notion that going to the hospital with rubber bullet injuries could directly lead to detention or criminalization. 

V. Factors Amplifying Mistrust

Interestingly, almost all farm-workers who brought up concerns of facing arrest in the hospital did so in a very matter-of-fact manner, as if police presence in medical facilities came as no surprise.  “In any strike, even in the apartheid years, when there is a strike or any action, they [the police] always watch out for people who has been shot and who has been beated,” declared one interviewee. As a result, he explained, the hospital was a logical place to go to make arrests. Indeed, this apartheid trend has been well documented, as has the subsequent fear of seeking treatment at the hospital for a protest-related injury. It has even been noted that “this phenomenon [avoidance of seeking medical treatment] was particularly common in rural areas where [doctor] collaboration with the police appeared to be much worse.[5]” This “phenomenon” of avoiding medical care has resurfaced once again in the same areas, re-awakened by similar patient-right violations and amplified by collective memory.

In addition, the idea of doctors compromising care because of conflicting duties was not restricted to the strike. Rather, it was a re-occurring theme during the interviews. For example, when discussing the farmer-owned clinic on her farm, one long-term farm resident and worker exclaimed, “the sister told us blatantly that she’s being employed by the farm owner and they have to go ask the doctor, she is just doing what he [the farm-owner] told her to do…” while another community leader described the relationship between farm clinic staff and doctor by saying, “the farmer has the key to the doctor. Because the pay of that doctor comes from the farmer. You understand what I mean?” Yet another worker attributed the lack of financial compensation for a debilitating work-related back injury (and subsequent hospitalization) to his farmer persuading his doctor not to record his injury as a work-related injury. These allegations raise interesting questions about the autonomy of medical staff on farms, as well as how they are perceived by farm-workers.

Moreover, the phenomenon of police overstepping their boundaries was also unsurprising to my interviewees. After all, the Mail and Guardian reported police committing atrocities including the following: shooting a farm-worker in the stomach while he was sleeping, kicking down a door of a house unprovoked, and entering another dwelling to forcibly remove the woman, strike the adolescent and shoot the man four times in the back.[6] My interviewees reported being forcibly removed from their houses and shot outside, and witnessing neighboring children being shot while watching TV or doing homework.

Finally, most of my interviewees expressed deep discontent with local health service delivery. Among the four biggest complaints were inaccessibility (distance and lack of money for transport) and excessive wait times (in four independent interviews participants asserted that community members had literally died while waiting to be treated in the clinic). The problem of inaccessibility was exacerbated for people with disabilities, who had increased difficulty reaching their points of care, and often had to travel farther than their local clinics to receive specialized care.  Other re-occurring complaints included routine breaches of confidentiality (in the words of a farm-worker in De Doorns, “when someone is walking there you are looking at that somebody like yeah, the sister said you are going to die on such and such time”), and verbal abuse, such as clinic staff shouting and swearing at farm-workers. All this led one farm-worker to declare: “Your life [as a farm-worker] is worth nothing here for anyone that you’re working for and it’s even worse for those who have to look after you.”

In conclusion, due to historic precedent, perceived dual loyalties between doctors and authority figures, widespread police brutality, and pre-existing mistrust due to poor service delivery in the rural Western Cape, the idea of medical staff and police collaborating carried particular weight. While it is clear from testimony that police did make arrests from hospitals (at least from Worcester), there is no evidence to show that any doctors, nurses, or medical staff had reported their patients to the police. Nevertheless, these few incidents — contextualized in reality in which farm-workers live in — bred a mistrust that became a significant barrier to healthcare.

VI. Recommendations

Based on the findings above, and conversations with health professionals, we make the following recommendations to the provincial Departments of Health in the case of another strike/service delivery protest:

A) In light of the fact that the right to access healthcare is a constitutional right, and that health services have been declared an essential service according to South African labour law, we recommend that the Department of Health make every effort to keep health facilities functioning during strikes and service delivery protests, and provide support to the clinics/hospitals in the areas affected in any means possible (e.g. contracting in security or even volunteers from within the community to protect safety of staff).

B) If safety/security threats to clinic personnel (or any other pressing problem) cannot be satisfactorily resolved in any other way but to temporarily close medical facilities, we ask that the Department of Health develop and circulate a clear and detailed contingency plan for providing critical medicine and medical supplies in the case of a clinic/hospital shut down.

One strategy to ensure a back-up plan could be to appoint one “emergency service-delivery point person” (or team) in each facility to keep note of all patients receiving medications for chronic conditions, and whose treatment would be most disrupted by a clinic shut-down. This point person or team would then use these records to assist community health workers in distributing medicines to these patients should the facility be forced to shut down.

C) Work with health and human rights organizations to create a simple database of independent, voluntary doctors in the province that are willing to be “on call” in case of emergencies, strike-related shut-downs, and/or instances in which the community members are being criminalized for rubber bullet injuries. This can be part of the back-up plan (point a), and may also provide the protesting communities with doctors they are more likely to trust.

