Early morning is the best time of day for the nurses working at the Bophirima municipality health department in Vryburg, a small town established on the banks of the Huhudi River in the North West Province.

Between preparing folders, the nurses snatch few moments of silence and grab a quick cup of coffee. Afterwards they pop in at the local petrol station before setting off on their journey across the hot, dry and dusty byways of the North West Province, the sixth largest of the country’€™s nine provinces.

Sister Jeanette Joubert has spent the past 23 years driving distances of 3000km a month to reach patients in the harsh and dry conditions of the region. Now acting head of the local municipality’€™s mobile health clinics, 61-year-old Joubert gets into her stride when she talks about ‘€œlife on the road’€.

Snakes, kudus, bad roads and uncooperative farmers are just some of the problems encountered by ‘€œdie susters van die plase’€ (the sisters on the farms).

It’€™s no easy job providing basic healthcare services in a province where 65 percent of its more than three million inhabitants live in rural areas such as the Bophirima district that borders the Northern Cape and Botswana.

‘€œYou’€™re a driver, then a nurse, a social worker and then if you’€™re really good ‘€“ a mechanic because you must be prepared to get stuck ‘€“ these roads are terrible,’€ Pinky Motlhabane, a primary health care nurse who has been with the unit for the past 10 years, pointed out.

It’€™s not unusual to drive for 500km in one day, only to see two patients. Or sit outside your van in the heat the whole day, waiting for a car to come by and ‘€œhelp   push you out of the mud,’€ she added.

But today’€™s ‘€œa lucky day’€ for Pinky, her route is ‘€œrelatively easy’€ as she’€™ll only be travelling to nearby farms and sticking to the tar road most of the time.

Driving out of Vryburg, a town infamous for the racially motivated stabbing incident between two high school boys, her first stop is a farm just outside the small town of Stella in the heart of Stellaland ‘€“ the breadbasket of the province.

Agriculture is the main source of employment in this area and clinics usually use the farms as a base for treating patients who work on the farms.

‘€œSometimes the farmers won’€™t let us in and we just have to work in the middle of the road or stand by the gate,’€ Joubert noted.

This farm is relatively easy to get into and the fields are filled with sunflowers ‘€“ the second most important crop in the province after maize.

As the familiar sight of the white van pulls up to the farm worker’€™s compound, the children playing in front of the three mud houses run up to greet the nurse and her assistant. Their thin malnourished bodies are covered in shabby clothes caked in the red soil they play in.

Some of the province’€™s nutrition indicators are a cause for concern. In 1999, there was 24.9 percent stunting in children between the ages of one to nine years ‘€“ high when compared to the national percentage of 21.6 percent.

The canopy behind the van opens to reveal gleaming white surfaces and cupboards packed with medication and supplies. A small bench stores nifty gadgets like the gleaming baby scale as well as packets of fortified porridge for ‘€œbadly malnourished’€ infants and people suffering from chronic illnesses.

But the families living on this compound will have to get by on the irregular supply of food rations from the farm – five litres of milk a day and fifty kilograms of mielie meal a month.

Betty Ketshabile sees the van coming from the large pink farmhouse down the road where she works as a domestic worker and rushes out to meet us. Her youngest son, Kgotsomang, is due for his nine-month measles injection today.

The provincial health department had reached an immunisation coverage of 72 percent by the end of the 2002/2003 financial year, according to its most recent annual report.

Nodding wearily towards Margaret, her son’€™s 17-year old girlfriend, Betty says she also wants an injection today. ‘€œI’€™m already a grandmother now, I have six children and I can’€™t be having any more. It’€™s too much now.’€

Margaret looks barely sixteen, the over-sized floral blue dress hangs on her tiny frame and her 13-month-old son sits uncomfortably on her hip as she breastfeeds him. Margaret left school in Standard 2, and helps the family by occasionally working in the sunflower fields. She has also been ‘€œpersuaded’€ by the others to use the injection as a contraceptive.

Although the province’€™s teenage pregnancy rates decreased slightly from 11 percent in 2001 to nine percent in 2002, the effects are more evident in communities like these, with low illiteracy and unemployment rates.

The way Keaorata or ‘€œLovers’€, a 23-year old artist and volunteer at the Ganyesa PPASA clinic sees it, teenagers here have no other options. ‘€œPoverty is a way of life and all we do is go to taverns and drink, and then make babies,’€ he says.

Even more disturbing, however, is the indifference towards condoms and HIV/AIDS ‘€“ particularly among the youth.

In 2002, the national antenatal survey found that 26.2 of women attending antenatal clinics in the province were HIV-positive. National figures for 2002 stand at 26.5 percent.

