'Closing the gate' on rural communities: Health care during COVID-19

Over the past six months, many have seen the COVID-19 crisis through a metropolitan lens. In the rural Eastern Cape, communities say that the government ‘closed the gate’ (ukuvala isango) when COVID-19 came and left them to struggle in the dark. Leslie Bank, Nelly Vuyokazi Sharpley and Ndipiwe Mkuzo highlight how a city-centric, biomedical and hospital-focused state response to the COVID-19 crisis, along with the consequences of years of public-sector health service neglect, shut rural communities out. The article is based on the findings of a rural research project, undertaken by the HSRC in association with Walter Sisulu 20University, that looked into the impact of the lockdown on rural communities in the Eastern Cape.

In her 2014 book, Biomedicine in an Unstable Place, Alice Street argues that public hospitals have long served as sites for imagining the state and, beyond that, modernity. The collapse of a single hospital, she says, can become a critical indicator of the failure of development in an entire region or city. In the Eastern Cape, the Livingstone Hospital in Port Elizabeth, which was meant to lead the provincial effort against COVID-19, became the lens through which the readiness of the province and country was judged by the outside world.

In April 2020, Health Minister Zweli Mkhize visited the hospital, where he confronted the provincial MEC for health, Sindiswa Gomba, for the poor state of readiness of her department and promised to bring in his own expert team to assist the province. It was also here, when coronavirus cases were surging in South Africa in July 2020, that several international TV stations such as the BBC and Sky News broadcast images of rats eating medical waste and patients sleeping in the corridors to a global audience.

Nursing staff at Motherwell NU2 clinic stand outside the main gate. The clinic was closed after staff members tested positive for COVID-19.
Photo: Joseph Chirume, GroundUp

These visuals of conditions in urban hospitals such as Livingstone, shaped the public imagination of the pandemic and encouraged Eastern Cape families to try to bypass local urban hospitals for those in other provinces, such as the Western Cape, to get better service. But while residents in urban areas still had choices, most of the rural poor in the Eastern Cape were left without formal health services for much of the winter of 2020, as rural hospitals and clinics closed down and some never reopened.

Crackdown on customary practices
There was high drama in March 2020 in the Eastern Cape after the lockdown regulations had become known and the provincial government had moved to curtail customary practices with the support of the Eastern Cape House of Traditional Leaders. In a province-wide blitz, the police closed dozens of initiation schools in rural areas and created chaos at rural funerals when they overturned drums of beer, confiscated meat and chased people away.

When researchers from the HSRC and Walter Sisulu University (WSU) visited the rural areas, some older men and women said that they had not seen a violent crackdown on customary practices since apartheid, when the police hunted down Pan-Africanist Congress cadres they suspected were colluding with traditional healers. Many complained that the state had no business sending the police to disrupt cultural practices without calling community forums to discuss the matter.

People said that families had saved for these events and had already spent much money on rituals, which were stopped without explanation. Others said that there had been no information about COVID-19 in the villages, not even at the clinics. One man said, “If you want to know about COVID-19, you have to read the billboards in town, which are all in English.”

Local reaction and anger to the crackdown restrained police action, but the criticism and displeasure with urban elites and state officials continued. Many wondered why the COVID-19 rules seemed not to apply when ANC leaders were buried in the big cities such as Johannesburg, but were implemented with force in the rural areas. Rural communities also spoke out later against the alleged widespread corruption of urban elites and members from the Health Department.

Deep cleaning and frightened nurses
But the real crisis for rural communities was not the government crackdown on customary practices or the inadequacies of the rural health service. They knew that rural hospitals were crumbling and lacked qualified staff and basic equipment, and that clinics no longer had medicine to give out, but the system had been at least partially functional before COVID-19.

The speed at which rural health-care facilities and institutions shut down during the COVID-19 crisis took rural communities by surprise. It started with the Zwide township clinic in Port Elizabeth in April, which suspended service to over 500 daily patients when several nurses tested positive for the coronavirus. The public service and nurses’ union supported the closure, arguing that the state was responsible for implementing the standard operating procedures to deep-clean the facility to make it safe for the nurses and patients to return. It took the state weeks to sort this problem out.

The Zwide case set the agenda for how doctors, nurses and civil servants generally responded to cases of infection. They left their workstations, engaged their union representatives and went home until the state was able to prove that the facility had undergone thorough deep cleaning. The unions were adamant that workers did not have to work where the state could not implement the standard operating procedures needed to keep them safe.

As infections spread, more rural clinics and hospitals closed. In some cases, as happened at hospitals in the OR Tambo district, health-care workers downed tools and walked out. In others, partial services were provided, such as those of the administration office that issued death certificates.

During this crisis, no one addressed the elephant in the room: the fears of health-care workers and how widespread mental-health issues were among them, especially given that many nurses had comorbidities. Moreover, the hard-line biomedical approach to the crisis meant responses in poorly resourced areas such as the rural Eastern Cape could not be improvised.

Local knowledge and improvisation
In her influential 2012 book, Improvising Medicine, Julie Livingston showed how hospital patients in a cancer ward in Botswana navigated between traditional and modern biomedical systems to address their everyday needs and medical requirements. She demonstrated how health care was always a relationship among people concerning illness, as much as it was one between biomedical practitioners and patients. In a context of infrastructural challenges and limited facilities, she argues that improvisation is essential to delivering the best and most responsive health-care service.

With COVID-19 the state took a rigid, formalised, hospital-centred and biomedical approach. It created regulations enforced through the police and other state agencies. In this role, the state was not a facilitator and it did not encourage improvisation or create relationships of mutual dependence. In fact, its approach hindered local adaptation and resilience.

But even though lines were drawn in the sand by both the state and health-care workers, we noted several encouraging responses. At one hospital that stayed open, doctors and nurses worked together to repurpose paediatric equipment for child chest ailments to create functional ventilators for adults. These make-shift ventilators used water pressure to force oxygen into the patients’ lungs and saved lives. The staff at the hospital attributed their capacity to innovate to their willingness to discuss their fears upfront and then face the local challenges of COVID-19 in open and adaptable ways.

On the other hand, the HSRC and WSU researchers found that the state did not engage with traditional healers in rural areas, despite the fact that rural households used them widely. This puzzled and angered the healers, but they continued to support rural families. We found that many people who feared COVID-19 visited traditional healers, who gave them hope and prescribed medicinal herbs and plants for chest ailments and flu symptoms.

Dozens of patients were sent away in May 2020 after the Eastern Cape Department of Health shut down Zwide Clinic in Port Elizabeth following the death of a nurse and 11 other staff members testing positive for the coronavirus.
Photo: Mkhuseli Sizani, GroundUp


Rural people in the Eastern Cape felt excluded from the state’s COVID-19 response. They complained that they were never consulted or properly informed about the approach adopted by the government, which they described as an exercise in ‘closing the gate’. They objected to the way government came into the rural areas and tampered with their culture and customary practices, while at the same time failing to ensure that the local clinics and hospitals were open for business. Local community leaders said that they hoped government and traditional leaders would be more consultative and participatory in their approach should there be a second wave of infection in the province.

Authors: Prof Leslie Bank, strategic lead in the HSRC’s Inclusive Economic Development (IED) division, and Dr Nelly Vuyokazi Sharpley, head of Social Sciences at the Walter Sisulu University, and Ndipiwe Mkuzo, research intern in the IED