D) Work to address the factors that alienate rural farming communities from their public points of care  and breed mistrust in the first place — lack of transport, inaccessibility, excessive wait times, breaches of confidentiality, and verbal abuse of patients. One way to do this would be to assist in the setting up health committees (formal structures for community participation in health, mandated by the National Health Act of 2003) for each clinic or community health centre, and strengthening already-existing committees.

Health committees are community-powered resources which can be key in bringing community concerns directly to decision-makers, monitoring and evaluating the clinic/community health centre, and otherwise serving as a “bridge” between the community and the health facility. This participation has the potential to lead to more community ownership over the clinic, higher quality of care, and greater accessibility and acceptability of care. All of this will greatly increase trust of the health facilities. 

Other Stakeholders

Finally, other stakeholders could also participate in putting these recommendations into action. For example, union leaders could also help recruit independent voluntary doctors and advocate for their members’ right to accessing healthcare. They could also accompany patients to the hospital to ensure that their rights are not being violated, and mobilise legal support if their patient is detained. Employers should ensure that they are not creating a situation in which the doctor they employ faces dual loyalties between the well-being of the patient and the pressures of the employer, as this can lead to severe human rights violations, strike or no strike. Finally, all organisations striving to improve health service delivery (particularly in rural areas) can engage in the effort to establish and strengthen health committees and move towards a more participatory, accessible and trusted health system.


[1] Davis, R. (2013, January 16). Farmworkers’ strike: Clanwilliam example may provide way out of the tight, ugly corner. Daily Maverick. Retrieved from http://www.dailymaverick.co.za/article/2013-01-16-farmworkers-strike-clanwilliam-example-may-provide-way-out-of-the-tight-ugly-corner/#.UdLSx4VvHY0

[2] Western Cape Department of Health: Cape Winelands District (2013, January 14). Service Delivery interruptions due to Farm Worker Strike [Press Release]

[3] Fogel, B. (2013, 18 January). De Doorns: Police Action Breeds Hostility. Mail and Guardian. Retreived from http://mg.co.za/article/2013-01-18-00-de-doorns-police-action-breeds-hostility.

[4] London, L. (1991, July). Ethical Issues in the Management of Civil Unrest Injuries. SA Family Practice. Retrieved from http://www.safpj.co.za/index.php/safpj/article/view/2761

[5] London, L. (1991, July). Ethical Issues in the Management of Civil Unrest Injuries. SA Family Practice. Retrieved from http://www.safpj.co.za/index.php/safpj/article/view/2761

[6] Fogel, B. (2013, 18 January). De Doorns: Police Action Breeds Hostility. Mail and Guardian. Retreived from http://mg.co.za/article/2013-01-18-00-de-doorns-police-action-breeds-hostility.

 

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**Update:
After numerous attempts to contact the Department of Health spanning well over a month, they responded to this report.

Comments from the Department of Health

On instruction of Mr Theuns Botha, Minister of Health in the Western Cape, herewith please find a more comprehensive reply to the issue. I trust that this reflects exactly how serious we are about continued service delivery to our communities.

As indicated before the findings of the research are not an accurate reflection of the efforts that were made by the Department to maintain access to health services in the de Doorns area.

Points to note:

The effect of the farm worker protests in November, was completely unexpected, the Farm Worker Protest Action was further fuelled by a political agenda which created a hostile environment.

  • This was the first time in current history that WCG Health was forced to close facilities due to protest action.  Not even during the turbulent late 80’s and early 90s, when there were at times quite violent marches, did protestors ever threaten the safety of health workers or facilities.
  • The staff at De Doorns Clinic was highly traumatised and all have required one-on-one as well as group debriefing sessions.  These were arranged by the District Management via the ICAS programme. The counselling has been on-going.
  • Despite the threats made by protestors – including that homes and children of staff would come under fire; staff opened the clinic within an hour after an agreement that community members would assist in keeping the clinic, its staff and patients safe from protestors.  This agreement came about after the department requested that the community send representatives to assist.
  • Constitutionally, provincial Health is required to offer emergency medical services as the basic access to health.  This was always provided, and no patients were ever turned away.
  • Emergency measures to provide health services were in fact brokered by the District and included the following:
  •   Interim medication distribution via the CBS platform (where possible ).
  •  Doctors without Borders negotiated with CWD Management and the agreements were reached that they assist with mass screening and distribution of ART’s. In any event MSF helped at De Doorns Clinic for two days.
  • Large scale messaging was deployed via radio and local networks (CBS, SAPS, Ngo’s, Churches etc.) that any person requiring medication such as Insulin, should make use of the ambulance services at the Police Station for safe access to Worcester hospital where medication would be dispensed.
  • The event took place during Diarrhoeal season.  In an effort to assist mothers with babies showing the first signs of diarrhoea, and to prevent de hydration while waiting for emergence transport, the following measures were put in place:
  • Infant feeding formulas were distributed via a community member to at risk babies. This was on the instruction of the MEC.
  • Oral rehydration sachets (Re-hidrat) were stocked at all Community Care Workers homes for ease of distribution.

