Lara Fairall: Where there are nurses and community health workers

lara_fairallAugust marked the fourth anniversary of the shootings at the Marikana mine in North West Province of South Africa. It’s one of those events that so etches itself onto our collective soul that you remember exactly where you were when you learnt about it.  I was in an upmarket coffee shop—I live in one South Africa and work in another—indulging my Friday morning fix of precious alone time and caffeine—when I saw that front page and reeled at those images. Thirty-four miners gunned down—many shot in the back—by South African policemen during wage protests in an act that reproduced the worst atrocities of apartheid. It was, and always will be, outrageous that such brutality could be part of our democracy—it belonged to another time, to another South Africa. The lead-up to the massacre was as brutal as the act itself—mining security guards hacked to death with pangas. In the months and years that followed we have learned more of the miners’ lives—the long shifts, day and night 24/7—during which rock drillers core the earth, extracting its riches to line the pockets of the wealthy and perpetuate the landscape that surrounds these mines—a narrative of generations of migrant labour, dismantled families, alcohol, AIDS and the silent rage of the dispossessed. 

An official enquiry into the events on that koppie, or little hill, next to the mine at Marikana followed and I think many of us hoped that it would take on some of the form of our ground-breaking Truth and Reconciliation Commission. But the enquiry felt mechanistic and was dominated by officials, the mine-owners, the rich, the state, dodging accountability while the miners’ widows sobbed quietly in the gallery. It lacked any real sense of either truth or reconciliation. Last month the Minister of Police reported to our Parliament on progress with adopting recommendations made by the commission. He started by saying how the police had acquired high tech auditory equipment to aid police communications in the field. In doing so they may well have ticked a box, but it feels like it’s sorely missed the point. When will the real healing that is required begin?

I drive past the turn-off to Marikana regularly now as I help lead an implementation science trial that has extended to clinics in the surrounding health district, aptly named Bojanala Platinum. The trial is investigating the effects of strengthening mental health care on mental and physical outcomes in people on lifelong antiretroviral treatment with co-morbid depression. Mental disorders are five to eight fold more common in people with chronic diseases. HIV, thanks to the Lazarus drugs that are antiretrovirals, is now such a chronic disease, and depression can negatively impact the high rates of adherence required to produce durable clinical effectiveness in individuals, and perhaps more importantly, to drop community viral load levels so that one day there might thrive a generation free of HIV. You’ll be able to read more about the trial when we publish the protocol (it’s being finalised for submission) but for the time being you can check out the details on

I must admit to a sigh of relief when the clinic at Marikana was randomised to the control arm of our trial. Our intervention involves equipping people at the level of community health workers, usually younger people with limited formal qualifications, as a clinic-based counsellor able to provide manualised depression counselling, one on one or in groups, and support for adherence. I couldn’t imagine putting a young person into the aftermath that is Marikana. It is an albatross that casts a tall shadow across the district; that turns one’s blood cold as you speed past the signpost. Marikana. Mari-ka-na. You can see the outline of the koppie where the bloodshed of four years’ ago played out clearly from the main road. But some two hours down the road is another clinic serving the township of Reagile close to the town of Koster, the proverbial middle of nowhere. Pairs of townships, known as “locations” and formal towns, or “dorps,” dominate rural South Africa, where segregation has been slow to dismantle. The locations are now fringed with housing developments, some of them the rows of matchbox houses built as part of a Rural Development Programme, beleaguered by corruption, contractors taking short-cuts and allocation processes prone to nepotism. Others show the rise of the black middle classes as informal shelters or traditional dwellings on small holdings are replaced by formal brick houses. Every community has its own flavour. In some developments it’s outlandish front doors, in others its Tuscan-style columns. In Reagile it’s roof-tiling. Roof tiles in Escher inspired graphic designs provide a much needed injection of creativity into an otherwise bleak landscape.

I am in Bojanala district to run a doctors’ workshop with the handful of doctors that serve its 1.2 million people. We are wanting to address the woefully low antidepressant prescribing rates in the area. As in most countries, antidepressants are considered psychotropic medications, scheduled and their access tightly restricted. Unlike the developed world, antidepressant prescription rates are low. Our data from an adjacent district showed that only 1% of depressed patients were receiving them. The scheduling also means that, unlike antiretrovirals, their prescription has to be limited to doctors—well, not unless there’s a change to our current legislative and regulatory frameworks. I’m there to see how we can make these drugs, which cost 21 US cents a month, more available to people who genuinely need them. People who live in extreme poverty are vulnerable to depression, but unbelievably not all who have to cope with such adversarial life circumstances develop it. It’s been a hard task to draw these lines and persuade health workers and communities that addressing depression can mitigate poverty, improve adherence and equip people better to lead the hard lives they have been dealt.

But before the doctors’ workshop I am visiting the Reagile clinic. It’s a cold Highveld winter morning. Mist stubbornly clings to the earth and the Highveld sun, usually so bright, is instead diluted and tepid, unable to take the chill off the early morning. Later, when the mist burns off, the sun will scorch the burnt earth, rendered a deep ochre by the worst drought on record in sub-Saharan Africa. We pull into the clinic parking lot.  A group of chickens strut past led by the most magnificently coloured rooster I have ever seen. I pull my coat close to brace the cold. And as I open the car door I hear a familiar refrain. I shake my head. I must have put on my headphones. I often listen to Beethoven’s Symphonies when I am needing to focus, to work, to write. But I’m not wearing headphones. It takes a moment to sink it. And then I recognise it. It’s the first movement from Beethoven’s Symphony number 1 in C major ringing forth from a tin shack on the perimeter of the clinic at full volume at 8 o’clock am on a winter’s Highveld morning. Just beautiful.

