Part I: Northern Province

Our Journey to Kangwane, Gazankulu and Lebowa

We decided on this journey because the average fertility rate per woman (TFR) of these regions was given in the 1991 census as about six.

What we found was in some ways hopeful and in some ways not. Very often we found that women seemed willing to limit their families, but that unless they lived near a clinic or hospital or had great initiative they were unlikely to pursue the matter further.

The attitude of Community Health Workers (CHWs,) and family planning nurses was positive, but they simply did not have enough time. This was summed up for us by a Kangwane nurse who said, "We do a hit-and-run operation. We go into a village, throw information at them and leave them confused."

This can be remedied. More problematic are the women whose only reason for living is having babies. "You should see how her eyes light up when she brings her latest baby to show me. That never happens at other times," said a nurse.

Kangwane - Themba Hospital

All former Independents have only estimated figures for population and fertility rates. In the case of those homelands on the borders of South Africa the problem is compounded by migrancy. Kangwane, bordering on Mozambique and Swaziland, was said in the 1991 census to have one million people and a fertility rate of 5,3 children per mother.

In July 1994 we visited Themba Hospital, between Nelspruit and White River. We were told by the superintendent that "600 babies are born here every month". We have now been sent a hand-written fax from Matron Maphanga for statistics for 1994:

Births at Themba Hospital: 4 991

Births at surrounding clinics: l 781

Total: 6 772

Average per month: 564

An unknown number of births take place at home. Antenatal visits at the hospital: 3 582. This represents about 600 women who came for more than one check. Of these women, 91 turned up for family planning post delivery.

The total number of family planning visits at the hospital in this year, 1994, was 4 926. (A possible 1 250 women were protected by family planning methods.)

At the clinics surrounding Themba Hospital there were 34 035 antenatal visits, representing about 7 000 women who came for more than one check.

The total family planning visits were 34 795. (A possible 8 700 women were protected by family planning methods.) If there was good motivation at the pre-natal visits then nearly all women having babies ought to be protected from having another baby soon afterwards. This would give a very much higher total for the family planning acceptors.

At Themba Hospital we met a group of nursing sisters from various parts of Kangwane who were attending a conference. They told us that there is no very great resistance to family planning in the area. "There are so many ways - if you put the problem in a friendly way they will often tell you their problem themselves."

They say, "I only want how many I can afford" and "Too many are too difficult to discipline - children are not scared any more, you have to give them sensible answers for things, and that takes time." The deep rural areas and densely populated areas are not well covered. "We do a hit-and-run operation. We go into a village, throw information at them and leave them confused."

There are clinic committees in the villages, but these are not trained people. 1 The Kangwane nurses liked our idea of leaving "mini-experts" in the villages. However we did not choose this area for a pilot scheme as there was no organization we could latch on to.

It could not be done through the hospital itself because of existing hierarchies and wage demands.

We also could not find any church or environmental organizations willing to supervise a RESA-nompilo scheme. We thought Ecolink would be ideal because of its excellence in all other aspects of sustainable living. However, the director, Sue Hart, when our scheme was explained, said to us out of the blue, "Why do you always blame the poor?"

We did subsequently get interesting Ecolink booklets from Sally Sawyer - excerpts will follow. Karl Lane of Kangwane Parks Corporation thinks that a community fp scheme is a good idea, but his company does not want to take on another controversial issue at the moment - "It's someone else's problem." They currently provide basic skills training, from candle and brick-making to agriculture. They even have an environmental game which they play together. It always leads to smaller families. The women want it, but the men don't, and no one has the initiative to change that.

Sibyl Renkin of TPA in Nelspruit says there is a large clinic in Hazyview, near the Kangwane border. She says people flock in from Lebowa and Gazankulu. She says, "We don't tell them what to do," and "They make the decisions, we don't go around giving education about the value of using birth-control."

Two later comments made to us:

A woman wanting a steri in the Nelspruit area waited at the wrong place on the wrong day.

TPA advisers from Nelspruit used to fetch people wanting steris from Kangwane. Hospitals in Kangwane objected, but the women sterilised liked the arrangement.

Kangwane - The Nkomazi Region

From Shongwe Mission Hospital we have been sent statistics for Shongwe Hospital and 20 clinics.

These statistics are from January to December 1993:

The total number of births in the hospital and the clinics was 5 461.

The family planning figures are given in number of visits and not number of people protected.

The number of people using the pill, the IUD or condoms is negligible. There is also a figure given under "Default". I have allowed these figures to cancel each other out (i.e. 50 condom or pill users against 50 people who missed visits.) and have concentrated on the injection figures which are very much higher.

4 visits per year are needed for Depo Provera injections and 6 visits per year for Nuristerate, so I have divided the visits by 4 and 6.