Margaret Mokgothu, HIV/AIDS coordinator for the Ganyesa sub-district situated south of Vryburg admits that farm-workers have been neglected in HIV/AIDS awareness programmes.

‘€œFarmers refuse for workers to participate in our awareness campaigns’€¦they just see it as a waste of time. Condom distribution is usually done by farmers and the usage is still relatively low,’€ she noted.

No condoms ‘€“ male or female – were distributed during Sister Motlhabane’€™s first stop, as all the women thought the injection was enough of a preventative measure for them. Condoms are rarely seen as an option.

‘€œWe tell them about condoms but they don’€™t want to use them. They tell us ‘€˜ons loop nie rond nie’€™ (they don’€™t sleep around),’€ Sister Joubert remarked.

The mobile clinics have been equipped to provide voluntary counselling and testing (VCT), as well as nevirapine for the prevention of mother-to-child transmission. But the movement of farm-workers and the migration to more developed cities like Rustenburg has made it difficult follow-up such services.

Platinum mines in the area produce about 70 percent of the world’€™s platinum and mining including gold, forms the backbone of this province’€™s economy.

The provincial health department had increased its PMTCT sites from two to 89 by the end of March 2003. A year later, ‘€œIn theory, each and every clinic in each health district should be providing nevirapine,’€ MEC for Health Dr Molefi Sefularo said.

In Taung, only four out of 23 clincs in the sub-district serving a population of 231,000 have PMTCT and only 26 HIV-positive women have enrolled on the programme since last year March. The VCT programme is doing only slightly better.

According to regional manager, Gladys Crisp-Mokoto, none of the three mobile health clinics have started VCT and only 18 of their 23 clinics have ‘€œa well-functioning VCT service’€. This, she explained was due to a lack of training and capacity.

Those sites that are up and running tested and counselled 583 people between October and December last year. A private company has been contracted to train up to 30 people in a year ‘€“ a process which was ‘€œfrustratingly slow’€, she added.

Nevertheless, preparations for the roll-out of antiretrovirals in the province are underway. The MEC points to the accreditation of Tshepong Hospital in Klerksdorp as the first step in the provinces’€™ plans. Taung District Hospital ‘€“ another ARV distribution site ‘€“ is setting aside a 25-bed ward and has advertised posts for more staff.

Advertising for posts is all very well, but what if no-one responds? There were only 11.5 doctors for every 100,000 people living in the North-West province in 2003 and the situation has not improved much since then.

Bophirima district manager, Konrad Motlhabane, is in charge of the country’€™s best-run rural health district ‘€“ a title awarded to Motlhabane and his staff in 2003 for their efficient management of health services in region. But all the awards and titles in the world will not bring doctors and qualified nursing staff to work here. Last year he personally went to all nursing colleges in the region and ‘€œI begged and pleaded with them to come and work here.’€

‘€œThis is a serious problem bordering on a crisis. We are trying everything to make this place as attractive as possible,’€ he said.

The ‘€œlack of doctor manpower’€ as Motlhabane puts it, has placed the burden of patient care on nurses. Margaret Mokgheti is sister in charge of Morekwong clinic, about 130km outside Vryburg. The clinic is a 24-hour health centre that acts as a referral base for smaller clinics. A doctor hasn’€™t been there since November 2003.

Back at the farm near Stella, Sister Pinky Motlhabane has seen her last patient and is ready to move on, she has four more points to visit. Her next trip to the farm will be in a month’€™s time. Staff shortages have meant she and the rest of the mobile clinic nurses have had to double up as nurses at the short-staffed Stella clinic since November 2003.

‘€œIf I go on leave, patients will have to wait for another month before I come. If they’€™re lucky, the farmer can transport them into town or they hike as sick as they are,’€ she says.

Pinky acknowledges that there are still more people who are falling through the cracks. There are only eight mobiles travelling around the Vryburg district, servicing up to 300 mobile points ‘€“ isolated farming communities like this one.

North West Indicators

  • Population ‘€“ 8.2% of total population
  • Unemployment ‘€“ 30.7 %
  • Households with no toilet ‘€“ 9.6 %
  • Households with piped water inside ‘€“ 18.3%
  • Households using electricity for cooking ‘€“ 44.6%                
  • Medical Practitioners per 100 000 population ‘€“ 11.5
  • Professional Nurses per 100 000 population ‘€“ 88.9
  • Life expectancy ‘€“ 52.7
  • Infant mortality – 56.0
  • Maternal mortality ratio ‘€“ 6.32 per 100 000 women
  • HIV prevalence (% antenatal)   ‘€“ 26.2
  • TB incidence –   481.2 per 100 000
  • Teenage pregnancy ‘€“ 9%
  • Social grant beneficiaries ‘€“ 8.02%

E-mail Kanya Ndaki