During the Covid-19 lockdown, the Phelophepa Health Train chugged on, bringing healthcare to isolated and impoverished communities around the country. As the restrictions eased and the pandemic’s disruptions became more evident, the train made a historic stop in Gauteng, ensuring access to affordable healthcare wherever it is most needed.

Since the train’s maiden journey in 1994, more than eight million people in South Africa’s most rural and indigent communities have accessed medical services onboard. The moving medical facility has created a one-day, one-stop health solution. The project started as a three-carriage eye-care clinic in 1994 and now consists of two separate trains with 19 carriages each, boasting five clinics: general health, optometry, dentistry and psychology, and an onboard pharmacy.

Low prices ensure the train’s promise of accessible healthcare. A visit to the general clinic costs R5 and includes the consultation, diagnosis and medications. A pair of spectacles cost R30, while a full basket of services from the dental clinic, which includes cleaning, extractions, fillings, just R10. Psychosocial services are free of charge.

Dr Mathapelo Mashaphu is the train manager of Phelophepa II, one of the two locomotives that travel around 30 000km for 35 weeks of the year. Phelophepa means ‘Good, Clean Health’ and Mashaphu makes sure the train lives up to its name and reputation.

“When we arrive at a station, you can hear the people talking. They say the Train of Hope has arrived,” she smiles.

Mashaphu’s own journey on Phelophepa started as a dentistry student in the late 90s.

“When I got here… oh my word, the spaces were so confined and the rooms were so tiny, but the impact was so big! That’s when I first fell in love with the project.”

She returned to the Phelophepa family in 2016 and now manages the clinical team of around 20 professional nurses, pharmacists, optometrists, dentists, and optical dispensers, as well as the security, logistics, maintenance and hospitality staff. Under normal circumstances, up to 55 university students from the various healthcare disciplines make up the bulk of the workforce, working on biweekly rotations.

More than vision

Like Mashaphu, optometry clinic manager Lebo Mphela decided as a student to one day return to work aboard Phelophepa. The optometry clinic was the first to open and remains one of the busiest, partly due to the continued backlog of cases in the public health sector.

“Issuing spectacles is a big challenge,” she sighs. “There are some provinces where they have the staff and the equipment, but the problem is awarding the tender for the spectacles.”

This is not the case on the Phelophepa. Here, optometrists conduct eye exams and strength test prescriptions. Thanks to an onboard laboratory, they’re able to cut optical dispensers fit spectacle lenses immediately. At just one station in one day, one hundred people are assisted.

Mphela and her team often see easily treated conditions that worsen without diagnosis. An allergic condition called vernal keratoconjuctivitis, or ‘brown eyes’ is a good example. When diagnosed, it is easily treated with eye drops. If left untreated, it results in irreversible vision loss and even blindness.

Myopia, or near-sightedness, also gets progressively worse if untreated. Mphela remembers meeting a young girl during screening at a school.

“The teachers thought she was illiterate, and it was affecting her psychologically. She started bunking school, and they just concluded that she didn’t want to be there.” During testing, optometrists detected problems with the girl’s vision and gave her a pair of glasses.

“She cried and cried because she could see things for the first time in her life,” Mphela recalls. “I know we don’t just help with sight, but with dignity and independence.”

Passion, humility and respect

Restoring communities’ dignity and humanity are as important as delivering primary health care services for the staff on Phelophepa.

“They are disenfranchised and marginalise, but they’re resilient. They’ll wait a whole year for the train to come, even if it means they progress further into disease or discomfort,” says Mashuphu.

As the train approaches, she says, many sleep outside the station to ensure their spot on the train when it arrives by morning, often in adverse weather conditions. Though they’re only passing through, the train’s clinical teams approach their patients with a commitment that could be inspiring to colleagues in the public healthcare system.

“This is doable, it’s not impossible,” says Mashuphu. “If we can achieve this on a mobile facility like this, then they can do better in a fixed facility.”

Strengthening the Covid-19 response

Like other primary healthcare facilities, the train continued to travel through the Covid-19 lockdown, to strengthen the country’s response to the pandemic. The train operated on a skeleton staff, with only a small core logistical team that remained onboard. As they travelled from town to town, the socio-economic effects of the pandemic became glaringly obvious.

“So many children rely on the school nutrition programmes for just one meal a day, and during lockdown these children went hungry,” says Mashaphu. “We said bring the kids to school, let’s screen them for Covid and at the same time give them something to eat.”