The figures are given separately for adults and teenagers:

Adults using in injectables: Depo Provera: 2 116

Nuristerate: 1 118

3 234

Teenagers using in injectables: Depo Provera: 298

Nuristerate: 1501

1799

Teenagers had 20% of the births in this region:20% of 5 461 1 092 Adults had 80% of the births in this region:80% of 5 461 = 4 369

These two figures represent only births which took place in clinics and the hospital. An unknown number were born at home. This would have been more in 1993 than in 1994 as the facilities were not yet free.

Adult births to adult contraceptive users: 4 369:3 234 Teenage births to teenage contraceptive users: 1 092:1 798

So the proportion of teenagers using contraception is higher than the proportion of adults using contraception.

It is perhaps surprising that contraception exists at all in an area where everyone seems so afraid of the Catholics, the chiefs and the men. However the percentage of users must be very small compared with the total fertile population - say 5%? 

The Ecolink Booklets

Nine booklets on the environment have been sponsored by Ecolink and the Green Trust. These are written in clear language - both Zulu and English in each booklet.

They have been put together by Sally Sawyer from conversations held by Theresa, a "care worker, teaching skills and literacy", with women from the gardening and sewing groups. The booklets cover water, air, recycling, etc.

Sally Sawyer told me that she did not see how you could ask people to go from 6 children to 2 children. She felt it would be too disruptive of their culture. However, when I suggested that the way we design our communities is now what matters - so that children from small families can play easily and safely together she thought that might work.

She said she knew of professional men who owned houses in Nelspruit which they lived in during the week, but then they came "home" to their villages.

The following extracts come from the booklet called "Our Family":

Intro: "Smaller families will improve our health and the quality of family life, and give our children a brighter hope for the future, but it is for us to decide."

Conversations: "It's her third. It's a girl again. Her husband says they must go on trying for a boy. He needs a son to carry on his name and for the inheritance."

"It's a pity that girls can't inherit. When my friend's husband died, his mother and brothers just came and took everything."

"She is going to the clinic. She's had those three children very close together and she needs to get strong and well again before thinking of more children. Besides, she's afraid that her husband may lose his job, so many factories are being closed down now."

,, Some of our men don't like us to go to the clinics. Some of them think they have to build up a big tribe, like in the old days."

"My husband wants me to go to the clinic. He says we can't afford children just yet. He had to pay 15 'cows' for lobola and he only earns R400 a month."

""My husband likes to have a baby in the house all the time. He says a baby makes him smile even when he is feeling sad."

"I agree, even strangers in the street smile at a baby and greet you nicely."

"It's different now. If we have fewer children they have a better chance of gaining a good education, useful skills and well-paid jobs. So just a few children will then be able to look after us better than a lot of poor children can."

"You're right. I had a big family but they can't help me now. I have to help my daughter's children with my pension."

"It cost me a lot to send my daughter to university, but she has a good job now and helps me a lot."

"You know something ... that lady near me who has seven children...she's having another!"

"Yes, I know that lady. Her husband has another wife as well because the first wife is so tired all the time."

"It's bad. Their daughter is pregnant as well and she's only 15."

,, Hau! We should talk to them about the clinic. They could get a lot of help."

"No, I tried. The husband won't listen. He says all those pills and things are just ways of murdering us."

"Some of us need to have better information. My neighbour believes that if you have those injections to prevent pregnancy, you'll never be able to have a baby afterwards."

"No, that's not true. I had injections for many years but have had two children since then. They are good, strong children as well."

"Many of our young girls, even in the cities, still feel that they won't find a husband unless they can prove that they are fertile. It is sad - many of those babies are abandoned."

"It's a shame when they are just young schoolgirls. It's happening a lot now. There's no lobola for them either. Those schoolboys haven't got money and they won't own up anyway."

"In the old days, if a young girl got -Pregnant they used to marry her to an old man as a warning to others."

"It was different then. The whole community was responsible for the good behaviour of the young."

"Yes, any member of the community could reprimand someone else's child. Today we have to mind our own business."

"Today the children are getting only half a teaching."

"The teachers have such big classes. They might also be shy and the classes are mixed."

"I think we parents should teach our children."

"Well, I don't like it all. It is all private and just for marriage. Besides, what we learned in our traditional schools was secret. Mothers were not allowed to speak about it, even to their daughters."

"It's not much use teaching them about sex unless we also teach them good morals and a sense of responsibility for their actions."

,, Even if they have injections or pills they could still be in trouble with AIDS..."

"I have a friend at the hospital and she says that many people have died of AIDS. There are many who don't know they have it and are still passing it around. It's very sad for the innocent babies. What kind of chance will the next generation have - just when we have such fine hopes for our new South Africa."

"Do you remember when Elsie had been to that talk about AIDS and then came straight out to lecture those builders?"