*Note: Unless otherwise specified, the facilities in question are:

  • De Doorns Community Health Centre
  • Sandhills Clinic
  • Orchard Clinic

This is because Wolsely and Nduli clinics were only closed intermittently.

 

1.     Methods used by the researcher

a.      The researcher interviewed only 25 Farm Workers, of the hundreds of people that were actively involved in this action, only 25 were spoken with. Given the population of Stofland alone, this is substantially less than the required 39% participation per population, which is the accepted sample group for any survey.

b.      The survey does not indicate whether or not any of the people interviewed were active participants in protest action or if they were innocent bystanders.

c.      It is unclear whether these farm workers were workers living on farms or ‘casual’ employees. This would have an impact as there are reports that many farm workers living on farms were intimidated and their safety threatened by casual labourers for not taking part in the protest.

2.     Physical Barriers

a) Closure of clinics was evaluated on a twice daily basis.   In the morning and afternoon to establish whether it would be safe to reopen.  On a few occasions clinics were closed because staff could not get to the clinics due to rocks in the roads.

b) Facilities were only closed once staff had been advised, by the disaster management committee to evacuate the area. Initially during marches that took protestors past the clinic, staff would simply close the gates and lock the clinic doors, thus offering themselves and patients some form of safety.

c) The decision to close the clinics on 14 -16  January was fuelled by the stone throwing of rocks at the vehicles of staff.

d) An ambulance was stoned and further vandalised, and even so, EMS staff chose to stay, but moved their base to the police station.

e)  It was interesting to read that one farm worker stated that the ‘clinic was closed for three weeks’ although clinics were closed on and off; the longest period being 3 days. (14- 16 January).  However a few times the clinics would open and then close and evacuate before the next march took place.

f) It was however difficult to communicate to patients when and if the clinics would reopen as reopening could only take place once the police could assure the safety of staff which could only be done after the 8:00amdisaster management meeting.

g) On  17 January the re-opening of the clinic after the 3 day closure was brokered between the department and local community elected representatives.

h) Availability of Chronic medication, this presented problems in December, but in January was very limited, as most patients who use chronic medication had received medication for 2 months as is the practise during the festive season.

3.     Mistrust of Health Facilities:

a) This allegation came up during the action in November.

b)The rumour surfaced on the day that both police officials and farm workers were being treated at Worcester Hospital, which may have given rise to the rumour of ‘police are waiting for you’ and the subsequent fear of incarceration.

c) A further catalyst could have been that at times ambulances were denied access by the protestors, for those requiring medical assistance the only access point was to go to the Police station where EMS was temporarily stationed.  When no ambulance was available SAPS transported patients, especially women and children to the closest facility.

d) Should it have been the case that police arrested an injured protestor, it would the norm to take that person to the closest facility for treatment before incarceration.

e) As far as can be ascertained no person with injuries related to the unrest was ‘handed over’ to police.  A number of patients were treated at clinics and received follow-up care too.

f) It is unfortunate that two patients were arrested at Worcester Hospital; however this should be discussed with SAPS.

4.Factors Amplifying Unrest

a) WCG H personnel are required by law to treat any patient who seeks assistance at the facility where they work.

b) Staff in Emergency units in both effected areas treated protestors and police; often at the same time!

c) Staff were placed in a very uncomfortable position, one of our staff members stated during the group debriefing,   “that man who was on TV, throwing stones at the clinic, told us he would kill us.  He is one of our patients and next week we will need to care for him.  It will be difficult, because now I don’t trust him.”

d) We cannot comment on the services available via private farm Clinics; however it may have been that the Doctor refused to travel to the area.

e.      WCG H cannot comment on SAPS behaviour.

5.     Recommendations

a) Clinic closure is not taken lightly, however if threatened services will be closed – WCG H cannot wilfully place staff in an unsafe situation.

b) Alternatives will always be available, and communicated.

c) Chronic medication. As the CDU (Chronic Distribution Unit) become more and more proficient, it should only be a handful of people who require delivery during such times.

d) All staff who normally worked in the clinics that were closed was deployed into casualty areas and other clinics, for the purpose of dealing with the influx of patients.

e) Staff Attitude, etc. are being addressed throughout the Department.

f) The clinic has an active health committee, but finds it difficult to find members who are committed to serving on the committee.

Conclusion:
A factor that has remained concerning was not only the aggressive manner toward healthcare workers, but the complete lack of respect shown by protestors toward their own community members requiring health services.

A total of 73 patients with injuries directly related to the protest action (rubber bullet or stone throwing injuries were treated at various facilities.

The research serves to refocus energy on instilling good relationships with the communities we serve, however it is up to the community that the staff serve to ensure that the clinics are able to continue their work, irrespective of the political action surrounding the facility.

There is after all a relationship of trust between a health carer and her patient.

About Tinashe Njanji