We enter the clinic. I am travelling with the Intervention Co-ordinator for the district, and the Training Implementation Lead from my unit in Cape Town. “Dumela. Le kae?”—yet another tonal treat as we acknowledge, and are acknowledged by the many people already filling up the waiting room. I love the cadence and measured, stretched vowels of Setswana, so different from the quick bubbling of syllables that is typical of isiXhosa spoken in my part of the country. As I walk the length of that waiting room I feel my whiteness, my privileged background, the diamonds in the ring on my finger, and I feel the ache that is the inequalities of the two worlds in which I live and work tighten in my chest. We greet the on-duty clinic manager who is better equipped than her visitors for the iciness of the morning, decked out in fingerless gloves, a puffer jacket and beanie. It’s only 8am but already the clinic is in full swing, a meagre bar heater trying to compensate for the open doors of the reception area. After a lengthy exchange of pleasantries I ask if we can visit the nurses who are consulting patients. Of course we can. We are most welcome.

We enter the first consulting room, and immediately I’m scanning the desk to see if one of our guidelines, just recently updated for the trial, is on the desk and being used. It is. I love walking unannounced into consulting rooms across South Africa and finding our guidelines and tools being used, consulted, drawn on to aid explanations to patients. A further thrill when I see a pile of “other” guidelines consigned to the top of a crowded counter—not being used. I check to see what page of our guideline is open as I always do—“Throat and/or mouth problems.” You can have your peer-reviewed publications, impact factors and H indices. Finding our work being used in real consultations by real nurses is worth more than any of those indicators of success that define the currency of academia. We have a brief discussion about detecting depression, how it’s time-consuming, how it requires real commitment on the part of the nurse. How repeating the script and handing out the next months’ supply of medication is easier, less taxing. The nurse tells me how she never knew that recurrent symptoms, like headache, might be clues to an underlying mental health problem. I ask whether I might take a photo of her at her desk, and she agrees, and smiles broadly.

Another consulting room, another guideline. This time open on the “Weight loss” page . We move through a rabbit warren of corridors and low ceilings, through a courtyard to the prefab buildings that have been added on to the clinic. Clinics in South Africa, thousands of them built in the first decade of democracy, are literally bursting at the seams. Our counsellor, a young, elegant woman is working from the tea room, in between tea breaks and other clinic gatherings. She describes her patients, how for the most part they are responding well to the counselling sessions. Her counselling manual is already, only weeks into the trial, very well-thumbed. Her eyes well up as she talks about two women she is deeply concerned about, who are severely depressed, who need antidepressants as well as her sympathetic ear. But there are very few doctors in the region, and those who are there are run ragged at the local hospital. There is no time to visit clinics.

The last stop is the vaccination room, with an old fridge that fills most of the space and ensures the cold chain in these usually hot parts of the country. I scan the desk; I can’t help myself. I am pleased to see a local adaptation of WHO’s Integrated Management of Childhood Illness in poll position. But beneath is one of our guidelines. Immediately I panic. Is it being used to see children? Don’t they know that our guideline is only for adults? We are currently working on a version to bridge the gap between IMCI, which goes up to 5 years, and ours but it’s still very much a work in progress. And so I motion to the desk “It’s really great that you are using IMCI” I say. “But I see you have a copy of PC101 (the name of our guide, short for Primary Care 101, the South African version of PACK) as well. Are you using it to see kids? If so what ages?” The nurse who runs the vaccination services straightens, takes the measure of this white doctor woman from the big city in a fluster because she has assumed that he is using an adult guideline to see children and says “Madam, in this room we provide a one-stop shop. When the mothers bring their children for vaccinations I attend to them as well.” I am floored. Such services are not available in the most privileged parts of the country, or even the world. I take a moment to regain my composure “That’s truly excellent” I respond “Real integrated care.”

And as we drive out through the dusty roads of the location I am left thinking that the real wealth in the Bojanala Platinum district lies not beneath the ground but above it; that the narrative of where there is no doctor has evolved, moved on. I have just witnessed integrated care, an engaged and committed group of nurses, community health workers and a counsellor providing a compassionate service to their community, consulting the latest guides to provide the best possible care for their patients. There is a new narrative, a narrative where there are nurses, where there are clinical officers, community health workers, health extension workers. The potential of these people is to rewrite primary care. And that’s exactly what they are doing.

Lara Fairall is a doctor by training and a scientist by choice. She heads up the Knowledge Translation Unit at the University of Cape Town which is responsible for the Practical Approach to Care Kit programme aimed at improving the quality of primary care. The KTU has partnered with The BMJ to ensure the content is in line with latest evidence, and to respond positively to the many primary care managers and clinicians who are requesting to use it in their settings.

Competing interests: We have read and understood BMJ policy on declaration of interests and declare LF is an employee of the KTU which has a partnership with the BMJ to provide continuous evidence updates for PACK and will be selling PACK related support services and licences to PACK content in future. No license fees were levied for the Florianὸpolis localisation to acknowledge the significant contribution of local staff to localising the content for Brazil in general and Florianὸpolis in particular.