"Oh, yes. They were so surprised! Even shocked. But Elsie isn't shy. I would never have dared. We are all too shy about these things. But AIDS will wipe us out if we don't start educating our people about these things soon."

"Well, don't tell my husband. He doesn't believe in all this birth control stuff. He likes to have a big family and says that all children are gifts from God and we shouldn't interfere."

"I think that we women should be able to decide for ourselves. If we want big families, we should have them and not let anyone else dictate to us. It is very nice for our children to have cousins and brothers and sisters and aunts and uncles." "People with small families, seem to get selfish."

Gazankulu - Julian's Phone calls

From Julian's phonecalls, starting in March 1994:

Sister Manzini of the Gazankulu Health Dept. Mrs Manzini says that there are 46 clinics built. There are 11 main health centres and two to three hundred "Pick-up points" in Gazankulu. These are the equivalent of mobile clinics and provide everything including fp.

They also provide counselling for contraception. Depo is fairly popular although there is still some perception that it causes sterility.

Sister Manzini has just attended a conference in Zimbabwe where she received the latest FDA, WHO reports clearing all major suspicions over Depo. She thinks community-based fp schemes are a good idea and would like to train people only from and around Gazankulu. This will step up efficiency and reduce complications that come from dealing with isolated central departments.

(The latest information from Gazankulu is that they are sending out combis specifically for fp, inoculations and minor baby ailments.)

May 1994.

Nico Makunyani, N.Tvl Drought Forum:They are a broadly-based development NGO and have a lot of contact with deeper rural areas. He confirms that the 'G' region, or what is now the Northern Transvaal Province, is definitely one of the poorest and least developed regions of the country.

Thangy Chikala of the National Progressive Primary Health Care Network (NPPHCN). They are addressing the same sort of rural health problems, finding gaps in existing services.

June 1994 Andrew Venter. Forum for Kruger Park area. The forum includes all the communities along the outside of the Western border of the Kruger National Park. 

The forum represents between 200 000 and 300 000 people, all rural. Propositions, needs, complications etc. are put forward at the forum. Representatives, headmen, councilors, etc. work together to get ideas, find solutions, problem-solve. He thinks the SAPLER-nompilo scheme could work very well in these communities.

November 1994. Since incorporation, Malamulele does steris but lacks motivators, which they seriously need. Shilubani Hospital also does steris and is still discussing a fp scheme policy. At the moment their CHWs (Community Health Workers) have to be qualified assistant nurses through the hospital. They then go and give information to the community on everything from development to Primary Health Care.

Human Sciences Development Unit (HSDU)

In July we visited the Wits HSDU - behind Tintswalo Hospital in Gazankulu.

HSDU. Shirley Ngwenya. Will be doing a Public Health course in New York next year. Told us how oral contraceptives are sold at the market places in Nigeria.

She does workshops with clinics, the youth, teachers, men, traditional leaders, burial societies, ministers. Family planning methods given by traditional leaders DON'T WORK.

Around there women have no other work but to have babies. Told us about the 10-child women who have been dumped and the fed up grandmothers.

Tintswalo Hospital serves half a million. It often has to close down for 3 days at a time because of water failure. Shirley herself has no running water at home. The situation is critical: 500 apply for 25 bursaries so people do want to "move up", but the applicants are the "too many" children of the women who were fatalistic and traditional.

Shirley is very keen on involving the men. She suggested that we use the Londolozi men to help win over the resistant men in the villages. Shirley says that women are trying to please men but that women are sexually nicer if they have few children and are not worried.

Seventy per cent of the men in the area are migrant workers. They don't say when they are coming so women don't feel it is worth while taking contraceptives all the time. The men don't have correct information and yet they say, "Why expose women to all these things?"

Meanwhile the women with 10 children could die - and then what happens to the children?

The Agincourt Clinic has an ambulance which could transport women on quiet days.

WE MUST NOT GIVE UP. "Don't expect agreement - they all say no the first time.

"In the meantime we are all re-learning."

Shirley and Mpho Maunye took us to a school. Mpho had formed a club for young teenage girls which meets in break on Wednesdays. It was Wednesday so we joined the club. Out of a mixed class of 60 about half the girls belong to this club - 15 girls. One tiny prepubertal 13-year-old wears a T-shirt which says, "AIDS IS OUR RESPONSIBILITY".

The girls talk about their problems with the boys who worry them. "They say we are stupid." "They say we won't pass our exams if we don't have sex." "They say we will get very sick if we don't have sex."

Mpho asks them how they reply. "Just wait for me. If you really love me you will wait for me. I want to get educated."

Outside the classroom the boys ask Julian for condoms.

Mpho lives next door to a woman who has 11 children. Mpho has finally persuaded her to use birth control.

