In order to throw your toys out of the cot with such great aplomb you must feel that your voice means something, that shouting from the rafters will achieve something, that someone is listening. The privilege of being heard.

The people of Canzibe, in the heart of the rural Eastern Cape, know no such privilege.

They live in a subdued state of emergency. Their cries for a tarred road, an upgraded hospital, more nurses and better emergency services reverberate quietly in the lush valleys.

Canzibe district hospital, based in the Nyandeni sub-district, serves a population of around 143,000 people. Thirteen clinics in this vast area refer patients to the hospital. According to the latest District Health Barometer (2016/2017) the district is ranked amongst the 10 worst districts in the country with regard to the numbers of babies, children, and mothers dying. The former Eastern Cape homelands have also been identified as among the “most deprived” areas within South Africa according to an older study by the Centre for Analysis of South African Social Policy at the University of Oxford. The study based on results from the 2001 Census in South Africa reflects income and material deprivation, employment deprivation, education deprivation, health deprivation and living environment deprivation.

The desperate plight of Canzibe Hospital (and other EC health facilities) was highlighted in a shocking report by public interest organisation; Section 27 and the Treatment Action Campaign, entitled Death and Dying in the Eastern Cape almost five years ago. At Canzibe, little seems to have changed.

Just last year, the hospital only had one doctor remaining on its staff. Efforts from the Eastern Cape Health Crisis Coalition resulted in the placement of additional doctors. But the situation remains precarious with gaps being plugged in the short term by foreign doctors and doctors serving their community service. For the first time in many years, the hospital has acquired the desperately needed services of an occupational therapist to work in the rehabilitation department. However, the only dietician serving at the hospital will be leaving next month. This lack of continuity speaks to the absence of a concrete long-term plan for development and progress at the institution. Furthermore, the poor quality of the staff accommodation in an area which is impossible to commute to daily exacerbates the shortage of health workers serving the hospital.

In fact, Canzibe hospital does not feel much like a hospital at all – more like a makeshift operation operating from deep in the forest. The old buildings are disjointed and dilapidated and the sandy ground perilously uneven. Despite forming part of the OR Tambo District – a district earmarked as a National Health Insurance pilot site – the hospital has not been rebuilt/upgraded since 1955, when it was built by Dutch missionaries.

“At least it doesn’t feel like a hospital,” I quip to an intern based in Canzibe for one year.

“Would you like your Caesarean section to be performed at this hospital?” he shoots back.

“No….,” I mutter quietly.

The surrounding area is punctuated with colourful rondawels perched precariously on hilltops or deeply obscured in valleys. The astounding beauty of this fertile land masks a rough and unforgiving terrain – which makes the delivery of health services all the more challenging.

Everyone talks about the state of “the road”. “The road” is a 26km untarred stretch of pothole infested gravel that can easily determine the difference between life and death as it critically delays the time taken for people to access health care. It is the main (and only road) serving the area and no alternative routes exist. “The road” also serves as a major deterrent to health professionals wanting to work in the area. No emergency service vehicles operate in the Nyandeni area. During an emergency, an ambulance has to be dispatched from a centralised location at Buntingville Clinic (about 30-40km away) to collect patients – a round trip that could easily take up to six hours (if there is an ambulance available at all). The going rate for transport to the hospital in a private car is R600 – unaffordable in a community reliant on social grants and facing an unemployment rate of around 92%. As a result of “the road” patients often delay seeking care. I was told that “the clinic is the last resort if everything else has failed”.

Section 27 of the Constitution guarantees everyone’s right to have access to health services, to have access to sufficient food and water, and to have access to social security. At Canzibe Hospital and in the surrounding area, there appears to be a complete breakdown in service delivery. Feeble attempts to plug holes and save face in the short term are compromising the well being of thousands of people. NGOs working in the area describe the multiple roles they play – walking from door-to-door teaching new mothers to breastfeed, providing education on nutrition, advocating for maternal and child health, providing palliative care for sick TB and HIV patients, assisting the disabled, dealing with domestic violence and substance abuse, helping children to get identity documents so that they can apply for grants, and the list goes on.

Surely the acid test of a caring government manifests in the manner it treats the most vulnerable members of society – not the most outraged. In fact, our Constitution mandates that the most vulnerable members of our population be prioritised. It is almost 25 years post-democracy, and the community of Nyandeni appear to be more disenfranchised than ever before – their basic rights to life, dignity, and service delivery are being violated.

Life Esidimeni happened under our watch.

Canzibe is happening under our watch.

Already, at Canzibe Hospital, psychiatric patients have to share a ward with other patients and be transported in the same ambulances, when travelling to Umtata General Hospital, 46km away. Already, at Canzibe hospital, there is a dire shortage of health workers – in an area where the infant mortality rate is one of the worst in the country. Already at Canzibe, the state will not pave the road into health services, let alone provide a way out of this sorry situation.

I asked a senior nurse who works for an NGO in the area, if she could have a wish list for her people, what it would look like. To my surprise, she didn’t ask the government to fix the road, or upgrade the hospital or hire more staff. Her requests were small. “Help me get medication for my patients especially TB meds” and “help me to get a social worker into the area”. This community has been deprived to such an extent that they have buried their outrage, they have lowered their expectations in the hope that someone will listen.

In the 2017/2018 Eastern Cape budget speech, Finance MEC Sakhumzi Somyo stated: “We hear you, we see you, we live among you, and we know your daily experiences.”

I certainly hope this insight will afford the people of Nyandeni the privilege of being heard, before it is too late? DM

Thania Gopal is an Atlantic Tekano Fellow for Health Equity in South Africa and is currently completing a Masters degree in Public Health at the University of Cape Town