“This pandemic is not just skin-deep,” she says. “It’s not just an infection but a destructive force that has seeped into spaces we had never even considered, affecting people in ways we never saw coming.”

This is especially evident in rural, marginalised communities the train has always served.

“We saw people lose their jobs, their families. We saw a spike in gender-based violence and we saw children forced to become breadwinners,” she says, shaking her head as she speaks. “We’re talking about three or four months, yet for millions of people life changed forever. We watched it happen in front of our eyes.”

Making history at the Olifantsfontein Station

As lockdown eases, life board the Phelophepha Health Train is returning to normal, with a full staff and full services. Outside, masked people wait in queues to be attended to. A small group of children twirl and play around a sign post: Welcome to Olifantsfontein Station.

It’s an historic stop on the route: Phelophepa has arrived in Gauteng for the first time in its 26 years of operations.

The decision to visit Gauteng was driven by the need for services in Covid-19 hotspots and infections spiked. As in other stops on the route, the pandemic revealed Gauteng’s deeper needs.

“As things unfolded, we realised that Gauteng needs more than just Covid interventions—the need for access to primary healthcare is high,” Mashaphu explains. From 2021 the Phelophepa route will run through all nine provinces.

Outside the optometry carriage, a family stands in the shade of one of the trees that line the station platform. They gather around a young boy as he gingerly balances his first pair of spectacles on the bridge of his nose. Nine-year old Lesedi Hlatshwayo is excited to go home and look at his school books. When asked how the world looks through his new lenses, he smiles shyly and answers: “Perfect!”

In the general clinic, funded by Roche, professional nurse and acting clinic manager Phiwokuhle Mhlongo smiles nostalgically. Hlatshwayo’s story reminds her of her own early experience on the train.

“It was 1994 and my twin brother got his first pair of spectacles from this train too,” she recalls.

The health clinic treats children, adults and the elderly. It also conducts cervical cancer and prostate cancer screening. “We offer high quality medication and only close our doors when the last person has been seen, providing services that are not easy to get from the public sector,” explains Mhlongo. “Even if you can access them, you wait! It’s not immediate like here on the train.”

Community building

When the Phelopepha Train pulls into a station, it’s not only those in need of medical services that benefit, says train manager Mashaphu. At each stop, around 100 people from the local community are recruited to help stage the station, erect tents and assist with general work.

The professional nurses of the Phelophepa train also run community training and education programmes on topics like home-based and palliative care. Many of these training programmes are certified so community members can use their new skills to find employment, with the paperwork to back it up.

Translators from the community are also trained in basic counselling in order to assist in the psychology clinic. Educational psychologist Claudie Munyai helps mentor and train the psychology students who work onboard.

“We never really know when a patient arrives what they’re going to bring with them,” she says. Stress, financial hardships, trauma, family problems and difficulties at school make up a large number of their cases, she adds. It is challenging to address mental health and wellbeing when people are just trying to meet their basic needs for survival, says Munyai.

“Our sessions often focus on the question of how to meet these needs,” says the psychologist. A large part of their work is fighting the stigma attached to mental health. “You find that the patients are quite fearful or scared to seek psychological support.”

Their therapeutic approach is solution-focused—it has to be since the train is only in an area for two weeks. “The aim is to ensure that the patient leaves here with some sort of structure devised during the therapeutic session that they can put into action in their own life,” says Munyai.

Many of the patients that are seen by the psychology clinic are internally referred from other Phelophepa clinic. This is either because practitioners suspect that physical symptoms may have psychological causes, or for supportive therapy after a difficult diagnosis.

For example, abuse and child neglect are often picked up in the dental clinic, then then referred to the psychology clinic for further investigation.

“A child’s dentition shows if they are not taken care of,” Dr Paballo Mokwana, who heads the dental clinic explains.

“With sexual abuse it’s visible in the oral mucosa, the cheeks and the hard palate. Certain lesions are questionable in children. Also physical abuse—when somebody comes in with fractured teeth, we are able to pick up that they might be experiencing violence.”

This interdepartmental communication and cooperation is part of Phelophepa’s winning recipe, says Mashaphu. It’s also the advantage of having multidisciplinary services on one train.

“Our communities need to know that these services are available to them, they cost close to nothing and they are world-class,” says Mashaphu. “We want people to take advantage of this. Visit us when the Phelophepa is in your area, and come experience this for yourself.” — Health-e News