Gazankulu - Londolozi

Londolozi is a prize-winning "sustainable living" organization which has now started to operate outside their game reserve. John Varty and Sister Siphiwe are members of SAPLER. Sister Siphiwe sees the point of our SAPLER-nompilo scheme. In fact she can't wait for us to come. (See letter). She visits a different area every working day and urgently needs help and she particularly means "family planning" help.

We have raised money through Ithuba for nompilos and will use this for Londolozi. When Caroline has finished establishing the Winterveldt project she will go to Londolozi and organize whatever is appropriate in that area. Shirley Ngwenya suggested that we use the men of Londolozi, who are already educated in sustainable living, to help educate any reluctant men. In Winterveldt 3 of our 9 nompilos are themselves men.

Wits Rural

Wits Rural is an attempt at giving Wits students a chance to experience what life in the rural areas is really like and to do research there.

Julian and I stayed there last July. It is just north of Tintswalo Hospital, in the Hoedspruit area. The day after we left some students were coming from the law department to help local people with legal problems.

In the canteen over supper we talked to a woman who was doing genetic research. She said there was one disease she had wanted to study but never found any examples, and she presumed it was because babies born with that condition did not survive.

Another research worker told us that we would never have any success with these rural women with large families. "They are too depressed and passive and worn-out. Their children are so malnourished and worn-out from fetching water that they never attend school regularly."

The next day we met Mpho who had persuaded his 11-child neighbour to stop having children. Later when we got to Lebowa we found Frans Themba who does the same thing every day with the women he meets in connection with his Operation Hunger work.

At Wits Rural we spoke to community worker Soko Mandla. He told us about the teachers who seduced schoolchildren.

"It takes credibility away from the teacher. He says that if the girl says no she may fail at the end of the year." "So what can you do?"

"We need the parents of the school to be independent. At the moment they are co-opted by the manager of the school and they are not doing their duty."

He tries to arrange meetings which include both parents and youth to get real communication going and problem-solving started. "Once we get a clear policy..." He thinks that nompilos in the classroom would be a good plan.

In August I spoke again t o Shirley Ngwenya of HSDU. She had had a meeting with religious leaders - Baptists, Lutherans etc. only not ZCC and Catholics.

All were in favour of fp and had horrendous stories to tell about ignorance and superstition and misconceptions. It is nompilos backed by health educators who are needed. They would not want mobile clinics not accompanied by awareness training".

There is still something of a fear of "just throwing fp at them". But this is not our mission. Our mission is education combined with seeing that the informed and willing people actually get to the services and use them.

For all the professional input that goes on around Wits Rural and HSDU, the Tintswalo family planning figures are not much higher than any other big rural hospital - and they do not increase. This seems to me to indicate that the women who already fully understand about contraception and the women who are determined at all costs to use it are getting it. But there is here, just as is found internationally, a vast number of people who would use it if helped to use it.

        University of the Witwatersrand, Johannesburg

Tintswalo Hospital, Arconhoek

Ann Cluver Weinberg

SAPLER Population Trust

P 0 Box 51446

Raedene 2124.

Fax: 011 640 7180

Dear Ann,

Thank you for your letter and Proposed donation of R3 000.00 towards the development of community based education, with specific emphasis on family planning in the

Your offer came at a time when awareness on contraception is our priority. Within the Sexual Health Program for example, interactions at workshops with men ( teachers, clergy, and other public servants), revealed a whole web of myths surrounding contraception, thus reflecting an urgent need for some intervention in the form of health education on contraception. 

As I discussed with you earlier, our first .step in this regard will be to deploy trained community members to disseminate information to fellow communities, in a socially sensitive and culturally acceptable manner, thus demystifying the whole realm of contraception.

Considering your proposed strategy of some payment to the Nompilos who are equivalent to our local care group members working on voluntary basis some consideration need to be made in terms of the envisaged changes. 

One option might be to pay for the transport to the nearby clinic or Health center during training as well as to nearby groups for health education, and be able to provide meals during those days that the educator will be away from her/his normal chores. 

You need to understand that the present care group members are not paid, and I'm trying to avoid creating confusion among care group members. The second option might be to employ such a person oven it it's for a period of six months to do the work, attached to Agincourt Health Centre or to Londolozi, on a full time basis.

I did have a discussion with Kathy of the implications of your donation, and feel a more detail discussion might help in order to reach consensus on the form of this intervention, probably with siphiwe as well. At this stage, we feel that community should be used for informing and educating Communities, to the extent that a trusting relationship exist. Monitoring of the situation at the

health service ( Londolozi or Agincourt) for more requests in contraceptive methods, or counselling on contraception hopefully by women with their partners, or by men alone, and the skill of the community educator will determine further input and need for the community educator to provide re- fills of contraceptive supplies. The results of our study on male involvement in contraception in Xanthia by then would help in further developing this service.

I may still be around as there are some hiccups at present with my study arrangements. I will keep you posted of my movements.

Once more, thank you for your interest in our work, and the struggle for accessible and acceptable contraception. Sincerely yours,

Shirley Ngwenya.

cc. Dr Kathy Khan.

Gazankulu Statistics

Tintswalo Hospital. Total family planning attendances, including pill, injection, and sterilization, but not condoms. Condoms listed but not included in the totals:

1993 January to December: 52 177        Per month 4 356

1994 January to September: 42 793       Per month 4 754

1994 October to December: 13 565       Per month 4 521

(if family planning promotion was in place at Tintswalo the attendances between Oct to Dec would probably have gone up, since the free peri-natal services are now in place and more pregnant women attend the hospital.)

An attendance number which includes sterilisation may come near the beginning or near the end of a woman's fertile years.

We also have, for Tintswalo, a breakdown into the different methods for 1993:

1993 Jan to Dec

Condoms 11 892

Sterilisations 137

Pills 11 574

Injections 40 464

It is difficult to compare the injections with Shongwe because Tintswalo does not say whether these are Nuristerate or Depo Provero.

To take a rough average - divide by 5 - (between Depo's 4 attendances a year and Nuristerate's 6) we would get 8 093.

Shongwe's total was 5 032 compared with Tintswalo's 8 093 on this reckoning.

Tintswalo has the Wits Human Sciences Development Unit in a mobile just behind it. From here all sorts of people go out and do all sorts of research - and family planning is talked about.

The HSDU is now doing a very detailed survey of the Agricourt area which will soon be available.

Other Gazankulu Hospitals report total family planning attendances for 1993 as follows:

Elim 37 255 Letaba 17 843 Malamulele 37 480 Matikwana 825 Nkhensani 38 164 Shilubana 8 533 (and Tintswalo 52 177)

Of the three homelands we visited, Gazankulu was able to give us the most detailed statistics. But the total fertility rate for Gazankulu according to 1991 census was 6,3 compared with Lebowa 6 and Kangwane 5,3.

Lebowa - 1

Pietersburg. Pietersburg, when we started our survey, was not theoretically attached to Lebowa. Pietersburg was RSA. However there had been a breakdown in the Lebowa administration so the TPA were helping out.

In addition to this, the Lebowa govt. had been headed by Dr Phatudi who was not only against fp, but who wanted the Lebowa population to grow. However, women themselves often did want family planning. The mobiles which were sent to Lebowa were unreliable and overworked. The Pietersburg single-purpose fp clinics were good.

The result was that on Saturday morning these clinics were used entirely by women from Lebowa. There were two clinics, not close together, one for adults and one for teenagers.

Mrs Saasa, who runs the teenage clinic, says she counsels teenagers in private. If they have never started sex she encourages them not to start. The others she helps with contraceptive advice and STD prevention. "You can't reverse."

Mrs Saasa says she has been told she must offer all methods. She describes a situation in which a woman comes from Lebowa and says, "I want Depo." Then Mrs Saasa describes all the other methods and ends by saying, "So you see you have a choice!" All this time the woman has been staring out of the window.

Mrs Saasa says, "So! Now you know about all this choice, which method will you choose?" The woman says, "I want Depo."

Mrs Saasa says that the mobiles which go out to Lebowa are creating havoc with people's hormones. They don't take enough of the various sorts of contraceptives with them, so a woman gets one hormone one month and another the next.

Igme Terblanche. Head of Nature Conservation in Lebowa.

There has been a massive influx from the violence in cities. People have come from the East Rand to Lebowa in their thousands.

Igme Terblanche has no trouble with the chiefs and counsellors. He gets their written approval for his ideas. He is getting great co-operation from the chiefs. "They may be traditional in one area of their lives but are Western in another."

This trust makes undeveloped land available next to the villages. The villages benefit because they are given infrastructure - roads, building, fencing. 50% of the income goes back to the local govts. The other 50% is decided between the conservation trust and the community.

SO NONE OF IT GOES INTO THE LEBOWA TREASURY.

"It is not our experience that the chiefs are difficult." The people have direct use of the parks for picnics etc.

"If we don't want them to pollute the rivers with their laundry we give them laundry facilities and then they co-operate."

Terblanche says it is not possible for anyone in that area not to understand ecology. It is an extremely denuded and drought-stricken area. His most highly educated black officer is Shokeng Mahlake who has a degree in geography and zoology and honours in environmental studies.

I ask Terblanche whether Mahlake would understand the population issue and he says he has no doubt about it. Mahlake has been seconded to ANC environment for the Northern Region until April.

This seems to SAPLER to be another way in. People involved in drought forums etc. are not trapped in jargon about "We say two-child" versus "We only ever say spacing." Terblanche has 250 black officers and 8 white officers.

"But why don't you think it is sensitive?"

"Oh I know about that sensitivity - we get it from the animal husbandry people. There is over-grazing but they don't want to talk about it."

At the head office of the new Region of the North we speak to Prof. Bopape of the Population Development Programme. He says that in Pietersburg it is just like it is in Pretoria. The PDP promotion and marketing people talk about small families and the Family Planning people talk about Primary Health Care clinics.

"We don't talk to each other. There is no overlapping." He is fed up that he was not told that the PDP is now in the Dept of Welfare.

"This indicates to me that the govt does not take population seriously." Bopape continues, "Zambia high-ups are talking population. I am just going by the RDP."

Dr Hennie van Wyk is director-general of Health and Welfare in Lebowakgomo. He says it is only some chiefs who want to burn the clinics down.

He doesn't believe that Dr Helen Rees is "against population policy" but that it's a question of terminology. The "two-child" idea might take us back. (Dr Helen Rees and a team of people had been in Pietersburg doing a survey for the WHO.)

There are millions of people in South Africa. Some are influenced by "political correctness" but millions are not.

  February 1995 Update and statistics. Pietersburg family planning clinics

Youth Health Centre.

April 1992 to March 1993. April 1993 to March 1994

Adults seen: 85 457

Youths seen: 12353 12415

Clients seen

on Saturdays: 996 958

Clients seen on

Mon-Friday: 11442 11914

Adult Family Planning Clinic: Clients who received methods:

1992/93 1993/94

Mon-Friday 22 736 24 201

Saturday 1 350 1 150

Mrs Saasa reports: Due to lack of security at the clinics our clinics stopped rendering Saturday services as from 24 Sept, 1994.

Lebowa - 2

The Hans Merensky Estates

These estates are not in Lebowa, but since their workers come from Lebowa I will include them here.

Hans Merensky was a mining engineer who was also a pioneer in understanding environmental degradation. He used the money he got from his mineral discoveries to buy up estates in the Tzaneen area.

He found that farmers had planted eucalyptus in the catchment areas, thus preventing the water flowing properly. He found that peasants lived on high areas and ploughed vertically, so good topsoil was washed away.

He changed all this and created model timber and fruit farms.

All that he did makes no difference now, because devastating droughts have dried up the dams, and devastating veld fires have decimated the forests.

On the Hans Marensky Estates there are also model villages. These villages are well built and attractive to look at. The villages compete for prizes to see which one has been kept the tidiest and which has the best gardens.

There is also a well-built primary school (up to Standard 7) and a well-built clinic.

Now for the problems: No one stays permanently in the well-built, pretty, tidy villages. The men live there while they are working with their village wives. As soon as there are children they get sent home to the other wives in Lebowa. The well-built Hans Merensky crèche has had to close down.

The wives in the villages and the wives in Lebowa are friends - they look after each other's children and visit each other. When an HM wife gets pregnant she goes home and another comes.

Some of the children are now attending the school on Hans Merensky. The headmaster is good and is trying to build it up. But all rules for teenagers have disappeared, and the teenagers go into the plantations for sex at break.

This school has been visited by Health Workers - but not often enough to make any difference. They now come even less frequently because of their limited petrol allowances.

There is a lot of seasonal work for women in this area, both on Hans Merensky and on the nearby tea estates. The women work hard during the week and then drink at the weekends. They pick up men at the shebeens and they go into villages and entice out the men there. The villagers (i.e. not only from HM villages but from other surrounding villages as well) object - but there is nothing that can be done about it because there are no walls round the villages and plenty of plantations to run to.

In the off season HM holds education sessions in health and social matters. When I first phoned the personnel manager, Mr Snyman, he said the men were laughing at him: "You have been telling us about AIDS for 5 years now and none of us is ill." When we reached HM Mr Snyman told us that he now had an AIDS case.

" Well at least now they will believe you." "No, you don't understand. Not only will the man himself be ostracised, but the workers will come out on strike because they will say that we have done it."

He told us how a man had fallen and broken his leg in the ablution block. The workers said that HM had put a ghost in there to make this happen, so it was up to them to build a new one. Which was what was eventually done.

Almost no women go to the well-built clinic for family planning. If they do they slip in secretly when there are no men around. They don't want to be beaten up. Most women who decide to use family planning go to the hospitals in Tzaneen.

Dr Phatudi told the Lebowans they must have children. Now a new leader would have to give a different message. TV is available in the villages, but few programmes are understood and watched.

The new prime minister of the North could have a good influence. If he says, "Stop toy-toying" then they stop.

The radio is very powerful. If Mr Snyman says something which the workers have heard on the radio, then they listen. The radio is the first thing people buy when they have money. "Yes, the radio also says that..." they say.

When Bishop Lekganyane of the ZCC drives past they call him "God". At the Zion centre at Moria they buy water which has been blessed by the bishop (or which they believe has been blessed by the bishop). If Mandela says something then that is taken to be a fact.

Tzaneen is a boom town. The former govt gave concessions to businessmen to build factories in that area. The hundreds employed in these factories do not support wives and children that is taken care of back home in Lebowa. So they have money to spend. The shops are crowded with people buying the glittering goods.

Many workers on HM have a third wife working as a domestic worker. We heard about a woman who had babies by six different men. As soon as she became pregnant the man left. Every time she believes that the latest man will stay. This is a story we have heard many times in the last year.

Dr Milne, who is a scientist working for HM, tells me (Feb, 1995) that he recently met a black priest who said to him, "Why do you white people have so few children?"

Dr Milne explained to him about the population explosion. The priest had never heard about it. He was interested. Such a man could be brought in to help spread the message.

But on the whole we left Tzaneen pretty depressed. It seems like a no-win situation. People are rewarded for behaviour that will lead to STDs and pregnancies.

We hear now (Feb, 1995) that about 10 mechanics applying for one job on HM. All the rest had been laid off in the last year of drought and fire.

Lebowa - 3

Ithuseng

The Ithuseng Community Centre is a thoroughly hopeful place to visit after the hopelessness of Tzaneen and Hans Merensky.

Ithuseng is a village south of Tzaneen which used to be in Lebowa. Compared with the villages written about in the last section it is more like a small town. There are houses of all sorts and plenty of greenery. It has an organic settled feel to it.

This is the "village" to which Dr Mamphela Ramphele was exiled after the death of her partner, Steve Biko. Since she was a doctor she started a community health centre.

"Ithuseng (Help Yourselves) serves an impoverished rural population of approximately 100 000 people, a mixture of Tsonga and North Sotho-speakers who have been living for decades in an area that has in more recent years been divided into parts of Gazankulu and Lebowa.

"The major difficulty at first was to generate a relationship of trust and to affirm people's inherent ability to rise above the degradation of their powerlessness and their sense of despair.

"Emphasis is placed on preventive health and demystification of knowledge, through discussion (for instance) of the importance and role of immunisation in health care and the relationship of this to traditional forms of protection against ailments; or the promotion of oral rehydration treatment in the management of diarrhoeal disease for both young and old. The starting point is always the skills base that people already have, and linking that to correct scientific approaches."

The above quotes are taken from the book on South African poverty written by Dr Ramphele together with Monica Wilson.

The health centre is presently run by Mankuba Ramalepe and the mood there is anything but "degradation and despair".

We had tea with Mankuba in a room which gradually filled with about ten people. We told her Mitchell Warren's observation that, "South Africa is the most over-politicized and over-researched country in the world." (Mitchell Warren works for Population Services International, who sell good quality condoms at below cost.)

The WHO team under Dr Helen Rees had just visited Ithuseng as many people do - but nothing ever comes of it. What works is what they do for themselves.

Mankuba had a huge laugh over Mitchell's observation. When the room filled up with other workers she told the joke again and the whole room laughed. We realized that to South African problem-solvers everywhere this is a tremendously empowering joke.

Mankuba said, "Of course we must talk about population. By talking about it we understand it and we get used to it." Ithuseng has 3 to 5 nompilos in each of 70 villages. This is funded by the Kaiser Foundation.

Mankuba said that the idea of specialist fp nompilos was a good one, but then she added, "Our ladies have been handing out pills for years." I asked her later whether we should write openly about this illegal practice, since only qualified nurses are supposed to hand out pills. She said, "What do you think?" I said that it might do some good and it was highly unlikely that anyone would prosecute her. (March, 1995. Mankuba has now received the Nelson Mandela Award for Health and Human Rights!)

In the Northern Transvaal not only are pills often handed out by non-nurses, but nurse-aides often do injections when nurses are busy. All over South Africa private doctors do abortions illegally.

All these activities are "high standard" activities done by dedicated and well-trained people.

To return to our visit: "Don't you have any problems," I asked. One woman replied, " I don't want to hear the men ever saying again that women must have many children. I want them to believe that we will have better health with less children."

She was a thin, malnourished-looking woman. Mankuba said her only problem was contraceptive supplies. The old Lebowa govt was hopelessly inefficient and she was frequently out of supplies. At the time of our visit she was out of supplies again.

However, soon afterwards she persuaded the Tzaneen supply office to give her supplies; this is much nearer than the old Lebowa capital and much more convenient.

February 1995. I phoned Mankuba. I asked her whether the PDP had ever come to Ithuseng. "One lady came - Mrs Sithole - she came 3 years ago. But what have they done? They haven't done anything."

She says children are now dumped at Ithuseng. They are sick and malnourished and often the parents can't be traced - or they are known to be in Johannesburg but won't come back for their children. So the children remain in the Ithuseng crèche.

Mankuba says that men nowadays are starting to be more interested. If there was strong advocacy it would catch on. The men come to the centre for condoms and then there is a chance to talk to them. "They are very much willing and listening". But Ithuseng doesn't have the manpower to follow this up. They have one active and willing male volunteer.

SAPLER delights in other forms of constructive self-help. Here is another quote from the Ramphele book: "...the co-operative brickyard was started with women who already possessed skills acquired from a local brickyard where they were employed. There was also very little capital required: this minimised the dependence on outsiders and promoted self-reliance amongst the participants. There was also, given the shocking housing situation in the area, a ready market for bricks. Furthermore, the possibility of linking breast-feeding promotion and child care with the project was facilitated by involving those mothers who found it difficult to leave their young children at home. The brick project also had a multiplier effect in that the women produced the bricks which were used in the building of the model day-care centre." (Ramphele and Wilson)

Ithuseng Statistics

Clinic Acceptors, 1992. Family Planning 5978

Immunisation 3769

Patients 4310

Health education groups 4299

1993. Family Planning 7423

Immunisation 4010

Patients 4644

Health education groups 4673

Referrals to hospital 57

1994. Family Planning 8648

Immunisation 6753

Patients 8854

Home visits 71101

Referrals 294

Health Education 5 073

Lebowa - 4

Around Jane Furze Hospital

Jane Furze Hospital is in the poorest part of Lebowa Sekhukhuneland. The land degradation is obvious to the visitor driving from Pietersburg to Jane Furze. It is also documented in the Oliphants River ecology programme '

Behind the hospital there is an Operation Hunger outpost where we spoke to Johann Rissik and Frans Themba. Johann told us that the most outstanding family planning sister was now in Outpatients. This was not her wish. She was not only committed to fp, she also liked working in the outlying clinics, which most nurses hate.

Johann did not know why she had been shifted and none of the nurses at the hospital would explain. We later realized that this happened after family planning was taken away from the national outreach and put into the general provincial services where it is policy to circulate the nurses from department to department.

We spoke to the family planning nurse. She was young and timid and inexperienced.

At this hospital no attempt is made to motivate expectant mothers towards limiting their families. There is no fp outreach to explain fp to the community.

The only person who is doing fp motivation is Frans Themba of Operation Hunger. He talks to thousands of women in connection with his work for Operation Hunger. He meets the fatalistic women who live in well-built houses with 6 to 10 malnourished children. 

The children are mostly too tired to attend school regularly. The women say, "Why should I worry with taking pills all the time when my husband only comes twice a year, and then I don't know when he is coming."

Frans intervenes, prescribes, tells, teaches, shows call it what you will - he has a buoyant personality and he changes her from being passive to being active. Frans brings condoms. He shows the women how to confront their husbands. When they get it right there is much rejoicing.

At the back of the hospital Operation Hunger has a most outstanding vegetable garden. It is vast. It is worked in strips by different people from the community. This works much better than people trying to grow vegetables on their own at home. Apart from getting discouraged they often have no water. At Jane Furze there is water. The surplus vegetables are sold at the hospital gates.

The main ailment which brings children to the Jane Furze Hospital is malnutrition. They are cured of their immediate symptoms and sent back into the community - only to return to the hospital in 3 months' time.

Near Jane Furze is the Hlatlolanang Health and Nutrition Education Centre. They have a beautiful building, built by money from the Lutheran Church. "Hlatlolanang" means "remove the burning pot from the fire". The group has been very concerned with malnutrition and with childhood deaths.

They have invited help from agricultural experts and education experts and even from the PDP. But nowhere in their material is there anything about sexuality education, AIDS, and family planning. However, when we spoke to Nagaa Chiwayo (nutrition) she expressed great interest in our fp-nompilo scheme. She said the women she knows who want fp get very frustrated because the mobile clinics do not arrive on the right days.

Northern Transvaal (RSA)

3.       Services

3.1     Departmental

Fixed Clinics

Full time x 17 Part time x .3.

Community Health Centres with 24 hour maternity service x 4

Mobile teams 47 -

Part time clinics are served by mobile teams In the area.

3.2   Non - Departmental

Medical Practitioners, Private Clinics and Private practitioners are supplied free of charge with contraceptive methods on condition that:

- They do not charge clients for the contraceptive but they may if they choose levy a consultation fee

- They submit monthly statistics of their client turn-over

This is a low service for the department

4. Most Common Conditions Treated at Service Points

(U R T I - Upper Respiratory Tract infection)

[ Home ] [ Contents ] [ Introduction ] [ Northern Province ] [ Zimbabwe ] [ Winterveld ] [ Paarl ] [ FP and Prevention ] [ K/Zulu Natal ] [ Universality ] [ Learning from Others ] [ SA Policies ] [ The Youth ] [ Problem Areas ] [ Two Warring Depts ] [ Statistics ] [ Other Organisations ] [ Sterilization ] [ Appendicies ]